21 - If You Could Treat the Same Patient Again, Would You Do it Differently? A Multi-Surgeon Survey of Their Own Revisions

Friday, June 2, 2023

10:30 AM – 10:34 AM

Location: Salons 13-15

Co-Author(s)

FS

Frank Schwab, MD

Lenox Hill Hospital, Northwell Health
New York, New York, United States

Presenting Author (Person doing the Podium Present(s)

Virginie Lafage, PhD

AVP, Clinical Research
Lenox Hill | Northwell
Hospital for Special Surgery
New York, New York, United States

Co-Author(s)

AM

Ayman Mohamed, MD

Clinical Research Fellow
Lenox Hill hospital, New York, United States
JS

Justin Smith, MD, PhD

University of Virginia
Charlottesville, Virginia, United States
DO

David O. Okonkwo, M.D., Ph.D.

University of Pittsburgh Medical Center, United States
Robert K. Eastlack, M.D.

Partner, Spine Section, Division of Orthopaedic Surgery
Scripps Clinic
La Jolla, California, United States
HK

Han Jo Kim, MD

Surgeon
Hospital for Special Surgery
New York, New York, United States
EK

Eric Klineberg, MD

Professor/ Vice Chair Dept or Orthopaedic Surgery
University of CA, Davis
Sacramento, California, United States
AS

Andrew Sawires

Lenox Hill Hospital, Northwell Health, United States
DH

D Kojo Hamilton, MD

Associate Professor
University of Pittsburgh
Pittsburgh, Pennsylvania, United States
SB

Shay Bess, M.D.

Spine surgeon
Denver International Spine Center
castle rock, Colorado, United States
RL

Renaud Lafage, MS

Senior Biomedical engineer
Lenox Hill Hospital
new york, New York, United States
DB

Douglas Burton, MD

Department Chair, Orthopedic Surgery and Sports Medicine
University of Kansas Medical Center
Kansas City, Kansas, United States
II

International Spine Study Group Foundation ISSGF

na
ISSGF
Brighton, Colorado, United States

Submitter(s)

Virginie Lafage, PhD

AVP, Clinical Research
Lenox Hill | Northwell
Hospital for Special Surgery
New York, New York, United States

Disclosure(s):

Robert K. Eastlack, M.D.: No relevant disclosure to display

Introduction:
Despite improvements in Adult spinal deformity (ASD) surgery techniques, revision rates due to complications remain high. A case-based survey of what spine surgeons learned from their own revisions, and what they would have done differently may provide insight to reduce revision spine surgeries.

AIMS/

Objectives:
To investigate Surgeons’ reflections on their revisions.

Methods:
A multi-center database of ASD surgical patients was queried to identify patients with at least 2 surgical procedures by the same surgeon. Patient’s clinical vignettes were created including demographics, timeline of events, radiographs/measurements, PROMS, detailed complications, and surgical strategy for the index and revision surgeries. For each case, the operating surgeon was asked to fill out the following 5-question survey: Q1: Based on what you know today, would you do the exact same surgery? Q2: Why was a revision procedure required? Q3: What do you think is the underlying cause that led to a requirement for revision surgery? Q4: Are there particular circumstances or patient factors that played a role in requiring a revision procedure? Q5: What did you learn from this case that others should be aware of (for example related to patient, strategy, or operative execution)?

Results:
86/437 patients operated by the 6 participating surgeons were revised. The revised patients had similar follow-up than the non-revised (p=0.73). The most common indications for revision surgery were PJK (42% of the revised patients) and pseudoarthrosis (28%). Overall, surgeons reported that they would do the exact same surgery today in 52.3% of the cases. This ranged from 31.6% to 84.6% among different surgeons, and from 37.5% for pseudarthrosis cases to 100% for infection cases. The most common underlying causes associated with revision surgery were hardware/mechanical issues (24.4%), degenerative or progressive changes (20%), and biologics (17.4%). When asked about particular circumstances or patient factors playing a role in this need for revision surgery, “none” was the most common answer (40.7%), followed by bone quality (18.6%), alignment (15.1%), comorbidities (14%), technical decision (14%). The most common learning points were rod-related choice (23.3%), level selection (19.8), PJK prophylactic strategy (15.1%), and sagittal alignment objective (11.6%).

Conclusions:
PJK and pseudoarthrosis remain the leading cause of revision surgery. In this survey, 50% of the cases would have received a different treatment today by the same operating surgeon. Despite the large variability in their retrospective opinions about their own revisions, the surgeons' most common evolving strategies were rod-related techniques, upper and lower instrumented vertebrae, PJK prophylactic strategy, and better understanding of sagittal alignment objectives. While 40% of the failures remained unexplained from the surgeons’ perspective, this study highlights the evolving aspect of ASD surgical treatment over recent years.