Risk Factors for Spine Surgeon

Lumbar fusion is a frequently conducted surgery used to address various degenerative conditions of the spine that cause symptoms. Arthrodesis is a commonly utilized procedure that covers a diverse range of diagnostic indications.

These include addressing instability, deformity, stenosis, disc pathology, as well as providing relief for individuals experiencing chronic low back pain. The interconnected progress of surgical techniques, indications, and instrumentation has resulted in significant rises in the frequency of lumbar fusions.

The rates of complications associated with lumbar fusion have been reported to be as high as 13%, despite its widespread use. Research efforts remain concentrated on discovering evidence-based connections between risk factors and the rates of complications, emphasizing the importance of such associations.

The impact of the surgeon’s specialization on the occurrence of complications following lumbar fusion surgery is still not fully comprehended. While studies in various surgical disciplines have demonstrated variations in outcomes depending on the surgeon’s training, there is a dearth of comprehensive research specifically examining this aspect in relation to spine surgeons and the specific procedure of lumbar fusion.

Utilizing the extensive American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, researchers aimed to investigate whether there are discrepancies in 30-day complication rates following single-level lumbar fusion based on the surgeon’s specialty.

By analyzing data from over 250 private sector hospitals in the United States, the study specifically compared the outcomes between orthopedic surgery (OS) and neurosurgery (NS) specialists.

Lumbar fusion has become increasingly popular for treating degenerative conditions of the lumbar spine, but it poses risks of complications and mortality. Improving surgical outcomes requires identifying factors that may increase risk and optimizing them.

The study examined how the specialty of the spine surgeon affects the occurrence of postoperative complications within 30 days for patients undergoing single-level lumbar fusion. Despite considering other factors, the study revealed no correlation between surgeon specialty and an elevated risk of any of the examined complications within the 30-day timeframe.

The duration of training, the range of clinical cases encountered, and the role of post-residency fellowship training are notable differences between orthopedic and neurosurgical training for aspiring spine surgeons. These variations in training background can lead to divergent clinical decisions among spine surgeons.

Unadjusted analyses have indicated that orthopedic surgeons have a higher rate of performing fusions compared to their neurosurgical counterparts.

Furthermore, in specific countries, there may be a prevailing dominance of either orthopedic or neurosurgical subspecialties in delivering spine care. This situation could be influenced by the perceived complication rates and clinical outcomes associated with the distinct training backgrounds of each specialty.

Previous research has examined the impact of surgeon-related factors on surgical outcomes. In the field of general surgery, studies have demonstrated that surgeons who have completed additional fellowship training tend to have lower complication rates compared to those without such training.

This holds true for various procedures such as major pulmonary, esophageal operations, and carotid endarterectomy. Similarly, in the context of spine surgery, research has indicated that a higher volume of surgeries performed by a surgeon or hospital is linked to lower complication rates across a range of procedures.

Through a retrospective analysis, researchers have compared the rates of reoperation-free survival in patients undergoing surgery for degenerative lumbar spine conditions, taking into account the specialty of the surgeon. The analysis revealed no notable differences between orthopedic and neurosurgical cohorts.

Building upon these findings, studies reported in literature involve examining a comprehensive nationwide database for a specific procedure and confirming the absence of significant disparities in complication rates. These results strengthen the existing surgical care model for patients with lumbar spine conditions who require arthrodesis.

In a study reported by literature, various factors were identified that exhibited a significant correlation with overall complications, in addition to the spine surgeon’s specialty. These factors included age, BMI, dependent functional status, prior stroke, ASA class exceeding 2, and total operative duration.

It was particularly noteworthy that an increase in operative duration independently predicted a wide range of complications among patients undergoing single-level lumbar fusion. Furthermore, preoperative functional health status has consistently demonstrated an association with unfavorable outcomes in the field of general surgery.

Due to its design, the NSQIP database does not include procedure-specific or specialty-specific outcome variables, which hinders the ability to assess factors such as quality of life measures or radiographic parameters for comparison purposes.

