The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

Restricted access

OBJECTIVE

Posterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.

METHODS

A retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.

RESULTS

A total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.

CONCLUSIONS

Surgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

ABBREVIATIONS ASD = adult spinal deformity; BMP = bone morphogenetic protein; EBL = estimated blood loss; PSO = pedicle subtraction osteotomy; SRS = Scoliosis Research Society; TXA = tranexamic acid; UIV = upper instrumented vertebra; VCR = vertebral column resection; 3CO = 3-column osteotomy.
Article Information

Contributor Notes

Correspondence Darryl Lau: University of California, San Francisco, CA. darryl.lau@ucsf.edu.INCLUDE WHEN CITING Published online October 25, 2019; DOI: 10.3171/2019.7.SPINE19656.Disclosures Dr. Deviren reports being a consultant for the following companies: NuVasive, Biomet, SeaSpine, Medicrea, and Alphatec Spine; he receives institutional fellowship work in spine surgery from AOSpine, Omega, and NuVasive. Dr. Ames reports being an employee of UCSF. He reports being a consultant for DePuy Synthes, Medtronic, Stryker, Medicrea, Biomet Zimmer Spine, and KM2. He receives royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea. He does research for Titan Spine, DePuy Synthes, and ISSG. He is on the editorial board of Operative Neurosurgery. He receives grant funding from the SRS. He is on the executive committee of ISSG. He is the director for Global Spine Analytics.
Headings
References
  • 1

    Acosta FL JrMcClendon J JrO’Shaughnessy BAKoller HNeal CJMeier O: Morbidity and mortality after spinal deformity surgery in patients 75 years and older: complications and predictive factors. J Neurosurg Spine 15:6676742011

    • Search Google Scholar
    • Export Citation
  • 2

    Ahn JIqbal AManning BTLeblang SBohl DDMayo BC: Minimally invasive lumbar decompression—the surgical learning curve. Spine J 16:9099162016

    • Search Google Scholar
    • Export Citation
  • 3

    Auerbach JDLenke LGBridwell KHSehn JKMilby AHBumpass D: Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:119812102012

    • Search Google Scholar
    • Export Citation
  • 4

    Baldus CRBridwell KHLenke LGOkubadejo GO: Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976) 35:2352392010

    • Search Google Scholar
    • Export Citation
  • 5

    Bianco KNorton RSchwab FSmith JSKlineberg EObeid I: Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus 36(5):E182014

    • Search Google Scholar
    • Export Citation
  • 6

    Bourghli ACawley DNovoa FRey MAlzakri ALarrieu D: 102 lumbar pedicle subtraction osteotomies: one surgeon’s learning curve. Eur Spine J 27:6526602018

    • Search Google Scholar
    • Export Citation
  • 7

    Buchowski JMBridwell KHLenke LGKuhns CALehman RA JrKim YJ: Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976) 32:224522522007

    • Search Google Scholar
    • Export Citation
  • 8

    Cahill PJPahys JMAsghar JYaszay BMarks MCBastrom TP: The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis. J Bone Joint Surg Am 96:133313392014

    • Search Google Scholar
    • Export Citation
  • 9

    Cahill PJSamdani AFBrusalis CMBlumberg TAsghar JBastrom TP: Youth and experience: the effect of surgeon experience on outcomes in cerebral palsy scoliosis surgery. Spine Deform 6:54592018

    • Search Google Scholar
    • Export Citation
  • 10

    Choi HYHyun SJKim KJJahng TAKim HJ: Surgical and radiographic outcomes after pedicle subtraction osteotomy according to surgeon’s experience. Spine (Phila Pa 1976) 42:E795E8012017

    • Search Google Scholar
    • Export Citation
  • 11

    Daubs MDLenke LGCheh GStobbs GBridwell KH: Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine (Phila Pa 1976) 32:223822442007

