For Safety in Spine Surgery, Doctors Weigh Risks and Benefits

Jun. 7, 2018

spine surgery safety

For the third year running, it was a sold-out event.

The 2018 Spine Surgery Safety Summit was held in the Heart Conference Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital early this spring. For one day, the center thronged with spine surgeons, neuro nurses, OR directors, hospital executives and more. They were there from all corners of the country to delve into the risks and rewards of spine surgery.

Our own Dr. Paul McCormick, Director of The Spine Hospital at the Neurological Institute of New York, co-chaired the event. “Patient safety is something we should be relentless about improving,” says McCormick, “The field of spine care is increasingly complex—today, there are so many opportunities to make sophisticated decisions that optimize patient safety.”  These range from evaluating the latest technologies and research data to the fundamentals of working as part of a safety-focused health care team.

Three of our neurosurgeons served as faculty for the Spine Surgery Safety Summit. Dr. McCormick presented on Recombinant Human Bone Morphogenic Protein-2 (rhBMP-2), a sometimes-controversial substance used after certain spine surgeries to promote bone growth. Neurosurgeon Dr. Peter Angevine spoke about protecting against dangerous blood clots after surgery and the human consequences of a spine team’s decisions. And pediatric neurosurgeon Dr. Richard Anderson presented on the use of high-tech navigation in spine surgery.

A theme in all these presentations was the balance of risk and benefit for individual patients. And that makes sense. If the presentations had said, for example, “Never use rhBMP-2!” or “Always use every available method to prevent blood clots!” or “Always use high-tech navigation in spine surgery!”… well, the presentations would have been very short, and patient safety would not necessarily be improved.  

All these interventions have side effects and risks of their own. rhBMP-2, for example, helps bones fuse (knit together), which is the goal after many types of spine surgery. A good, strong fusion will last indefinitely, and a poor fusion may require a patient to have another operation down the line. But rhBMP-2 also carries risks of side effects, including swelling or bone growth where it’s not wanted. The risk of poor fusion must be balanced against the risk of using rhBMP-2.

Dr. McCormick’s presentation helped surgeons understand the ample data about the use of rhBMP-2 in different parts of the spine, at different doses, for different types of surgeries, in different age patients, with different additional medical conditions—all factors that affect a surgeon’s decision about what will be safest for any given individual patient.

Similarly, Dr. Angevine’s presentation examined the risks and benefits of something that might at first seem straightforward: preventing blood clots after spine surgery. Blood clots are a potentially serious complication, and they happen after roughly 1 percent of all spine surgeries. So doctors should always do everything possible to prevent them, right?

Well, it’s not quite that simple. That 1 percent is an average taken from a huge group of surgery patients. Not every individual patient has an equal 1 percent risk. Some patients are at greater risk—way higher than 1 percent. Some patients have a lower risk—way lower than 1 percent. For patients at low risk of blood clots, the risk of a side effect from a medication may outweigh any potential benefit of that medication. No-risk options like automatic inflating leg wraps to improve blood flow may be the best choice for these patients initially. Then they can get out of bed and move around. Exercise and walking after surgery are known to help protect against blood clots. For patients at high risk of blood clots, on the other hand, it may make sense to use medication as well.

Dr. Anderson’s presentation focused on the risks and benefits of using high-tech navigation systems (such as 3-D models, intraoperative scanning and surgical robots) in spine surgery. He explained that in cranial surgery, high-tech navigation is used in more than 90 percent of cases. In spine surgery, however, the prevalence is much lower. Research shows that spinal screw placement is more accurate when surgeons who are experienced with high-tech navigation systems use those systems.

Not all patients can benefit from the use of high-tech navigation, however. The system requires the patient to have at least one CT scan, ruling this method out for those patients who aren’t able to undergo that particular test.. The navigation system is also highly sensitive to patient movement and won’t work for patients prone to involuntary movements.  When deciding whether to use high-tech navigation systems, the surgeon also needs to consider their high cost and the fact that they come with some radiation exposure.

In the end, Dr. Anderson has a suggestion for doctors working in facilities where such equipment is feasible: If part of the surgeon’s normal practice is to administer a CT scan after surgery to check screw placement, it may make sense to just go ahead and use the navigation system during surgery. The patient will get a CT scan anyway, and surgeons will know during the operation—not afterward—exactly how the screws are placed.

The full day of Safety in Spine Surgery ended with many insightful questions and nuanced discussions among the participants. The result was a greater understanding of the techniques and tools available to spine surgeons and the confidence to pass that on through better patient care.  Since patient safety is something our doctors will never stop caring about, the planning begins for the 2019 Spine Surgery Safety Summit.

Read more about Dr. McCormick on his bio page here.

Read more about Dr. Angevine on his bio page here.

Read more about Dr. Anderson on his bio page here.

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