Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing.

Enhanced recovery after surgery (ERAS) protocol in spine surgery.

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities.

How to start an awake spine program: Protocol and illustrative cases.

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia.

Regional Anesthesia for Spine Surgery.

Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery.

Awake Spinal Fusion.

»: Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints.

»: ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia.

»: The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Regional Anesthesia for Spine Surgery.

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery.

Awake spinal fusion.

'Awake spinal fusion' is a novel approach to spine surgery that combines modern anaesthetic and surgical technique resulting in improved patient satisfaction and overall outcomes. Along with techniques of regional anaesthesia, minimally invasive or endoscopic surgical techniques are used to minimize surgical dissection and blood loss. Although, it is a relatively new concept with limited supporting evidence till date, it may prove to be highly effective in reducing post-operative hospital stays, in-hospital complications and cost of surgery while at the same time expediting recovery and rehabilitation.

Subsidizing the Sick: How Community Rating Works.

Insurance premium rates have typically been calculated using a variety of rating algorithms. Passage of the Patient Protection and Affordable Care Act mandated that all individual and small group plans must use the community rating method. This method gives the same insurance rate to all members of a community, with adjustments only being allowed based on age, geography, and tobacco use.

Organizational Structural Design in Spine Care.

For a company to provide high value to its customers, its organization design is critical. As health care transitions to a value-based model, it is critical that spinal care organizations are structured in such a way that they can maximize value to both the patient and the payers. This article will discuss the 3 most common ways that an organization can be structured, and the benefits and problems of each design in spinal care.

Value-based Insurance Design.

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.

The Science of Health-Care Delivery.

As the health-care system evolves toward delivering greater value for the patient, orthopaedic surgeons are continually being challenged to manage the health of a population. The traditional focus of scientific inquiry within orthopaedics has been at the individual patient level. The science of health-care delivery is an evolving field that is aimed at bringing rigorous inquiry into determining the proper organizational design that can deliver high-quality and low-cost care for a population.

The Role of Incentives in Changing the Behavior of Spinal Care Providers: A Primer on Behavioral Economics in Health Care.

As spinal care transitions from individual practitioners working in a volume-based reimbursement system toward multidisciplinary health care organizations working in a population-based model with value-based reimbursement, it is critical that insurance companies, administrators, and spine care provider have a clear understanding of how incentives change physician behavior. This article will introduce the concept of behavior economics, and discuss 9 principles relevant to physician decision-making.

The Service-Profit Chain in Spine Surgery.

Medicine has always been a service industry (as opposed to a manufacturing industry), as there is a shift from volume to value in health care, this point is becoming increasingly important. The delivery of good care extends beyond the technical aspects of performing a complex operation or prescribing the right type of medicine. Intuitively physicians have always understood the value of the physician-patient relationship, and its correlation to a good outcome.

Understanding Business Models in Health Care.

The increasing focus on the costs of care is forcing health care organizations to critically look at their basic set of processes and activities, to determine what type of value they can deliver. A business model describes the resources, processes, and cost assumptions that an organization makes that will lead to the delivery of a unique value proposition to a customer. As health care organizations are beginning to transform their structure in preparation for a value-based delivery system, understanding business model theory can help in the redesign process.

Understanding Competition in Spine Care.

The changing landscape from volume to value represents a natural transformation in the health care industry. Increasingly provider groups are finding themselves responding to unfamiliar market forces. Whether explicit or implicit, competition is playing a larger role for the sustainability of providers.

Understanding Time-driven Activity-based Costing.

Transitioning to a value-based health care system will require providers to increasingly scrutinize their outcomes and costs. Although there has been a great deal of effort to understand outcomes, cost accounting in health care has been a greater challenge. Currently the cost accounting methods used by hospitals and providers are based off a fee-for-service system.

Innovation in Health Care Delivery.

As reimbursement transitions from a volume-based to a value-based system, innovation in health care delivery will be needed. The process of innovation begins with framing the problem that needs to be solved along with the strategic vision that has to be achieved. Similar to scientific testing, a hypothesis is generated for a new solution to a problem.

Redesigning Health Care Organizations: The Influence of Government Policy and Methods of Payment.

Over the last 5 years, there has been a growing trend toward consolidation in the health care field. As reimbursement moves from a fee-for-service model to a value-based model, there will be continued pressure on physicians to either be a hospital employee or to be in a large multidisciplinary practice. This is largely due to the Accountable Care Act, which directs payers to utilize population-based cost analyses, rather than an individual patient-based analysis.

The Role of Strategy in Health Care.

Significant changes are occurring in the health care field, and spine surgeons must have an understanding of business strategy if they are going to adapt to the new health care environment. Spine surgeons will be required to demonstrate how their service provides a unique value to their patients or else the patients will obtain care from competitors. Classic methods for demonstrating value such as academic prestige and superior clinical outcomes may no longer be sufficient in the evolving health care field, and surgeons will need to demonstrate a comprehensive and cost-effective treatment algorithm for a diagnosis.

Understanding a Value Chain in Health Care.

As the US health care system transitions toward a value-based system, providers and health care organizations will have to closely scrutinize their current processes of care. To do this, a value chain analysis can be performed to ensure that only the most efficient steps are followed in patient care. Ultimately this will produce a higher quality or equal quality product for less cost by eliminating wasteful steps along the way.

Managing the Delivery of Health Care: What Can Health Care Learn From the Business Community?

The passage of the Patient Protection and Affordable Care Act in March 2010 has resulted in dramatic changes to the delivery of health care in the United States toward a value-based system. While this is a significant change from the previous model, it presents an opportunity for high-quality health care providers to improve patient outcomes while also increasing revenue. However, those that lack a clear strategy to effectively implement change and communicate the increased value to the patients likely will suffer, regardless of how successful or prestigious they seem today.

Advances in the understanding of cervical spine deformity.

Cervical spine deformities pose substantial challenges for spine surgeons. The anatomy and biomechanics of the cervical spine play an important role in the decision-making process regarding treatment. The etiology of cervical deformities can be congenital, developmental, iatrogenic, degenerative, or inflammatory.

Extensive ossification of the ligamentum flavum treated with triple stage decompression: a case report.

Background Context: Concurrent ossification of the ligamentum flavum (OLF) in the cervical, thoracic, and lumbar spine is a rare occurrence often associated with rheumatologic abnormalities. Although the pathology may be asymptomatic and discovered incidentally on routine imaging, compression of the cord and surrounding nerve roots can produce myelopathic or radiculopathic symptoms that are best treated with surgical decompression. There is limited evidence to support the use of single versus multistage decompression for tandem ossification at multiple levels, although several factors including duration of symptoms have been associated with a worse prognosis.