    • Search Google Scholar
    • Export Citation
  • 12

    DeWald CJStanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality. Spine (Phila Pa 1976) 31 (19 Suppl):S144S1512006

    • Search Google Scholar
    • Export Citation
  • 13

    Fehlings MGKato SLenke LGNakashima HNagoshi NShaffrey CI: Incidence and risk factors of postoperative neurologic decline after complex adult spinal deformity surgery: results of the Scoli-RISK-1 study. Spine J 18:173317402018

    • Search Google Scholar
    • Export Citation
  • 14

    Glassman SDBerven SBridwell KHorton WDimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:6826882005

    • Search Google Scholar
    • Export Citation
  • 15

    Hofacer RDDeng MWard CGJoseph BHughes EAJiang C: Cell age-specific vulnerability of neurons to anesthetic toxicity. Ann Neurol 73:6957042013

    • Search Google Scholar
    • Export Citation
  • 16

    Ikonomidou CBosch FMiksa MBittigau PVöckler JDikranian K: Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain. Science 283:70741999

    • Search Google Scholar
    • Export Citation
  • 17

    Kelly MPLenke LGShaffrey CIAmes CPCarreon LYLafage V: Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study. Neurosurg Focus 36(5):E172014

    • Search Google Scholar
    • Export Citation
  • 18

    Kim BDHsu WKDe Oliveira GS JrSaha SKim JY: Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases. Spine (Phila Pa 1976) 39:5105202014

    • Search Google Scholar
    • Export Citation
  • 19

    Kim SSCho BCKim JHLim DJPark JYLee BJ: Complications of posterior vertebral resection for spinal deformity. Asian Spine J 6:2572652012

    • Search Google Scholar
    • Export Citation
  • 20

    Koster ABörgermann JZittermann ALueth JUGillis-Januszewski TSchirmer U: Moderate dosage of tranexamic acid during cardiac surgery with cardiopulmonary bypass and convulsive seizures: incidence and clinical outcome. Br J Anaesth 110:34402013

    • Search Google Scholar
    • Export Citation
  • 21

    Lafage RSchwab FChallier VHenry JKGum JSmith J: Defining spino-pelvic alignment thresholds: should operative goals in adult spinal deformity surgery account for age? Spine (Phila Pa 1976) 41:62682016

    • Search Google Scholar
    • Export Citation
  • 22

    Lafage VSchwab FPatel AHawkinson NFarcy JP: Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:E599E6062009

    • Search Google Scholar
    • Export Citation
  • 23

    Lau DDalle Ore CLReid PSafaee MMDeviren VSmith JS: Utility of neuromonitoring during lumbar pedicle subtraction osteotomy for adult spinal deformity. J Neurosurg Spine 31:3974072019

    • Search Google Scholar
    • Export Citation
  • 24

    Lee BHHyun SJHan SKim KJJahng TAKim YJ: Surgical and radiological outcomes after posterior vertebral column resection according to the surgeon’s experience. Medicine (Baltimore) 97:e116602018

    • Search Google Scholar
    • Export Citation
  • 25

    Lee JCJang HDShin BJ: Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: our experience in 86 consecutive cases. Spine (Phila Pa 1976) 37:154815572012

    • Search Google Scholar
    • Export Citation
  • 26

    Lenke LGFehlings MGShaffrey CICheung KMCarreon LDekutoski MB: Neurologic outcomes of complex adult spinal deformity surgery: results of the prospective, multicenter Scoli-RISK-1 Study. Spine (Phila Pa 1976) 41:2042122016

    • Search Google Scholar
    • Export Citation
  • 27

    Lenke LGNewton POSucato DJShufflebarger HLEmans JBSponseller PD: Complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: a multicenter analysis. Spine (Phila Pa 1976) 38:1191322013

    • Search Google Scholar
    • Export Citation
  • 28

    Lonergan TPlace HTaylor P: Acute complications following adult spinal deformity surgery in patients aged 70 years and older. J Spinal Disord Tech 29:3143172016 2012

