Association Between Surgeon Experience and Complication Rates in Adult Scoliosis Surgery

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

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Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery

Neurosurgical FOCUS ◽

10.3171/2012.7.focus12181 ◽

2012 ◽

Vol 33 (5) ◽

pp. E15 ◽

Cited By ~ 33

Author(s):

Judith M. Wong ◽

John E. Ziewacz ◽

Allen L. Ho ◽

Jaykar R. Panchmatia ◽

Albert H. Kim ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Adverse Events ◽

Significant Proportion ◽

Current Evidence ◽

Neurophysiological Monitoring ◽

Complication Rates ◽

Vessel Occlusion ◽

Surgeon Experience ◽

Major Vessel ◽

Monitoring Technologies

Object As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Methods The authors performed a PubMed search using search terms “cerebral aneurysm”, “cerebral arteriovenous malformation”, “intracerebral hemorrhage”, “intracranial hemorrhage”, “subarachnoid hemorrhage”, and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. Results The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%–57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. Discussion A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.

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Kickstand Rod Technique for Correcting Coronal Imbalance in Adult Scoliosis: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz306 ◽

2019 ◽

Vol 19 (2) ◽

pp. E163-E164 ◽

Cited By ~ 1

Author(s):

Thomas J Buell ◽

Avery L Buchholz ◽

Marcus D Mazur ◽

Jeffrey P Mullin ◽

Ching-Jen Chen ◽

...

Keyword(s):

Functional Outcomes ◽

Adult Scoliosis ◽

Scoliosis Surgery ◽

Major Curve ◽

Coronal Imbalance ◽

Medical Publication ◽

Alignment Correction ◽

Iliac Screw ◽

Coronal Malalignment ◽

The Impact

Abstract Restoration of spinal alignment and balance is a major goal of adult scoliosis surgery. In the past, sagittal alignment has been emphasized and was shown to have the greatest impact on functional outcomes. However, recent evidence suggests the impact of coronal imbalance on pain and functional outcomes has likely been underestimated.1,2 In addition, iatrogenic coronal imbalance may be common and frequently results from inadequate correction of the lumbosacral fractional curve.2,3 The “kickstand rod” is a recently described technique to achieve and maintain significant coronal-plane correction.4 Also, of secondary benefit, the kickstand rod may function as an accessory supplemental rod to offload stress and bolster primary instrumentation. This may reduce occurrence of rod fracture (RF) or pseudarthrosis (PA).5 Briefly, this technique involves positioning the kickstand rod on the side of coronal imbalance (along the major curve concavity or fractional curve convexity in our video demonstration). The kickstand rod spans the thoracolumbar junction proximally to the pelvis distally and is secured with an additional iliac screw placed just superior to the primary iliac screw. By using the iliac wing as a base, powerful distraction forces can reduce the major curve to achieve more normal coronal balance. This operative video illustrates the technical nuances of utilizing the kickstand rod technique for correction of severe lumbar scoliosis and coronal malalignment in a 60-yr-old male patient. Alignment correction was achieved and maintained without evidence of RF/PA after nearly 6 mo postoperatively. The patient gave informed consent for surgery and to use imaging for medical publication.

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Feasibility of Single-Staged Bilateral Anterior Scoliosis Correction in Growing Patients

Global Spine Journal ◽

10.1177/2192568219892904 ◽

2019 ◽

Vol 11 (1) ◽

pp. 76-80 ◽

Cited By ~ 1

Author(s):

Alice Baroncini ◽

Luis Rodriguez ◽

Kushagra Verma ◽

Per D. Trobisch

Keyword(s):

