Jonathan J. Rasouli
Jeremy Steinberger- 1Neurosurgery, Northwell Health, New York, NY, United States
- 2Department of Neurosurgery and Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- 3Director, Minimally Invasive Spine Surgery, Department of Neurosurgery, Mount Sinai Health Systems, New York, NY, United States
Editorial on the Research Topic
Optimization of spine surgery outcomes in the pre-, peri-, and postoperative settings
Patient optimization is one of the strongest predictive indicators to improve outcomes and mitigate complications after spinal surgery. While we have collectively known that optimizing a patient's cardiopulmonary and metabolic status are essential prior to any surgical procedure, it has been challenging to develop a set of clinical decision rules to help guide spine patients. Hence, the development of enhanced recovery after surgery (ERAS) protocols to standardize optimization across surgeons and healthcare systems (1).
The importance of pre-operative optimization was recently highlighted by Maitra et al. who demonstrated patients who medically optimized prior to spine surgery demonstrate improvements in satisfaction scores, decreased complications, and decreased length of stay (2). The results of this study were further supported with several reviews demonstrating reduction in the risk of surgical site infection with the implementation of pre-operative optimization protcols (3, 4). Patient-specific modifiable risk-factors that are potential areas for focused intervention include strict blood glucose control, weight loss, smoking cessation, optimization of bone quality in patients with osteoporosis, opioid weaning, and optimizing mental health disorders (5). Identifying and treating these pre-operative co-morbidities can directly improve outcomes after spinal surgery.
Interventions aimed at enhancing intra- and post-operative optimization are essential, as well. For example, the use of intravenous tranexamic acid to mitigate blood loss, patient positioning to reduce intra-orbital pressure while prone, the use of intraoperative cell salvage, and blood pressure control when operating on or near the spinal cord have been shown to improve outcomes after spinal surgery (6–8). While intra-operative optimization is generally heterogenous and can significantly vary among surgeons, post-operative protocols such as early ambulation, physical therapy, blood glucose monitoring, and reduced opioid use have been shown to clearly correlate with improved outcomes in patients undergoing lumbar fusion surgery (9). Of note, these protocols guiding pre-, intra-, and post-operative optimization are interconnected and focusing on all phases of the surgical process is critical to optimize outcomes.
Clinicians should make every effort to “optimize” our patients before, during, and after spinal surgery. While more prospective and larger population studies are required, there is a strong consensus that optimization is as important as patient selection, decision-making, and surgical technique in guiding post-operative outcomes (10).
Author contributions
JS and JR conceived of the presented idea and wrote and edited the manuscript together. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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References
1. Smith J, Probst S, Calandra C, Davis R, Sugimoto K, Nie L, et al. Enhanced recovery after surgery (ERAS) program for lumbar spine fusion. Perioper Med. (2019) 8:4. doi: 10.1186/s13741-019-0114-2
2. Maitra S, Mikhail C, Cho SK, Daubs MD. Preoperative maximization to reduce complications in spinal surgery. Global Spine J. (2020) 10(1 Suppl):45S–52S. doi: 10.1177/2192568219882349
3. Epstein NE. Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery. Surg Neurol Int. (2018) 9:251. doi: 10.4103/sni.sni_372_18
4. Ugiliweneza B, Kong M, Nosova K, Ugiliweneza B, Kong M, Nosova K, et al. Spinal surgery: variations in health care costs and implications for episode-based bundled payments. Spine. (2014) 39:1235–42. doi: 10.1097/BRS.0000000000000378
5. Rasouli JJ, Martini MM, Neifert BS, Krishnaney A. Patient selection for spine surgery—preoperative optimization. In: Benzel’s spine surgery, 5th ed. Chapter 67. New York: Elsevier - Health Sciences Division (2022). p. 612–9.
6. Yoo JS, Ahn J, Karmarkar SS, Lamoutte EH, Singh K. The use of tranexamic acid in spine surgery. Ann Transl Med. (2019) 7(Suppl 5):S172.31624738
7. Carroll C, Young F. Intraoperative cell salvage. BJA Educ. (2021) 21(3):95–101. doi: 10.1016/j.bjae.2020.11.007
8. Torres-Espín A, Haefeli J, Ehsanian R, Torres D, Almeida CA, Huie JR, et al. Topological network analysis of patient similarity for precision management of acute blood pressure in spinal cord injury. eLife. (2021) 10:e68015. doi: 10.7554/eLife.68015
9. Huang J, Shi Z, Duan FF, Fan MX, Yan S, Wei Y, et al. Benefits of early ambulation in elderly patients undergoing lumbar decompression and fusion surgery: a prospective Cohort study. Orthop Surg. (2021) 13(4):1319–26. doi: 10.1111/os.12953
Keywords: optimization, spine, outcomes, ambulation, physical therapy
Citation: Rasouli JJ and Steinberger J (2023) Editorial: Optimization of spine surgery outcomes in the pre-, peri-, and postoperative settings. Front. Surg. 10:1235095. doi: 10.3389/fsurg.2023.1235095
Received: 5 June 2023; Accepted: 29 June 2023;
Published: 21 August 2023.
Edited and Reviewed by: Ji Tu, University of New South Wales, Australia
© 2023 Rasouli and Steinberger. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jonathan J. Rasouli jonathanrmd@gmail.com Jeremy Steinberger jeremysteinberger@gmail.com