    • Search Google Scholar
    • Export Citation
  • 29

    Lunardi NOri CErisir AJevtovic-Todorovic V: General anesthesia causes long-lasting disturbances in the ultrastructural properties of developing synapses in young rats. Neurotox Res 17:1791882010

    • Search Google Scholar
    • Export Citation
  • 30

    Mayo BCMassel DHBohl DDLong WWModi KDSingh K: Anterior cervical discectomy and fusion: the surgical learning curve. Spine (Phila Pa 1976) 41:158015852016

    • Search Google Scholar
    • Export Citation
  • 31

    Nandyala SVFineberg SJPelton MSingh K: Minimally invasive transforaminal lumbar interbody fusion: one surgeon’s learning curve. Spine J 14:146014652014

    • Search Google Scholar
    • Export Citation
  • 32

    Park SMKim HJKim GUChoi MHChang BSLee CK: Learning curve for lumbar decompressive laminectomy in biportal endoscopic spinal surgery using the cumulative summation test for learning curve. World Neurosurg 122:e1007e10132019

    • Search Google Scholar
    • Export Citation
  • 33

    Park SMShen FKim HJKim HChang BSLee CK: How many screws are necessary to be considered an experienced surgeon for freehand placement of thoracolumbar pedicle screws?: analysis using the cumulative summation test for learning curve. World Neurosurg 118:e550e5562018

    • Search Google Scholar
    • Export Citation
  • 34

    Phan KKim JSKim JHSomani SDi’Capua JDowdell JE: Anesthesia duration as an independent risk factor for early postoperative complications in adults undergoing elective ACDF. Global Spine J 7:7277342017

    • Search Google Scholar
    • Export Citation
  • 35

    Qiao JXiao LXu LShi BQian BZhu Z: Comparison of complications and surgical outcomes of adolescent idiopathic scoliosis between junior attending surgeons and senior attending surgeons. World Neurosurg 115:e580e5842018

    • Search Google Scholar
    • Export Citation
  • 36

    Ryu KJSuh SWKim HWLee DHYoon YHwang JH: Quantitative analysis of a spinal surgeon’s learning curve for scoliosis surgery. Bone Joint J 98-B:6796852016

    • Search Google Scholar
    • Export Citation
  • 37

    Scheer JKSmith JSClark AJLafage VKim HJRolston JD: Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. J Neurosurg Spine 22:5405532015

    • Search Google Scholar
    • Export Citation
  • 38

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76 (Suppl 1):S33S412015

    • Search Google Scholar
    • Export Citation
  • 39

    Schwab FJBlondel BBess SHostin RShaffrey CISmith JS: Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976) 38:E803E8122013

    • Search Google Scholar
    • Export Citation
  • 40

    Schwab FJHawkinson NLafage VSmith JSHart RMundis G: Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:260326102012

    • Search Google Scholar
    • Export Citation
  • 41

    Smith JSKlineberg ELafage VShaffrey CISchwab FLafage R: Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:1142016

    • Search Google Scholar
    • Export Citation
  • 42

    Smith JSSansur CADonaldson WF IIIPerra JHMudiyam RChoma TJ: Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 36:9589642011

    • Search Google Scholar
    • Export Citation
  • 43

    Soroceanu ABurton DCOren JHSmith JSHostin RShaffrey CI: Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976) 41:171817232016

    • Search Google Scholar
    • Export Citation
  • 44

    Vutskits LXie Z: Lasting impact of general anaesthesia on the brain: mechanisms and relevance. Nat Rev Neurosci 17:7057172016

  • 45

    Wang MYBerven SH: Lumbar pedicle subtraction osteotomy. Neurosurgery 60 (2 Suppl 1):ONS140ONS1462007

TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 406 406 405
Full Text Views 55 55 55
PDF Downloads 19 19 19
EPUB Downloads 0 0 0
PubMed
Google Scholar