Learning Curve ◽

Retrospective Analysis ◽

Pulmonary Complications ◽

Future Research ◽

Scoliosis Surgery ◽

Complication Rates ◽

Scoliosis Correction ◽

Double Curve ◽

Thoracic Approach ◽

A Minor

Study Design: Retrospective analysis. Objectives: The objective of this study was to analyze the feasibility of correcting double-curve scoliosis using dynamic scoliosis correction (DSC, also known as vertebral body tethering), which requires a bilateral anterior approach with deflation of both lungs. Typically, this approach falls under the exclusionary criteria for the eligibility for anterior scoliosis surgery. No data exists on the feasibility of single-staged bilateral DSC. Methods: A retrospective analysis was performed utilizing the data from 25 patients who underwent a bilateral anterior thoracic approach and instrumentation. Thirty-day postoperative complication rates were analyzed. A learning curve subanalysis was also performed to compare the first 12 patients to the remainder of the 13 patients, with a T-test ( P ≤ .05). Results: Of the 25 patients treated, there was 1 intraoperative event: After performing lumbar DSC, the contralateral DSC was abandoned due to unexpected pleural scarring and staged selective thoracic fusion was performed. We observed 4 postoperative complications: 2 patients had recurrent pleural effusions, 1 patient was diagnosed with pneumonia, and 1 patient had a minor pulmonary embolism without cardiopulmonary consequences (after an international 24 hour flight). All patients recovered well. We observed a significant influence of learning curve on surgical time (328 vs 280 min, P = .03) and blood loss (480 vs 197 mL, P = .03). Conclusion: Data suggests that bilateral, single-stage surgery for DSC is feasible albeit with an elevated complication rate that may partially attributable to the learning curve. Future research should focus on the cause of pulmonary complications and include a matched comparative analysis with traditional posterior fusion.

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The Efficacy and Accuracy of Cone Beam CT (O-Arm) Navigation (StealthStation) on Screw Position in Adult Scoliosis Surgery

Global Spine Journal ◽

10.1055/s-0035-1554339 ◽

2015 ◽

Vol 5 (1_suppl) ◽

pp. s-0035-1554339-s-0035-1554339

Author(s):

Jason Strelzow ◽

Danny Mendelsohn ◽

Nicolas Dea ◽

Charles Fisher ◽

Marcel Dvorak ◽

...

Keyword(s):

Cone Beam Ct ◽

Adult Scoliosis ◽

Cone Beam ◽

Scoliosis Surgery ◽

Screw Position

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Surgeon Experience and Complication Rates in Anterior Cervical Discectomy and Fusions: A National Longitudinal Database Study

The Spine Journal ◽

10.1016/j.spinee.2014.08.304 ◽

2014 ◽

Vol 14 (11) ◽

pp. S123 ◽

Cited By ~ 1

Author(s):

Tyler S. Cole ◽

Anand Veeravagu ◽

Michael Zhang ◽

Ivan Cheng ◽

John Ratliff

Keyword(s):

Anterior Cervical Discectomy ◽

Complication Rates ◽

Cervical Discectomy ◽

Database Study ◽

Surgeon Experience

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Scoliosis in Children: Impact of Goal Directed Therapies on Intra-operative and Postoperative Outcomes

10.21203/rs.3.rs-765785/v1 ◽

2021 ◽

Author(s):

Claudine Kumba

Keyword(s):

Secondary Analysis ◽

Initial Study ◽

Abdominal Sepsis ◽

Postoperative Outcomes ◽

Scoliosis Surgery ◽

Complication Rates ◽

Wound Sepsis ◽

Intraoperative Complication ◽

Initial Cohort ◽

Surgical Setting

Abstract Background: Scoliosis is among interventions with high postoperative complication rates due to the characteristics of the surgery, where blood loss, transfusion and fluid requirements can be increased.A monocentric retrospective observational study was undertaken earlier to determine predictors of intraoperative and postoperative outcomes in surgical patients. In this initial cohort, there were patients who underwent scoliosis surgery, and a secondary analysis to describe outcomes in these patients was realized and is presented here.Objective: To describe intraoperative and postoperative outcomes in patients under 18 years old in scoliosis surgery included in the initial study and to propose improvement implementation measures.Methods: Secondary analysis of patients undergoing scoliosis surgery. The study was approved by the Ethics Committee.Results: There were 116 patients with a mean age of 147.5 ± 40.2 months. Twenty-eight patients (24.1%) presented intraoperative and/or postoperative complications. The most common intraoperative complication was hemorrhagic shock in 3 patients (2.6%). The most common postoperative organ failure was neurologic in seven patients (6%), respiratory in 3 patients (2.6%), cardio-circulatory in 2 patients (1.7%) and renal failure in one patient (0.9%).The most common postoperative infection was surgical wound sepsis in 8 patients (6.9%), urinary sepsis in three patients (2.6%), and abdominal sepsis and septicemia in two patients (1.7%).twelve patients (10.3%) had reoperations.Fifty-six patients (48.3%) had intraoperative transfusion.There was no in-hospital mortality.Conclusion: Integrating goal-directed therapies in this surgical setting could improve postoperative outcomes.

