The sub-speciality of spine surgery is rapidly evolving in the last decade, and it encompasses simple lumbar discectomy to complex deformity and intradural surgeries. The resilient myth that “touching the spine is very dangerous” took enormous propaganda and extensive awareness programs to break, albeit only partially. At least one patient in our out-patient clinic, regardless of his/her education and socio-economic status, mentions this myth and expresses his/her fear about spine surgery. This may be because, although rare, complications from spine surgery are devastating and can make a person bed-ridden for life, metaphorically black dot in a white paper. Our understanding of the various problems in the spine has evolved rapidly with better diagnostics and imaging. Hence in the last 2 decades, most of the inventions and researches in spine surgery are about increasing safety and preventing complications, which made spine surgery what it is now – safe and effective.
Understanding the problem is the first step towards a solution. A complication in spine surgery is defined as “a state, directly or indirectly resulting from a surgical operation that altered the anticipated recovery of the patient.” Complications were further graded as minor, moderate, or major.
Kaleel et al, in their study to investigate whether consensus exists with respect to spine-related adverse events, classified complications into avoidable and unavoidable. Our aim is to completely eliminate the avoidable and decrease the probability of unavoidable complications. This is achieved in Kauvery Advanced Spine Centre by strict adherence to protocols and utilisation of high-end technology.
Wrong diagnosis and wrong level: Detailed clinical examination and clinic-radiological correlation are vital in avoiding misdiagnosis. As the spine consists of several functional units (33 bones and their associated joints, discs, and ligaments), it is common to have radiological findings at more than one level. Most of these situations can be dealt with a clinical correlation like myotome and dermatome involvement. In case of persistent ambiguity, diagnostic injections like selective nerve root block can precisely identify the symptomatic level.
To avoid wrong level of surgeries, we utilise an image intensifier at a fixed strategic timing in all the patients. The skin level is marked with the image intensifier before draping. Once the surgical exposure is done, the level is rechecked with a probe in the interlaminar space or the pedicle, depending on the surgical procedure. A final check is done before wound closure with a probe in the disc space. This 3-level check will eliminate all possibilities of performing wrong level and wrong-sided surgery, which was common earlier.
Blood loss: Conditions causing bleeding tendencies like haematological derangements and anti-coagulant intake are addressed during pre-operative evaluation. Local anaesthesia mixed with adrenaline is routinely infiltrated in the surgical site to reduce subcutaneous and muscular ooze. Mean arterial pressure is maintained at around 65mmHg throughout the procedure (with exclusions in sick cord or patients with pre-existing neurodeficit). When blood loss is expected and in long-duration procedures, Tranexamic acid infusion is started with a loading dose of 20mg per kg body weight. Standard positioning of the patient with abdomen free from pressure is ensured to reduce epidural venous bleed.
Infection: Surgical Site Infection (SSI) is very dreadful in neurosurgery and orthopaedic surgery, which may result in prolonged hospital stay, sub-optimal functional outcome and recurrent surgical debridement. Prevention is the best management and starts pre-operatively with patient optimization, including glycemic control, hypoalbuminemia correction, and anaemia correction.
We utilise principles of Minimally Invasive Spine Surgery (MISS) in all surgeries with optimal indications, which has the added benefits of reduced blood loss, less collateral damage to soft tissue, and decreased infection chance. Post-operative sterile dressings are routinely done on 2nd post-op day with a silver-coated adhesive dressing. Patient education, including wound care, bathing practice, early signs of infection, and importance of mobilisation are taught by our nurse trained in spine specialty. They are also provided with audio-visual communication options to contact immediately in case of any emergency or doubts.
Intra-operative care: Patient positioning is vital in spine surgery, not only for ease of access and manoeuvrability but also because of the prolonged prone posture during surgery. We use different sizes of bolsters depending on patient morphology to position the abdomen that is freely hanging. The pressure points, elbow, chest, iliac crest, knee, and ankle are guarded with specialised silicone-based pads. Undue pressure over the face and eyes is prevented with the help of a foam headrest which also facilitates anaesthetists to visualise the patient’s face during surgery. If the expected duration of surgery is more than two hours and for high-risk patients, a pneumatic graded compression device is mandatorily employed. Temperature control (normothermia), which is essential for haemoregulation and infection control, is achieved with warmer blankets.
High-definition microscope: The surgical microscope has revolutionized the practice of modern spine surgery. The major advantages of the microscope include better illumination, magnification, and coaxial vision. The operating microscope, along with microsurgical instruments, can reduce the chance of inadvertent neurological injury, thus improving the safety of the procedure.
High-speed surgical burr and surgical bone scalpel: Utilisation of these instruments helps in improving the precision during bone cuts and reduce the chance of inadvertent damage to the dura and neural structures. They also significantly reduce the duration of surgery, which is beneficial in terms of surgical outcome and economy.
Intra-Operative Neuromonitoring (IONM): It is an integral part of our surgical armamentarium with a phenomenal role, especially in deformity surgeries (scoliosis and kyphosis) and intra-dural surgeries, in preventing neurodeficit during spinal column manipulations and in guiding optimum tumour resection. It also helps in avoiding neural damage due to malpositioned screws. With this equipment and neurologist interpretation, we were able to achieve good deformity corrections and margin-free tumour resection.
Navigation assisted surgery: In complex deformity, where the anatomy is severely deranged, navigation (CT-based and image intensifier–based) makes the process of pedicle screw insertion safer and easier. It is also utilised during high cervical and revision spine surgeries.
Ultrasonic curator and cutter: An ultrasonic machine is used to remove tumour, either soft or calcified, very precisely using ultrasonic cutting technology. This is also used to make accurate cuts in the vertebrae body or bone.
Post-operative care and rehabilitation: For early recovery as well as long-term good outcomes, these two factors are absolutely necessary. Our spine-specialised physiotherapist assesses the patient on the first post-operative day and starts early mobilisation and relevant exercises depending on the functional status. Rehabilitation as per WHO is “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” and is a part of our care to bring patients to their pre-ailment functional level.
Dr. G. Balamurali Head of Spine Service, Consultant Spine and Neurosurgeon Kauvery Hospital Chennai
Dr P Keerthivasan Consultant Spine and Neurosurgeon Kauvery Hospital Chennai
