Safety and Best Outcomes in Spine Surgery
Team, Experience, and Devotion
Baron Lonner, M.D.
My team and I are dedicated to the safest and best outcomes for each and every patient regardless of how severe or complex the individual’s condition is. Every patient has a unique presentation in terms of their condition whether it be a 100 degree scoliosis, a multiply operated spine, or a slipped disc. In addition to these differences in the severity of the spinal problem, there are also differences in the patient’s general health whether a child or an adult. Some patients have near perfect health and other’s have underlying conditions that require careful consideration from the standpoint of whether or not the patient is a surgical candidate, what type of surgery would be best for the individual, and how to minimize the risks of surgery to the patient.
As the leader of the team, it is my job as the surgeon to ensure, all members of the team are on the same page about the patient’s condition and that the best team is assembled to help the individual. The following are the steps the team takes to ensure the best possible outcomes with the minimum amount of risk:
The patient’s spinal condition is evaluated and a plan for surgical treatment is devised. In some complex cases, the patient’s “case” is presented in spine conference and to colleagues around the world to come to a consensus about the best approach. Based on the patient’s age and underlying health, various consults are obtained and medical clearance for surgery is requested. An internist, cardiologist, geneticist, pediatrician, gastroenterologist are all potentially part of that assessment. Once clearance is obtained, surgery can be performed. Hospital-based specialists may also be required to be part of the team while the patient is hospitalized. All patients are seen daily by either a pediatrician or internist. Special surgical equipment is arranged prior to the surgical date.
On the day of the surgery, the patient is brought into the operating room only after I (Dr. Lonner) has reviewed with the patient the plan for surgery, consent for surgery is confirmed, and the patient’s back is labeled by me with my initials to confirm the site of surgery. The anesthesiologist reviews the plan with the patient and the nurses confirm that the special equipment needed for surgery is present and that the patient is ready for the operation. The x-rays and other imaging studies are reviewed and confirmation that they are the correct studies for the particular patient is done.
In the operating room, the patient is placed under anesthesia and then positioned on the operating room table. Care is taken to pad all bony prominences and superficial nerves so the patient is protected during the procedure. All equipment is checked and double checked for sterility. A “time-out” is performed in which every member of the team identifies themselves, I tell the team again what our plan is, the time estimate for the procedure as well as potential challenges expected in the surgery. I make it clear that any member of the team can speak up during the operation if they have any concern. The anesthesiologist and I confirm the plan and communicate the specific needs for the patient. Antibiotics without prescription are given and that is confirmed to the team. The spinal cord monitoring technician ensures that good baseline functioning is reported. All of this is done with checklists to confirm that all of these important steps are taken for each and every patient. The procedure is then performed.
Surgical ProcedureSpecific Steps Taken During Surgery
Blood loss is minimized through a number of steps. First and foremost, meticulous care to the exposure of the spine is performed. Blood pressure is carefully monitored and controlled and Tranexamic acid, a special medication which has been shown by our group to lower blood loss during spine surgery, is used. A special cauterizing device is also used during surgery also to minimize blood loss. Cell saver suction captures the patients blood in the operative field which is then filtered, washed, and returned to the patient. Finally, family members of the patient may pre-donate blood to minimize exposure to blood transfusions from the general blood bank population. However, even bank blood offers an extremely safe supply of blood which is carefully tested for viruses and is typed and matched to the patient.
Spinal cord and nerve safety during surgery is one of the most important aspects of the surgery and is why one should chose an experienced surgeon to minimize risk of paralysis during spinal surgery. An experienced surgeon such as Dr. Lonner has done thousands of operations and is able to provide the safest outcomes by performing operations efficiently and avoiding unsafe maneuvers. Multiple forms of spinal cord and nerve root monitoring are performed to provide instantaneous and continuous feedback to the surgeon and the operating team so that neurological function is maintained. This allows the surgeon to proceed as planned or make adjustments in the procedure as needed based on the spinal cord monitoring. In this way, paralysis is avoided.
Infection is a risk of all surgeries and the likelihood of an infection occurring is affected by the type of condition the patient has, whether or not they have had previous surgery, and patient factors such as diabetes, being overweight, taking steroids, smoking history, or excessive alcohol consumption. For most patients, the risk of infection is very low. It is under 1% for adolescent idiopathic scoliosis, but is greater for adult scoliosis.
Infection after surgery, known as surgical site infection, is minimized in a number of ways. The surgeon and his team must be meticulous, efficient in surgery, and the team must pay strict attention to sterility during the operation. In addition, the patient is given intravenous (IV) antibiotics just before the operation starts and for 24 hours thereafter. Doctor Lonner has performed a prospective study on surgical site infection after spine surgery and found that giving antibiotics for more than 24 hours is not effective and may even result in a higher rate of infection so that 24 hours is the appropriate standard. In addition to administering IV antibiotics, local antibiotics are placed in the incision at the end of the procedure which has been shown to decrease the rate of infection. Furthermore, prior to that, a special iodine-based sterilizing solution is used to irrigate and cleanse the incision area. Lastly, in many cases, a plastic surgeon is brought in as part of the team to help close the incision which can be very extensive. Having a plastic surgeon may help to decrease complications including infection and drainage from the incision.
Two surgeons work together on all operations performed by Dr. Lonner. This has been shown to decrease operating time, blood loss during surgery, complications and reoperations. This is not standard at all hospitals, but is Dr. Lonner’s standard of care.
Postoperative Hospital Care
Thorough monitoring of the patient after surgery is just as important as an operation expertly and carefully performed. All patients are placed under intensive care monitoring for at least the first day after surgery. Neurological checks are done frequently to make sure neurological function is preserved and the patient’s blood pressure, heart rate, and oxygen in the blood stream for supply of vital organs is monitored. Pain is controlled with “anti-pain” medications. This is done with a combination of medications that limit the need for narcotic drugs so as to limit reactions to these medications. Most importantly, the patient is asked frequently about their pain level so that this very important aspect of the postoperative course is addressed. Finally, the risk of blood clots is minimized by getting the patient out of bed as soon as possible and using special compression stockings and in high risk patients, blood thinners.
Follow-up with your surgeon following surgery is crucial to ensure that healing is proceeding in a proper way and that the alignment of your spine is maintained and instrumentation (rods and screws) remain well positioned. This also gives the surgeon the opportunity to ask the patient about their recovery and how they are doing overall. They are given questionnaires that address the patient’s pain, function, mental health, activity level, and overall satisfaction. These questionnaires are useful to assess the patient’s progress following surgery and for research in to the outcomes of operations for various conditions. In Doctor Lonner’s practice, follow-up visits are typically at 4-6 weeks, 3 months, 6 months, 1 year, 2 years, 5 years, 10 years, and 20 years and are adjusted based on the individual’s personal circumstances. Out of town patients may have limited visits with Dr. Lonner but will be asked to send x-rays for review and have evaluations by their local doctor in their country or outside state.
An important component of improving care and outcomes in spine surgery is performing clinical research. This includes collecting data (information) on the patient’s condition and its severity, the nature of the operation, radiographic (x-ray outcomes), and most importantly the patient’s reported outcome as measured by various questionnaires that have been validated for this purpose. Dr. Lonner is committed to research in spinal deformities and spine surgery in general in order to improve outcomes for patients and to help answer questions that are posed by patients and their families.