The limited 30-day follow-up duration in the database hampers the tracking of complications or reoperations occurring after that period. Potential residual confounding may arise due to the limitations of the risk-adjusted models, which are constrained by the variables recorded in the database.

The database does not include surgeon- and hospital-level data, which limits their inclusion in the regression analysis. The coding protocol poses challenges in identifying and managing cases involving multiple surgical specialties. Furthermore, the analysis is susceptible to potential selection bias due to the lack of information on referral patterns.

Representing the first population-based inquiry of its kind, a comprehensive investigation is conducted to explore the impact of surgeon specialty in the realm of spinal surgery. According to an analysis reported in the literature, the specialty of the surgeon is not found to be a risk factor for any of the studied 30-day complications in patients undergoing single-level lumbar fusion.

These results provide validation for the current training model that spine surgeons adhere to. Additional research is necessary to verify this association in other types of spinal procedures and to assess various outcomes more comprehensively.

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Do you have more questions?Ā 

If I have Spondylolisthesis, will it be reduced?

Spondylolisthesis or slipping of one vertebra over the other are usually taken care by the surgery if it fails to give relief with conservative means. It is not necessary to get them 100% reduced, but the most important part is to relieve the neural elements of all the pressure, which is caused either by the bony vertebrate or the disc and prepare the vertebrae for fusion.

In case of lumbar spine, spondylolisthesis need not to be reduced fully 100%, especially if the patient has a high grade listhesis, it is not desirable to reduce it completely. An important part of surgery is to clean the pressure of the spinal and nerve roots and prepare a healthy environment for bones to fuse.

How soon after the surgery can I start physical therapy?

Patients are not required to start their physical therapy till two weeks after the surgery. After two weeks of surgery, physician reexamination will help in deciding if the patient requires physical therapy or not. Many of the patients do not require physical therapy after the surgery.

Does smoking cause spine problems?

Smoking has proven to cause spine problems, including neck and lower back. At the same time, smoking is detrimental for patients who requireĀ spine surgery, especially fusion surgeries. It has been shown that smoking delays spine fusion, as well as lead to higher incidence of nonunion and possible need for revision surgeries.

Do I have to give up smoking?

For patients undergoing fusion surgery, it is highly desirable that they quit smoking. Smoking is detrimental for bone healing and hence the fusion. Smokers are at a higher risk of nonunion, that means non healing of the fusion mass, and these patients may need revision surgery. If the patient is not able to quit smoking, it is at least highly desirable for them to quit for three months. Use of the nicotine patch in place of smoking has the same detrimental effect as smoking itself.

What if, during my surgery, you encounter a different issue other than expected?

Usually, before the surgery, we discuss with the patient regarding all the possible spine issues that we may expect and how to manage them. If there is an unexpected issue, which has not been discussed earlier, we would go ahead and discuss it with the patientā€™s relative and treat it accordingly from there. If there is something which can wait, and is not detrimental to the patient, and relatives are not able to make decision on it, we may leave it for a later date to be discussed with the patient after the surgery.

How long is it possible to stay for back surgery?

Most of the patients with back surgery can be discharged within one to four days after the surgery depending on the type of surgery and the type of recovery that they have. Patients who undergo complex spine surgeries may need longer period of hospitalization and recovery.

Which pain medications will I be sent home with? What are the possible side-effects of these prescriptions?

Most of the patients with cervical spine surgery, will be sent with some narcotic pain medication to take care of their pain. These medications do have their multiple side-effects, which may be constipation, nausea, vomiting, impaired judgement, drowsiness, headache. Though patients who are treated with narcotic pain medication for acute pain, mostly do not lead to addiction, but these medications do have addiction potential.

Will you know before the surgery if I need a brace afterwards? If so, will I be fitted for one before the surgery?

