Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature

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  • 1 Departments of Orthopedic Surgery and
  • 2 Neurosurgery, Stanford University Hospitals and Clinics, Stanford, California;
  • 3 Department of Neurosurgery, University Hospital Zurich; and
  • 4 Clinical Neuroscience Center, University of Zurich, Switzerland
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OBJECTIVE

Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD.

METHODS

The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed.

RESULTS

The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors’ literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported.

CONCLUSIONS

Establishing a dual-attending care management platform for ASD correction was feasible at the authors’ institution. Results of the use of a dual-attending strategy at the authors’ institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

ABBREVIATIONS AIS = adolescent idiopathic scoliosis; ALIF = anterior lumbar interbody fusion; ASA = American Association of Anesthesiologists; ASD = adult spinal deformity; DRG = Diagnosis Related Group; EBL = estimated blood loss; ER = emergency room; LLIF = lateral lumbar interbody fusion; LOS = length of stay; ODI = Oswestry Disability Index; PHQ-2 = Patient Health Questionnaire-2; PRBCs = packed red blood cells; PROM = patient-reported outcome measure; SNF = skilled nursing facility; SRS = Scoliosis Research Society; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

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Contributor Notes

Correspondence Martin N. Stienen: Stanford University, Stanford, CA. mnstienen@gmail.com.

ACCOMPANYING EDITORIAL DOI: 10.3171/2020.4.SPINE20465.

INCLUDE WHEN CITING Published online July 10, 2020; DOI: 10.3171/2020.3.SPINE2016.

I.C. and M.N.S. contributed equally to this work and share first authorship.

Disclosures Dr. Cheng reports receiving royalties from NuVasive, Globus Medical, SpineCraft, and Spine Wave and having direct stock ownership in Cytonics, Spine Innovations, SpinalCyte, and Notogen. Dr. Veeravagu reports being a consultant for NuVasive, Medtronic, and Surgical Theater.

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