Rajiv K Sethi1, Douglas C Burton2, Anna K Wright3, Larry G Lenke4, Meghan Cerpa4, Michael P Kelly5, Alan H Daniels6, Christopher P Ames7, Eric O Klineberg8, Gregory M Mundis9, Shay Bess10, Robert A Hart11. 1. Neuroscience Institute, Virginia Mason Hospital, 1100 Ninth Ave., Seattle, WA 98101, USA; Department of Health Services, University of Washington, NE Pacific St, Seattle, WA 98195, USA. Electronic address: Rajiv.Sethi@virginiamason.org. 2. Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA. 3. Department of Health Services, University of Washington, NE Pacific St, Seattle, WA 98195, USA. 4. Department of Orthopedic Surgery Columbia University, The Spine Hospital, 5141 Broadway, New York, NY 10034, USA. 5. Department of Orthopaedics, Washington University St Louis, 1 Brookings Dr, St. Louis, MO 63130, USA. 6. Department of Orthopedics, Brown University, 222 Richmond St, Providence, RI 02912, USA. 7. Department of Neurological Surgery, University of California San Francisco, 513 Parnassus Ave., San Francisco, CA 94131, USA. 8. Department of Orthopedic Surgery, University of California, 1 Shields Ave., Davis, CA 95616, USA. 9. San Diego Spine Foundation, 6190 Cornerstone Ct E, Suite 212, San Diego, CA 92121, USA. 10. Denver International Spine Center, Presbyterian St. Luke's Medical Center, Rocky Mountain Hospital for Children, 2055 High St, Suite 130, Denver, CO 80205, USA. 11. Swedish Neuroscience Institute, 550 17th Ave., Suite 540, Seattle, WA 98122, USA.
Abstract
STUDY DESIGN: Structured literature review. OBJECTIVES: To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery. METHODS: Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies. RESULTS: We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications. CONCLUSION: Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care. LEVEL OF EVIDENCE: Level II.
STUDY DESIGN: Structured literature review. OBJECTIVES: To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery. METHODS: Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies. RESULTS: We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications. CONCLUSION: Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care. LEVEL OF EVIDENCE: Level II.