Most of the patients with spine surgery do not need a brace. If we expect that the patient will need a brace, we will get the patient pre-fitted with a brace so that it is available immediately after the surgery. Occasionally the need for brace may be decided at the time of surgery. In such cases a brace is arranged in immediate post-operative period.

Will I need any other medical equipment like a walker when I go home? Should I get an adjusted bed or sleep downstairs?

Patient may need other medical equipment like walker or a stick. If that is required, patients are provided with such equipment in the hospital before their discharge and are trained how to use them by the physical therapist and occupational therapist. If the patient needs to use stairs, patients are trained by the physical therapist before they are let go home. If the patient needs an adjustable bed, they are informed about that. That can be done prior to the surgery. It is desirable for patients to stay downstairs for a few weeks if possible.

Who can I call if I have questions after the surgery?

In case patient has routine questions regarding after the surgery or regarding the surgery, they can call the physicianā€™s office and talk to the nurse or secretary or the physician. If theyā€™re not available on the phone, they can leave a voice mail and they will be answered later. In case the patient has a medical emergency, then they should not call the physician office but rather call 911 or get to the hospital ER as soon as possible.

How often will I see you after my surgery?

Patients are usually followed at two weeks, six weeks, three months, six months, and a year after surgery.

What symptoms would warrant a call to your office after the surgery?

If the patient develops problems like chest pain, breathing problems, sudden neurological deterioration, or any other emergency they should call 911, or go to the emergency room directly. Patients who develop worsening pain at the surgery site, discharge from the wound, fever; they should call in the office.

How long should I wait to bathe after the surgery?

Patients are usually asked to avoid bathing, until the incision heals, which may take two to three weeks. Patient can take shower after 72 hours of surgery with an impervious dressing in place. The dressing can be changes if the wound is visibly soaked. Patients are asked not to rub the area of surgery for about two to three weeks. They can gently dab it dry with a towel.

How long will I be out of work?

Patients with low demand work and desk job, can be back to work as soon as three to six weeks after the surgery depending on patient pain control as well as recovery. Patients who are in heavy lifting or control of heavy machinery or handyman job, may take three to four months, or even more to get back to work depending on their recovery from the surgery.

How soon after the surgery can I start physical therapy?

Patients after back surgery are usually started on physical therapy, if they need, depending on physicianā€™s advice, at two to four weeks after the surgery. Many of the patients do not need physical therapy. A decision to go into physical therapy will depend on the surgery as well their recovery.

What if I get an infection?

If the patient has a superficial infection, few days of antibiotics will help heal these infections. Occasionally patient may develop deep infection. In these patients may need IV antibiotics for a longer period. If despite all efforts or in patients with rapid deterioration due to infection, surgery may be needed to help clean off the infection.

How common is surgery?

Most of the patients do not need surgery and can be treated with conservative means. When the patients do not respond to conservative measures, or if they have worsening neurological deficit, or worse pain, they may need surgery.

Will I have irreversible damage if I delay surgery?

Patients who develop neurological deficit in the form of weakness or involvement of bowel or bladder may have irreversible damage if the surgery is delayed enough.

When do I need fusion?

When patient has back pain or has a surgery in which enough bone is removed to destabilize the spine, in these cases patient may need a fusion surgery to stabilize the spine, as well as to alleviate the symptoms.

What are my risks of low back surgery?

General surgical risks of low back surgeries include bleeding, infection, persistence of pain, reversible/irreversible nerve damage leading to tingling, numbness, or weakness down the legs or involvement of bowel or bladder, failure of resolution of symptoms, failure of fusion, failure of implants. Most of the patients can undergo a safe surgery due to the development of vision magnification as well as refined surgical techniques. There are anesthesia risks also associated with this surgery.

When will I be back to my normal activities?

Though these things depend on the type of surgery patient has undergone, patient can usually be progressively back to their normal activities, starting from three to five days from surgery. Patients are encouraged to take care of their activities of daily living, as well as light household activities. Patients can get back to driving once they are free from pain medication and are able to sit for a duration of period for driving, which may take upto 2-3 weeks or more.

