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Perioperative Optimization for Spine Surgery Patients: The University of Florida Experience

By Basma Abdalla Mohamed, MD

Basma Abdalla Mohamed, MD

Introduction
Adult spine deformity surgery is in high demand as the population ages. Limited activity and the overall deformity are the main factors that drive patients to have surgery. Spine deformity surgery is associated with a high rate of perioperative and postoperative complications1,2. The elderly patient population have limited physiologic reserve and multiple medical comorbidities, both factors will contribute to a higher rate of complications.  

While the focus of surgery is deformity correction, the perioperative team including surgeons, anesthesiologists, and intensivists should also focus on the overall medical condition and the patients’ multiple comorbidities that may compromise the overall perioperative course and affect postoperative outcome. As a result, a preoperative evaluation protocol has been developed at our institution. This protocol involves a multidisciplinary team consisting of neurosurgeons, anesthesiologists, medicine consultants (cardiologists, pulmonologists, endocrinologists and hematologists), neuropsychologists, physical therapists, and neuromedicine quality improvement team. 

A protocol-based clinical pathway has been developed to include high risk patients and or patients scheduled for high risk spine surgery. This protocol continues to intraoperative and acute postoperative phase through applying enhanced recovery after surgery recommendations. These recommendations were taken from ERAS guidelines used by other specialties (colorectal and orthopedic surgery) and modified to be applicable to spine surgery patients. In this review, we will discuss the preoperative evaluation of high risk patients undergoing spine deformity surgery.

Preoperative Evaluation Clinical Pathway
The preoperative protocol starts when the surgeon decides to do the surgery. Patient selection criteria for a preoperative anesthesia consult includes: high risk surgery, cardiac or pulmonary diseases, or limited physical activity. The protocol can also be started based on the clinician’s clinical judgement regarding patients’ risk of perioperative complications. Through the preoperative anesthesia consult, patients will have an extensive evaluation including the following goals:

1. Evaluation of physical capacity: obtaining subjective information regarding patients’ physical capacity and metabolic equivalents (METs) may not be as accurate. Patients usually attribute their lack of activity to back pain and spine disease process. Preoperative physical inactivity and frailty have been strong predictors of poor postoperative outcome3. Frailty assessment and six-minute walk test are objective methods to evaluate patients’ physical capacity and aerobic exercise tolerance. Frail patients are referred to further evaluation by physical therapy team as a prehabilitation consult. Based on physical therapy recommendations, patients get enrolled in an on-site or home-based exercise program for 4-12 weeks to improve endurance and physical performance. Physical prehabilitation is focused on strength training and aerobic exercise.
2. Medical Management: Management and optimization of comorbidities including optimization of cardiac and pulmonary diseases, early evaluation of anemia, and evaluation and treatment of poorly controlled diabetes.
   • Cardiac: Based on American Heart Association and American College of Cardiology guidelines, patients with coronary artery disease or risk factors for coronary artery disease, are evaluated through risk stratification for possible Major Adverse Cardiac Events (MACE). Patients with active cardiac conditions (decompensated heart failure, severe Valvular heart disease, unstable arrhythmia and angina) are referred to cardiology for further evaluation and treatment. Patients with cardiac disease and poor physical activity are evaluated on a case-by case basis to see if pharmacologic stress test is indicated prior to proceeding with surgery.
   • Pulmonary: Patients are evaluated using pulmonary risk assessment tool for postoperative pulmonary complications in addition to standard history and physical examination. All patients with dyspnea on exertion of unknown etiology, or history of smoking without confirmed diagnosis of chronic obstructive pulmonary disease, or patients at high risk of postoperative pulmonary complications are referred to pulmonary medicine for further evaluation. Initial work-up includes pulmonary function tests, chest-x-ray, and or transthoracic echocardiography. Smoking cessation for at least eight weeks before scheduled surgery is highly recommended by the surgeons prior to proceeding.
   • Anemia: referral to primary care physician or hematologist if hemoglobin is less than 13 or 12 grams/dl for male or female patients respectively. Early diagnosis of anemia and early intervention is necessary as part of our perioperative blood conservation management protocol for complex spine patients.
   • Diabetes: Hemoglobin A1C goal 7-8%. Referral to endocrinologist is required if Hemoglobin A1C > 9%.
   • Renal and Liver disease evaluation: Baseline renal and` hepatic functions are assessed during preoperative anesthesia consult. Abnormal test results are further evaluated and the decision to proceed with surgery is further discussed with the surgeon if patients have end-stage liver or renal disease.
3. Nutrition screening: Low pre-albumin, poor appetite and weight loss are predictors of malnutrition4. Nutrition screening and early intervention-in the form of high protein intake- in spine surgery patients will help improve their perioperative nutrition needs and the healing process. In addition, it will decrease the risk of postoperative wound infection5.
4. Pain management: We use Visual Analogue Scale (VAS) assessment tool to evaluate baseline pain control and set expectations during post-operative phase. Also, evaluation of current pain management regimen-including high dose narcotics-helps predict intraoperative and post-operative pain management plan. We evaluate the impact of narcotics on other systems including bowel function and the possibility of postoperative ileus in the preoperative phase. All patients receiving opioids before surgery are started on laxatives few days before surgery. This approach is highly recommended for elderly population.
5. Patient education: Current patient expectations may not be as realistic. During traditional preoperative evaluation, one to two weeks before surgery, patients receive a lot of information from different disciplines (surgery, anesthesia, medicine consultants). In traditional preoperative evaluation, patient may or may not truly verbalize understanding of perioperative instructions, postoperative expectations, and expectations after discharge from the hospital. In the protocol-based evaluation, different techniques of patient education were implemented. These techniques include video-based instructions for the day of surgery, videos explaining expectations after surgery. In addition, the preoperative evaluation team discusses these expectations and instructions directly with the patient using teach-back method. Family members and caregivers are actively involved in this discussion as well. If surgery is scheduled longer than two weeks after preoperative evaluation, a follow-up phone call a week before surgery is included in the clinical pathway to emphasize previously discussed instructions and expectations.
6. Cognitive evaluation: All patients in protocol-based evaluation receive preoperative cognitive screening in the form of a mini-mental status exam. If the screening is positive, they are scheduled for a 30-minute neuropsychology testing. Goals of testing are to evaluate baseline memory and mood disorders, and possible risk for post-operative cognitive dysfunction.
7. Discharge planning: Early discharge planning is the key to focused care and minimize unnecessary prolonged hospitalization. Discharge planning starts in preoperative phase using Risk Assessment and Prediction Tool (RAPT). Patients who are candidates for discharge to home with postoperative physical therapy receive the necessary education and expectations of discharge to home.

Conclusion
Use of protocol-based clinical pathway in the preoperative evaluation and optimization of spine deformity patients helps direct various disciplines to focus on patient-centered care and value-based care. In this clinical pathway, a comprehensive preoperative evaluation and communication within this multidisciplinary team help the transition of care from outpatient setting through surgery and until discharge. Early evaluation and optimization of patient’s comorbidities will minimize postoperative complications and improve perioperative outcome.

References

1. Sugrue PA, Halpin RJ, Koski TR. Treatment algorithms and protocol practice in high-risk spine surgery. Neurosurg Clin N Am. 2013;24(2):219-230.
2. Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG. The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine. 2007;32(24):2764-2770.
3. Kim S, Han H-S, Jung H, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.
4. Klein JD, Hey LA, Yu CS, et al. Perioperative nutrition and postoperative complications in patients undergoing spinal surgery. Spine. 1996;21(22):2676-2682.
5. Gillis C, Loiselle S-E, Fiore JF, et al. Prehabilitation with Whey Protein Supplementation on Perioperative Functional Exercise Capacity in Patients Undergoing Colorectal Resection for Cancer: A Pilot Double-Blinded Randomized Placebo-Controlled Trial. J Acad Nutr Diet. 2016;116(5):802-812.