Julian “JP” Price, MD, has spent enough time performing revision spine surgery to see what happens when an operation succeeds technically but fails to solve the patient’s problem.
The fusion may heal. The implants may remain intact. Yet if the original operation did not adequately address instability or restore alignment, the patient can find themselves facing another surgery, sometimes within a year.
“Even if the first surgery heals well, if it doesn’t address the patient’s problem, they can end up coming back for another operation,” Dr. Price, an orthopedic spine surgeon at Athens (Ga.) Orthopedic Clinic, told Becker’s.
Those cases have shaped how he approaches surgery the first time. Dr. Price sees an important distinction: The least invasive operation is not necessarily the smallest one. It is the one that adequately solves the problem without doing more than necessary.
The payer consequence
Dr. Price believes the stakes extend beyond the individual case. As payers scrutinize spinal fusion, he worries poor outcomes can make appropriate procedures harder to defend.
“If we’re not doing fusions well, we’re only shooting ourselves in the foot because they’re looking at the outcomes,” he said. “If we have poor outcomes because of a poor surgery or lack of enough surgery, in the end, we’re just hurting ourselves from being able to do what’s right.”
For Dr. Price, the response is not simply to perform fewer fusions. It is to make sure the ones surgeons perform adequately address the patient’s problem.
What a revision reveals
Not every revision means the original operation failed. A patient may undergo a lumbar fusion and return 10 or 15 years later because the next disc has deteriorated. Dr. Price considers that a potential progression of the underlying disease rather than a failure of the initial surgery.
Other revisions tell a different story. Dr. Price sees patients whose previous operations left mechanical problems or failed to establish adequate spinal alignment. In the lumbar spine, he pays particular attention to what he calls “building the base.”
“If we don’t build the correct lordosis or alignment, they often break down, sometimes relatively quickly above,” he said.
Correcting that later can be considerably harder, Dr. Price said. When evaluating a revision, he looks at whether existing implants remain secure and properly positioned. He also measures segmental and overall lumbar lordosis in relation to the patient’s pelvic anatomy to determine how much correction may be needed.
When a smaller operation isn’t enough
Revision surgery has changed how Dr. Price approaches those decisions.
Early in his career, he leaned more toward larger, open operations to achieve his alignment goals. As minimally invasive techniques have advanced, he has been able to accomplish those same goals through less invasive approaches.
But he cautions against allowing the appeal of a smaller procedure to dictate the operation. Patients may seek out an approach that sounds less invasive, he said, only to find that it does not fully address the underlying problem.
Dr. Price pointed to dynamic spondylolisthesis as one example. Patients with instability may undergo decompression without fusion, only to experience further slippage and a return of their symptoms.
“Sometimes fusion isn’t a bad thing,” he said. “It’s actually the right way to fix their problem.”
Getting the first operation right
In lower lumbar fusion, that means building the base correctly at L4-5 and L5-S1.
If that can be achieved minimally invasively, he said, “that’s great.” If not, surgeons should be comfortable using other approaches, including anterior or oblique techniques, to achieve the necessary alignment.
His advice to younger surgeons is not to let the desire to minimize an operation prevent them from adequately addressing instability.
“If their gut feeling tells them to go ahead and do a little bit more the first time to achieve their goals, go ahead and do it,” Dr. Price said. “If a patient has instability and we choose not to stabilize that, ultimately they will be back for more surgery.”
Don’t let the technology become the skill
There is one more lesson Dr. Price would pass to younger surgeons: Learn more than one way to operate.
He encourages surgeons trained primarily in minimally invasive techniques to learn open approaches as well, and those who rely on robotics or navigation to be comfortable operating without them.
Not every facility has the same technology, and even where it is available, Dr. Price cautioned against becoming dependent on it.
“There may come a day where if a robot breaks, they don’t want to buy another one,” he said. “Then you’re in a lot of trouble if you don’t know how to do it.”
That does not make Dr. Price a skeptic of surgical technology. His own practice uses it. His point is that the technology should expand a surgeon’s options, not define them.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
