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Clinician-to-Clinician Update

Latest Findings on Surgical Approaches to Complex Spinal Conditions

Disorders of the vertebrae, spinal disks and joints include structural and growth disorders as well as abnormal spinal curvatures, nerve impingement, and systemic problems resulting from trauma and tumors. Disorders that can result in malalignment and pain include adolescent and adult scoliosis, spinal deformities, and sacroiliac joint dysfunction.

Adolescent idiopathic scoliosis (AIS) occurs in 2% to 3% of the general population with about 10% of patients requiring some type of treatment.1 Some patients can be treated with bracing, but about 0.1% undergo surgery.1 Uncorrected severe curvatures can cause other problems, such as cardiac and pulmonary distress.1,2

Minimally invasive techniques for correcting scoliosis have been associated with less time in surgery, fewer ICU stays, and shorter lengths of hospital stay, although researchers have not been able to attribute these findings solely to the use of minimally invasive techniques.2 Corrective implants for AIS have also received research attention. Surgically placed corrective rods for scoliosis, spinal deformities (such as kyphosis), and other pathologies employ pedicle screws, with their placement and number tailored to the condition.3,4 In scoliosis procedures, both extensive and less extensive use of pedicle screws (known as high-intensity or low-intensity placement) have produced successful outcomes. Analysis of cases from the 2009 Kids Inpatient Database, however, suggests that reducing the number of screws placed could result in a cost savings of 7%.5 University of Minnesota Health surgeons are investigating outcomes related to the 2 approaches. The study will compare outcomes across groups that underwent either low-intensity or high-intensity implant placement to correct Lenke 1A scoliosis, the most common type of the condition. (See Program Notes.)

Nonsurgical management is most often indicated for low back pain. However, for patients with sacroiliac joint dysfunction, a common cause of chronic low back pain, minimally invasive fusion of the joint has been demonstrated to provide rapid and sustained pain relief and improvements in function.6 For complex spine disorders or trauma, multidisciplinary team-based care and dual-surgeon approaches to complex procedures provide improved outcomes. Spinal procedures conducted by dual-surgeon teams have been shown to produce superior outcomes, reduce time in surgery, and result in fewer complications than those led by a single surgeon.7

Comprehensive, team-based approaches from initial evaluation through surgery and follow-up care help support the best outcomes for orthopaedic patients. The University of Minnesota Health Comprehensive Spine Care Program facilitates cross-disciplinary assessment of complex spine cases through its monthly conferences. The conferences incorporate input from anesthesiologists, neurosurgeons, endocrinologists, and other specialists to assess candidates for surgery and to better anticipate potential treatment complications. Orthopaedic surgeons also regularly coordinate with their neurosurgery colleagues and conduct dual-surgeon procedures. The program’s new initiative Early Recovery after Surgery brings a coordinated cross-team effort to the implementation of evidence-based practices shown to speed spinal surgery patients’ recovery.

References

  1. Tambe AD, Panikkar SJ, Millner PA, Tsirikos AI. Current concepts in the surgical management of adolescent idiopathic scoliosis. Bone Joint J. 2018 100-B(4):415-424 DOI: 10.1302/0301-620X.100B4.BJJ-2017-0846.R2
  2. Cloney MB, Goergen JA, Bohnen AM, Smith ZA, Koski T, Dahdaleh N. The role of minimally invasive techniques in scoliosis correction surgery. Minim Invasive Surg. 2018 Jan 24;2018:4185840 DOI: 10.1155/2018/4185840
  3. Fujishiro T, Boissiere L, Cawley DT, Larrieu D, Gille O, Vital JM, et al. Decision-making factors in the treatment of adult spinal deformity. Eur Spine J. 2018 Mar 30 [Epub ahead of print] DOI: 10.1007/s00586-018-5572-6
  4. Polly DW Jr, Yaszemski AK, Jones KE. Placement of thoracic pedicle screws. JBJS Essential Surgical Techniques. 2016;6(1):e9 DOI: 10.2016/JBJS.ST.N.00114
  5. Larson AN, Polly DW Jr, Ackerman SJ, Ledonio CG, Lonner BS, Shah SA, et al. What would be the annual cost savings if fewer screws were used in adolescent idiopathic scoliosis treatment in the US? J Neurosurg Spine. 2016;24(1): 116-123 DOI: 10.317/2015.4.SPINE131119
  6. Polly DW Jr, Swofford J, Whang PG, Frank CJ, Glaser JA, Limoni RP, et al. Two-year outcomes from a randomized controlled trial of minimally invasive sacroiliac joint fusion vs. non-surgical management for sacroiliac joint dysfunction. Int J Spine Surg. 2016 Aug 23;10:28 DOI: 10.14444/3028.
  7. Ames CP, Barry JJ, Kesharvarzi S, Dede O, Weber MH, Deviren V. Perioperative outcomes and complications of pedicle subtraction osteotomy in cases with single versus two attending surgeons. Spine Deform. 2013;1(1):51- 58 DOI: 10.1016/jspd.2012.10.004.

When to refer

University of Minnesota Health orthopaedic specialists treat limb, joint, and spine conditions, including those resulting from trauma, arthritis, scoliosis, and musculoskeletal tumors. Our surgeons address orthopaedic injuries in adults and children and work in concert with other University of Minnesota Health specialists, including endocrinologists, rheumatologists, and neurosurgeons, among others. Our specialty teams have a reputation for providing careful and accurate initial diagnoses and for offering a range of treatment options, from physical therapy and braces to surgical procedures.

Comprehensive, multidisciplinary approaches to treatment ensure that patients experience the best possible outcomes. Orthopaedic surgeons in our Comprehensive Spine Care Program regularly coordinate with their neurosurgery colleagues to address complex spinal surgery cases and to perform dual-surgeon procedures. We apply innovative, comprehensive care approaches to recovery care. The Early Recovery after Surgery program brings to bear the latest evidence-based practices and coordinated care approaches to help reduce pain, speed recovery, and return patients to their daily activities.
University of Minnesota Medical Center has earned Blue Cross Blue Shield’s designation as a Blue Distinction Center for Spine Surgery as well as for Knee and Hip Surgery. This designation recognizes hospitals for expertise and efficiency in delivering quality care at a lower cost. University of Minnesota Medical Center has also been named a high-performing hospital in orthopaedics in U.S. News & World Report’s 2017-2018 rankings.

Our physicians are committed to working closely with referring physicians. Our physicians communicate the management plan and arrange consultations with the surgeons and any collaborating specialists so that referring physicians have all the information needed to continue follow-up care.

View clinical trials available at studyfinder.umn.edu.

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