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Indications

Background Revision lumbar spine surgery is predominantly associated with several distinct pathological processes resulting from an initial index surgery. For example, in the treatment of disc herniations, residual stenosis and recurrent disc herniations are well described in the literature. There is an estimated 5% to 25% chance of a recurrent disc herniation at the same level following discectomy. In addition, approximately 30% of patients undergoing primary…

Medical Fitness Evaluation

Introduction One major issue when considering reconstructive spinal surgery is medical fitness for surgery. This is defined as an individual’s ability to sustain the physiological stress of surgery and recovery. Medical fitness is related to the overall wellness of the patient and accumulated comorbidities. Although some assessment of medical fitness can be done during initial evaluations for spine care, work-flow and staffing issues may make a…

The Role of Osteoporosis and Bone Diseases in Revision Spine Surgery

Introduction Poor bone health can lead to failure of the primary spinal procedure and precipitate the need for a revision spine surgery. Postoperative complications related to poor bone health include failure of fixation, fracture, kyphosis, implant subsidence, pseudarthrosis, and worsening sagittal and/or coronal deformity. Elderly patients and those with comorbidities are at an increased risk of having poor bone health. Thus the risk of failure following…

Anatomy and Physiology/Biology of Bone

Anatomy Lumbar Spine Make-Up The typical vertebral column is composed of 33 vertebrae. The lumbar spine usually has five mobile lumbar vertebrae, denoted as L1–L5. As a group, the lumbar vertebrae create a lordotic curve. The vertebral bodies increase in size as the spinal column descends, because of the increasing demands of load bearing. The lumbar vertebrae have distinct features that make them discernible from the…

Use of a Physical Education and Nutrition Program to Improve Outcomes

Introduction Placing the needs of the patient above one's own needs has long been the call of duty badge worn by the physician. Indeed, emergent patient care needs trump immediate personal needs such as sleep, fatigue, hunger, and family commitments. However, personal health and well-being are paramount to leading long and productive careers. Balancing the demands of a busy medical career with personal wellness is a…

Use of Risk Model for Assessment of Resident Perception of Surgical Complexity and Evaluation of Procedural Competence

Introduction Value in health care is equal to the quotient of quality over payment. In this context, quality includes outcomes, safety, and patient experiences while payment is the cost to all who pay for health care. Value in healthcare is not an abstract ideal; it is objective and comparable across countries. Improved value can come from decreased cost of care, increased quality of care, or preferably…

Creating National Practice Standards Through Collaboration

Protocols and Guidelines As technology advances, the practice of medicine has been rapidly transforming from anecdotal, traditional techniques, and experience to sophisticated data-driven, evidence-based protocols. Significant variability exists in the practice of medicine, including neurosurgery where diseases with relatively low prevalence limit the size and ability to create controlled trials. Variability in practice can generate hypotheses about methods for improved care, but when the results of…

Quality of Care and Outcomes in Pediatric Neurosurgery: Incorporating Evidence-Based Practice

Introduction Since its origin, neurosurgery, as a field, has relied on expert opinion. After all, its development and advancement have been intertwined with names such as Harvey Cushing. In pediatric neurosurgery, there are relatively low disease incidences compared to conditions such as heart disease or prostate cancer. Neurosurgical care is generally expensive, and focused around academic or tertiary centers rather than widespread throughout communities. Culturally, neurosurgery…

Improving Outcomes With Subspecialization and Regionalization

Introduction The provision of high-quality, safe, affordable neurosurgical care is a goal sought after by the surgeon, patient, hospital, and insurers. Evaluation of hospital and individual neurosurgical performance has become more elaborate due to increased costs, rising patient expectations, demands for greater transparency and concerns over quality, efficiency, and safety. In neurosurgery, it is known that procedures and techniques involve learning curves with improvement as experience…