What type of surgery is recommended?

The type of surgery depends on the presenting complaint, examination findings, as well as imaging findings in the form of x-ray and MRI. Some patients may need to undergo just discectomy, or laminectomy, while others may need a fusion surgery on their back to relieve their symptoms. To know more about the type of surgery, the patient needs to discuss this with their spine surgeons.

How long will the surgery take?

Spine surgeries like discectomy and laminectomy usually last about one to one and a half hours. Spine fusion surgeries, may take longer periods, up to two and a half to four hours or more. It depends on type of surgery, and as well as the level of spine to be operated upon.

What is degenerative disc disease?

Degeneration means gradual damage of the tissue. Degenerative disc disease represents aging of the disc, either appropriate to the normal age of the patient, or maybe accelerated due to injury or chronic disease, or other factors like smoking, obesity.

What is Lumbar instability?

Lumbar instability means that the spine is not stable and there is excessive abnormal movement between two vertebrae. This is usually diagnosed by imaging in the form of X-rays, CT scan, or MRI of the patients. Instability may lead to compression of nerve roots causing radiculopathy with or without back pain.

What is Spinal Stenosis?

Spinal Stenosis means narrowing of the spinal canal. It is can be at the cervical or thoracic or lumbar level. Most common spinal stenosis is at lumbar level and it, when narrowed, can compress nerves, causing pain going down the legs, with or without tingling, numbness, weakness, or involvement of bowel or bladder.

What is Sciatica?

Sciatica is another name for lumbar radiculopathy, in which patient has pain going down their legs. The pattern of pain depends on the nerve root involved, but the most common is pain going down the outer side of the thigh and leg into the foot.

What is lumbar disc disease? How is this problem diagnosed?

The diagnosis of Lumbar disc disease is made by history and examination of the patient. The confirmation of diagnosis is done by imaging in the form of X-rays and MRI. Occasionally the patient is having contraindication to MRI, patient may need to undergo a CT scan. When a CT scan is done, occasionally the patient may need to get injected with a dye before the CT scan and this is called CT myelography. Occasionally patient may need a CT scan along with MRI also.

When should I consider surgery for the back pain?

Most of the patients get treated with conservative means. In case the patient is not getting relief despite continuous conservative measures, or if there is worsening of pain associated with or without weakness or involvement of bowel or bladder, the patient may need surgical intervention in the form of surgery.

Am I a candidate for minimal-invasive spine surgery?

Some patients are good candidates for minimally-invasive spine surgery and they can get better with that. History, physical examination, as well as special investigations like X-ray and MRI, are needed in order to discuss regarding options of minimal invasive spine surgery. Some patients are not good candidates for minimal invasive spine surgery and doing such a surgery in such patients may lead to non-resolved solution of the symptoms or worsening.

Are there any warning symptoms?

Warning symptoms of lumbar disc disease include worsening pain, tingling and numbness, development of weakness, or worsening of weakness, involvement of bowel or bladder in the form of incontinence of urine or stools, presence of fever, unintentional weight loss. In such conditions patients should immediately seek medical attention.

Do you need any tests?

General blood workup is needed in most patients before the surgery. This will include blood counts as well as metabolic profile. Special tests may be needed in some patients if the physician has suspicion of some other disease. Most of the patients will have to undergo X-ray and MRI, or a CT scan before the surgery to confirm their diagnosis.

What are the possible surgical complications from a low back surgery?

Common complications of a low back spine surgery are bleeding, infection, leak of cerebral spinal fluid temporary or permanent neurological deficits, blindness, worsening of pain, failure of fusion, failure of implants. There may be risks due to the anesthesia also.

What is spine stabilization?

Spine stabilization involves insertion of screws, rods, or plate to stabilize a spine. This surgery may be associated with fusion of the spine to be it a long-term solution to the instability of the spine.

Dr Vedant Vaksha

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.