Surgical Planning Techniques for Better Outcomes

Measure twice, cut once: It's not just for carpenters.

It may be incumbent on some spine surgeons to advocate for access to the latest tools. However, physicians don’t necessarily need cutting edge technologies to ensure the best possible outcomes from surgical interventions.

Recently, spine surgeon Ehsan Jazini, MD, shared a presentation about robotics in spine surgery at the Virtual Global Spine Conference. Dr. Jazini, a physician at the Virginia Spine Institute and Editor-in-Chief at the National Spine Health Foundation, has significant experience using Mazor Robotics products, including the company’s preoperative analytics software.

Other robotic surgery software offers similar advantages for preoperative planning, including screw placement, screw cadence, rod size selection, and more.

With or without such sophisticated tools, there are a number of surgical planning strategies that can improve outcomes. Dr. Jazini, who received his fellowship training at the renowned Norton Leatherman Spine Center in Louisville, KY, recently spoke with SpineUniverse about some of these surgical planning techniques.

Advanced Imaging

X-rays are often the only imaging option available for surgical planning as well as post-surgical analysis. There is often some degree of judgement call of, for example, the precise angle to place a screw. Being off by a few degrees might not be a problem. Being off by more than that could require a revision surgery or permanent nerve injury.

The more information surgeons have, the better patient outcomes may be. For this reason, doctors should actively seek out, wherever possible, advanced imaging such as CT scans in the operating room. With detailed imaging of the full range of spinal concerns, including secondary and also minor issues, physicians can better prepare for a broader range of potential needs and challenges in the OR.

Robotic-assisted surgery goes one step further, enabling physicians to watch in real time whether a screw being placed is going into the bone at the precise location and angle intended.

Robotic-assisted surgery can show in real time if hardware is being placed correctly.

Treat Fusions as Realignments

Dr. Jazini suggests thinking of all spinal fusion surgeries as deformity or realignment surgeries. Fusing bones without correcting alignment one or two levels up could set up a patient for surgical failure down the line, placing more stress at the levels above the fusion and potentially resulting in flatback syndrome, a type of sagittal imbalance in which the lower spine loses normal curvature.

Ideally, physicians will be able to obtain full 36-inch standing films to evaluate patients. Typically used for spinal deformity surgery, the films enable physicians to identify and manage sagittal imbalance – but at a more general level they provide the global rather than focal or regional view to plan for degree of alignment correction at each of the levels.  

Adopt ERAS to Limit Opioid Use

Dr. Jazini is a longtime proponent of ERAS, or enhanced recovery after surgery, protocols which have been spearheaded for the field of spine surgery at Virginia Spine Institute. The multimodal approach promotes early recovery after surgical procedures in part by optimizing presurgical health.

Research Dr. Jazini coauthored, published in The Spine Journal, found that decreasing presurgical opioid use led to less in-hospital opioid consumption after surgery. Other research co-authored by Dr. Jazini found that adopting ERAS protocols in adult spinal surgery decreased in-hospital as well as 90-day postoperative opioid consumption.

For more information on ERAS, visit https://erassociety.org. 

Pre-surgery Health Assessments

There probably isn’t a surgeon who doesn’t take risk factors such as smoking, heart disease, and diabetes into consideration before scheduling surgery. Dr. Jazini recommends adding these other health considerations as well.

• Bone density: Dr. Jazini is among a growing number of doctors emphasizing the importance of testing for and treating low bone mineral density in patients prior to elective spine surgery. Low bone density is associated with less favorable spine surgery outcomes, including screw loosening in lumbar fusion, pseudoarthrosis, and of proximal junctional failure following spinal fusion surgery.

• Vitamin D: There is a high prevalence of low vitamin D levels in patients with musculoskeletal pain, and vitamin D insufficiency is common among patients undergoing spine surgery. In addition, research suggests low vitamin D levels may negatively impact surgical outcomes. Physicians should ensure patients achieve and maintain sufficient serum vitamin D prior to spine surgery, particularly spinal fusion.

• Diagnostic injection. Selective cortisone injections can help pinpoint the level that needs to be addressed in patients who have multilevel pathologies. Furthermore, lumbar discography is not widely used, but it may nevertheless be a useful screening tool for certain surgical candidates. Dr. Jazini and colleagues occasionally use this diagnostic injection to help identify which discs may need to be removed prior to spinal fusion surgery