Improving Performance by Improving Education

Introduction A strategy for improving neurosurgical performance by improving education may comprise a broad spectrum of tactics. From a traditional educational standpoint, it can refer simply to improving the knowledge base of medical students, residents, and fellows. With regard to practicing physicians, it can involve refining workflow using quality improvement (QI)-specific education. Additionally, the identification of alarming suicide rates, burnout, and mental wellness gaps among doctors…

Improving Outcomes: Big Data and Predictive Analytics

Introduction Computational Neurosurgery Outcomes Center Dr. Timothy R. Smith and Dr. William B. Gormley founded Computational Neurosurgery Outcomes Center (CNOC) at Brigham and Women's Hospital and Harvard Medical School in 2015. The purpose of this center is to centralize disparate administrative, clinical, and financial data sources and detailed outcomes tracking and reporting in order to both internally increase quality improvement guidelines for high-value care delivery at…

Reducing Readmissions

Introduction Health care spending is a significant area of concern as the national health spending is projected to grow at an average rate of 5.6% each year from 2016 to 2025. In 2015, the National health expenditure accounted for 17.8% of the gross domestic product (GDP) and it is projected to grow 1.2 percentage points faster than the GDP over the next 10 years. In an…

Quality Efforts for Reducing Mortality in Neurosurgery

Introduction With recent changes in health care policy, patient health metrics and mortality rates are increasingly recognized as proxies for quality of care and determinants of hospital reimbursements. As a result, both medical and surgical specialties have begun to place increasing emphasis on mortality reduction through implementation of quality improvement initiatives. Quality improvement initiatives are especially warranted on neurosurgical services due to high baseline mortality rates…

Improving Efficiency and Mapping Surgical Procedures Using Lean Methods

Introduction The national health expenditure (NHE) is growing as a proportion of the United States gross domestic product (GDP). In 2015, NHE represented 17.8% of GDP and is expected to grow to 19.9% by 2025. In 2008, the Institute for Healthcare Improvement (IHI) proposed the Triple Aim, which is a directive to improve population health, improve patient experience of care, and reduce per capita cost of…

Using Multicenter Clinical Registries to Improve Outcomes

Introduction In the past few decades, a growing number of clinical registries have been set up across specialties for various purposes. Owing to their ability to cover a large number of patients and provide real-world data, they have been increasingly employed for outcome improvement projects. The Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network is a collection of research centers created by the Agency for…

Improving Operating Room Safety

Introduction Modern neurosurgical care is a complex, multidisciplinary enterprise, involving a broad consortium of providers and occurring in diverse settings, from preoperative clinics to postoperative rehabilitation facilities. Even so, the operating room (OR) remains the core of neurosurgery. Events in the OR have a profound impact on the patient's outcome and life thereafter. While modern neurosurgery is remarkably safe and effective, errors in the OR remain…

The Physician Handoff and Its Role in Quality and Safety

Introduction The clear, accurate, and effective exchange of clinical information has always played a central role in the delivery of health care. It remains one of the most critical events that allows for health care providers to be effective at managing patients and their conditions. There are multiple examples of the central aspect of interprovider communication in daily care delivery in the hospital setting. Delivering quality…

Evidence-Based Practice of Neurosurgery: Implications for Quality and Safety

The deepest sin against the human mind is to believe things without evidence. Thomas Huxley, English Biologist (1825–95) Introduction The fundamental assumption of evidence-based practice is that basing decisions in practice on best available evidence will maximize the likelihood of correct diagnosis, effective treatment, and minimal complications. Therefore, evidence-based practice should result in high quality, safe neurosurgical practice. It is therefore sensible to review the evidence-based…

Teams, Competence, and Safety in Surgery

Surgery and health care, in general, depends on quality teamwork. Highly functioning teams are not born but are built. In high-functioning and effective teams, members have a shared understanding of purpose, the system(s) in which they are to function, and the cultural norms that define acceptable behavior. The accomplishments of a team exceed the accomplishments of its members. A team learns and exhibits collective competence. The…