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Regional chemotherapy devices: effect of experience and anatomy on complications.

Journal of Clinical Oncology ◽

10.1200/jco.1993.11.5.822 ◽

1993 ◽

Vol 11 (5) ◽

pp. 822-826 ◽

Cited By ~ 71

Author(s):

K A Campbell ◽

R C Burns ◽

J V Sitzmann ◽

P A Lipsett ◽

L B Grochow ◽

...

Keyword(s):

Complication Rate ◽

Hepatic Arterial Infusion ◽

Regional Chemotherapy ◽

Complication Rates ◽

Arterial Infusion ◽

Technical Complications ◽

Surgeon Experience ◽

Technical Complication ◽

Arterial Anatomy

PURPOSE Regional hepatic arterial infusion (HAI) devices have been used for 17 years, but reports of unacceptably high complication rates have led to controversy about their use. Inadequate or misdirected infusion has been reported to occur in up to 45% of patients. We evaluated whether surgeon experience or presence of variant arterial anatomy related to risk of coagulation. MATERIALS AND METHODS We reviewed 70 patients undergoing placement of HAI catheters. Surgeons were classed as experienced after 10 procedures and arterial anatomy was evaluated angiographically with confirmation at operation. Complications were categorized as technical (17%) or chemotherapy-related (16%). RESULTS Inexperienced surgeons had a technical complication rate of 37% (80% of the patients involved had standard anatomy), while experienced surgeons had a technical complication rate of 7% (P < .01). Experienced surgeons had no complications in patients with standard anatomy, while inexperienced surgeons had a 42% (eight of 19) complication rate in similar patients (P < .01). CONCLUSION We conclude that technical complications are closely associated with surgeon experience and arterial anatomy.

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Thresholds for Surgery and Surgical Outcomes for Patients with Primary Hyperparathyroidism: A National Survey of Endocrine Surgeons

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jcem.83.8.5006 ◽

1998 ◽

Vol 83 (8) ◽

pp. 2658-2665 ◽

Cited By ~ 81

Author(s):

Julie Ann Sosa ◽

Neil R. Powe ◽

Michael A. Levine ◽

Robert Udelsman ◽

Martha A. Zeiger

Keyword(s):

Primary Hyperparathyroidism ◽

Clinical Outcomes ◽

High Volume ◽

Urinary Calcium ◽

Complication Rates ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Primary Operation ◽

Surgeon Experience ◽

Low Volume

abstract A 1991 NIH Consensus Development Conference statement provided recommendations for the management of patients with asymptomatic and minimally symptomatic primary hyperparathyroidism (1° HPT), but adherence to these guidelines has not been documented. We conducted a cross-sectional survey of North American members of the American Association of Endocrine Surgeons inquiring about surgeon and 1° HPT patient characteristics, thresholds for surgery, and clinical outcomes. Multivariate regression was used to assess the relationship of physician characteristics to practice patterns and outcomes. Of 190 surgeons surveyed, 147 (77%) responded; 109 provided complete responses (57%). These surgeons spend 66% of their time in patient care and perform an average of 33 (range, 1–130) parathyroidectomies/yr. More than 72% of 1° HPT patients who underwent surgery were asymptomatic or minimally symptomatic. High volume surgeons (>50 cases/yr) had significantly lower thresholds for surgery with respect to abnormalities in preoperative creatinine clearance, bone densitometry changes, and levels of intact PTH and urinary calcium compared to their low volume colleagues (1–15 cases/yr). Overall reported surgical cure rates were 95.2% after primary operation and 82.7% after reoperation. Compared to high volume surgeons, low volume endocrine surgeons had significantly higher complication rates after primary operation (1.9% vs. 1.0% respectively; P < 0.01) and reoperation (3.8% vs. 1.5%; P < 0.001) as well as higher in-hospital mortality rates (1.0% vs. 0.04%; P < 0.05). Endocrine surgeons operate on a large number of asymptomatic or minimally symptomatic 1° HPT patients. Even among a group of highly experienced surgeons who typically see patients after referral from endocrinologists, clinical outcomes and criteria for surgery vary widely and appear to be associated with surgeon experience. Their criteria for surgery diverge from NIH guidelines. These results implore the endocrine community to examine the evidential basis for decisions made in the management of 1° HPT.

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