Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

How to start an awake spine program: Protocol and illustrative cases.

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes.

Enhanced recovery after surgery (ERAS) protocol in spine surgery.

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Regional Anesthesia for Spine Surgery.

Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery. Regarding analgesic techniques, several new modalities have been described recently such as erector spinae and thoracolumbar interfascial plane blocks. These regional analgesic modalities are aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. This narrative review focuses on the techniques, indications and contraindications, benefits, and complications of regional anesthesia in the context of spine surgery.

Awake Spinal Fusion.

¼: Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints. ¼: ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia. ¼: The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Regional Anesthesia for Spine Surgery.

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

Awake spinal fusion.

'Awake spinal fusion' is a novel approach to spine surgery that combines modern anaesthetic and surgical technique resulting in improved patient satisfaction and overall outcomes. Along with techniques of regional anaesthesia, minimally invasive or endoscopic surgical techniques are used to minimize surgical dissection and blood loss. Although, it is a relatively new concept with limited supporting evidence till date, it may prove to be highly effective in reducing post-operative hospital stays, in-hospital complications and cost of surgery while at the same time expediting recovery and rehabilitation. The current review focuses on techniques, advantages, limitations and the available evidence on awake spinal fusion.

Subsidizing the Sick: How Community Rating Works.

Insurance premium rates have typically been calculated using a variety of rating algorithms. Passage of the Patient Protection and Affordable Care Act mandated that all individual and small group plans must use the community rating method. This method gives the same insurance rate to all members of a community, with adjustments only being allowed based on age, geography, and tobacco use. This effectively raises rates on low-risk individuals to subsidize high-risk individuals. With President Trump and Congressional Republicans vowing to repeal the Patient Protection and Affordable Care Act, this lesser-known but controversial portion of the law may be abolished. This paper will review the various rating methods used by insurance companies in determining premiums.

Organizational Structural Design in Spine Care.

For a company to provide high value to its customers, its organization design is critical. As health care transitions to a value-based model, it is critical that spinal care organizations are structured in such a way that they can maximize value to both the patient and the payers. This article will discuss the 3 most common ways that an organization can be structured, and the benefits and problems of each design in spinal care.

Value-based Insurance Design.

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.

The Science of Health-Care Delivery.

As the health-care system evolves toward delivering greater value for the patient, orthopaedic surgeons are continually being challenged to manage the health of a population. The traditional focus of scientific inquiry within orthopaedics has been at the individual patient level. The science of health-care delivery is an evolving field that is aimed at bringing rigorous inquiry into determining the proper organizational design that can deliver high-quality and low-cost care for a population. This article provides an overview of basic concepts involved in systems and organizational theory relevant to orthopaedic surgery.

The Role of Incentives in Changing the Behavior of Spinal Care Providers: A Primer on Behavioral Economics in Health Care.

As spinal care transitions from individual practitioners working in a volume-based reimbursement system toward multidisciplinary health care organizations working in a population-based model with value-based reimbursement, it is critical that insurance companies, administrators, and spine care provider have a clear understanding of how incentives change physician behavior. This article will introduce the concept of behavior economics, and discuss 9 principles relevant to physician decision-making.

The Service-Profit Chain in Spine Surgery.

Medicine has always been a service industry (as opposed to a manufacturing industry), as there is a shift from volume to value in health care, this point is becoming increasingly important. The delivery of good care extends beyond the technical aspects of performing a complex operation or prescribing the right type of medicine. Intuitively physicians have always understood the value of the physician-patient relationship, and its correlation to a good outcome. As patients are increasingly being forced to spend a greater portion of their personal income on health care through high-deductible plans and larger co-pays, physicians have to differentiate themselves through the delivery of great service beyond the delivery of superior health outcomes. Understanding the service-profit chain can help physicians succeed in the transition to a value-based health care system.

Understanding Business Models in Health Care.

The increasing focus on the costs of care is forcing health care organizations to critically look at their basic set of processes and activities, to determine what type of value they can deliver. A business model describes the resources, processes, and cost assumptions that an organization makes that will lead to the delivery of a unique value proposition to a customer. As health care organizations are beginning to transform their structure in preparation for a value-based delivery system, understanding business model theory can help in the redesign process.

Understanding Competition in Spine Care.

The changing landscape from volume to value represents a natural transformation in the health care industry. Increasingly provider groups are finding themselves responding to unfamiliar market forces. Whether explicit or implicit, competition is playing a larger role for the sustainability of providers. For spine care providers who are attempting to navigate the transition from volume to value, understanding the forces that shape competition in health care can help achieve success.

Understanding Time-driven Activity-based Costing.

Transitioning to a value-based health care system will require providers to increasingly scrutinize their outcomes and costs. Although there has been a great deal of effort to understand outcomes, cost accounting in health care has been a greater challenge. Currently the cost accounting methods used by hospitals and providers are based off a fee-for-service system. As resources become increasingly scarce and the health care system attempts to understand which services provide the greatest value, it will be critically important to understand the true costs of delivering a service. An understanding of the true costs of a particular service will help providers make smarter decisions on how to allocate and utilize resources as well as determine which activities are nonvalue added. Achieving value will require providers to have a greater focus on accurate outcome data as well as better methods of cost accounting.

Innovation in Health Care Delivery.

As reimbursement transitions from a volume-based to a value-based system, innovation in health care delivery will be needed. The process of innovation begins with framing the problem that needs to be solved along with the strategic vision that has to be achieved. Similar to scientific testing, a hypothesis is generated for a new solution to a problem. Innovation requires conducting a disciplined form of experimentation and then learning from the process. This manuscript will discuss the different types of innovation, and the key steps necessary for successful innovation in the health care field.

Redesigning Health Care Organizations: The Influence of Government Policy and Methods of Payment.

Over the last 5 years, there has been a growing trend toward consolidation in the health care field. As reimbursement moves from a fee-for-service model to a value-based model, there will be continued pressure on physicians to either be a hospital employee or to be in a large multidisciplinary practice. This is largely due to the Accountable Care Act, which directs payers to utilize population-based cost analyses, rather than an individual patient-based analysis. To succeed in this environment, practices will have to break down traditional organizational barriers to create evidence-based algorithms for the treatment of individual diagnoses from the initial onset of symptoms until the resolution of symptoms.