Perspective

Studies review effect of overlapping spine surgery on outcomes

Spine and orthopedic surgery that is concurrent or overlapping is a hot topic that has led hospitals and investigators to examine this practice at their institutions. Two retrospective reviews published in the Journal of Neurosurgery showed the effect on outcomes after neurosurgery performed when two procedures were overlapping, or surgical steps were performed concurrently in different cases at any time during surgery.

“One of the positive things about all of this controversy is it caused a lot of institutions and surgeries as a specialty to look a bit closer at the topic and look at the data and see whether or not this practice is safe,” Jian Guan, MD, of the department of neurosurgery at University of Utah and co-author of the study that focused on the management of overlapping spine cases, told Orthopedics Today.

Low complication rates

In the study by Guan and his colleagues, among 1,018 patients who underwent nonemergent neurosurgical procedures, the rate of overall complication and the rate of serious complication were not significantly higher among patients who underwent overlapping surgery — defined as when two patients under the care of a single lead surgeon were under anesthesia at the same time — vs. patients who did not. Overlapping surgery remained unassociated with overall complications after the investigators adjusted for surgery type, surgery duration, BMI, American Society of Anesthesiologists (ASA) physical classification grade and intraoperative blood loss, according to the study results.

Michael T. Lawton, MD
Michael T. Lawton

In addition, investigators found no association between overlapping surgery and serious complications after they adjusted for surgery type, surgery duration, BMI, ASA grade and neurological comorbidity.

“Through looking retrospectively at our data series in our institution ... overlapping cases were not any more risky to the patients in terms of complication rates compared to cases that did not overlap,” Guan said.

Inform patients

Guan noted the research he and his colleagues did revealed a “big gap between what the patients know about the practice and what physicians know about the practice” of performing overlapping surgery. For instance, he said many patients believe any surgeon can perform overlapping surgery with any patient at any time.

“You need to be upfront with your patients about it. You need to have a discussion about what that entails and what that means, and I think you need to give your patients some degree of insight and some degree of choice in the matter,” Guan said. “If they do not feel comfortable with that, then that is absolutely their prerogative, and I think they need to have that input.”

Overlapping surgery should be performed within the appropriate framework and regulations, and by surgeons with many years of surgical experience, he added.

“If you are at a place that generally has one room running a day, I think that trying to double your volume by doing two cases a day is probably not something a lot of smaller practices will be able to do safely and efficiently,” Guan said.

A study of 1,219 neurosurgical procedures performed from 2012 to 2015 at University of California, San Francisco that Michael T. Lawton, MD, and his colleagues conducted showed equivalent rates of severe sepsis, postoperative stroke, intraoperative aneurysm rupture and postoperative aneurysm residual between nonconcurrent and concurrent cases. In the study, they defined concurrent surgery as when one case of the attending surgeon overlapped with another of his or her cases being done in a separate room by 1 second or more.

The mixed-effects models the investigators used showed no significant difference in acute respiratory failure, severe sepsis, 30-day readmission, postoperative stroke, estimated blood loss, length of stay, discharge status or intraoperative aneurysm rupture between the groups after controlling for procedure type, patient demographics and clinical indicators.

The concurrent cases in Lawton’s study had significantly longer procedural times and more unplanned 30-day readmissions. However, there were shorter mean lengths of stay, higher rates of discharge to home, lower rates of 30-day mortality and acute respiratory failure and decreased 30-day unplanned returns to the OR.

“The terminology has shifted since our article was published. ‘Concurrent’ surgery has taken on a negative connotation,” Lawton told Orthopedics Today, noting overlapping surgery is a more appropriate term. “Overlapping surgery is two simultaneous cases where the critical parts do not occur simultaneously, whereas concurrent surgery is two simultaneous cases where the critical parts do occur simultaneously. Our cases were overlapping surgeries,” he said. – by Casey Tingle

Disclosures: Guan reports no relevant financial disclosures. Lawton reports he receives consulting fees from Zeiss and Stryker.

Spine and orthopedic surgery that is concurrent or overlapping is a hot topic that has led hospitals and investigators to examine this practice at their institutions. Two retrospective reviews published in the Journal of Neurosurgery showed the effect on outcomes after neurosurgery performed when two procedures were overlapping, or surgical steps were performed concurrently in different cases at any time during surgery.

“One of the positive things about all of this controversy is it caused a lot of institutions and surgeries as a specialty to look a bit closer at the topic and look at the data and see whether or not this practice is safe,” Jian Guan, MD, of the department of neurosurgery at University of Utah and co-author of the study that focused on the management of overlapping spine cases, told Orthopedics Today.

Low complication rates

In the study by Guan and his colleagues, among 1,018 patients who underwent nonemergent neurosurgical procedures, the rate of overall complication and the rate of serious complication were not significantly higher among patients who underwent overlapping surgery — defined as when two patients under the care of a single lead surgeon were under anesthesia at the same time — vs. patients who did not. Overlapping surgery remained unassociated with overall complications after the investigators adjusted for surgery type, surgery duration, BMI, American Society of Anesthesiologists (ASA) physical classification grade and intraoperative blood loss, according to the study results.

Michael T. Lawton, MD
Michael T. Lawton

In addition, investigators found no association between overlapping surgery and serious complications after they adjusted for surgery type, surgery duration, BMI, ASA grade and neurological comorbidity.

“Through looking retrospectively at our data series in our institution ... overlapping cases were not any more risky to the patients in terms of complication rates compared to cases that did not overlap,” Guan said.

Inform patients

Guan noted the research he and his colleagues did revealed a “big gap between what the patients know about the practice and what physicians know about the practice” of performing overlapping surgery. For instance, he said many patients believe any surgeon can perform overlapping surgery with any patient at any time.

“You need to be upfront with your patients about it. You need to have a discussion about what that entails and what that means, and I think you need to give your patients some degree of insight and some degree of choice in the matter,” Guan said. “If they do not feel comfortable with that, then that is absolutely their prerogative, and I think they need to have that input.”

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Overlapping surgery should be performed within the appropriate framework and regulations, and by surgeons with many years of surgical experience, he added.

“If you are at a place that generally has one room running a day, I think that trying to double your volume by doing two cases a day is probably not something a lot of smaller practices will be able to do safely and efficiently,” Guan said.

A study of 1,219 neurosurgical procedures performed from 2012 to 2015 at University of California, San Francisco that Michael T. Lawton, MD, and his colleagues conducted showed equivalent rates of severe sepsis, postoperative stroke, intraoperative aneurysm rupture and postoperative aneurysm residual between nonconcurrent and concurrent cases. In the study, they defined concurrent surgery as when one case of the attending surgeon overlapped with another of his or her cases being done in a separate room by 1 second or more.

The mixed-effects models the investigators used showed no significant difference in acute respiratory failure, severe sepsis, 30-day readmission, postoperative stroke, estimated blood loss, length of stay, discharge status or intraoperative aneurysm rupture between the groups after controlling for procedure type, patient demographics and clinical indicators.

The concurrent cases in Lawton’s study had significantly longer procedural times and more unplanned 30-day readmissions. However, there were shorter mean lengths of stay, higher rates of discharge to home, lower rates of 30-day mortality and acute respiratory failure and decreased 30-day unplanned returns to the OR.

“The terminology has shifted since our article was published. ‘Concurrent’ surgery has taken on a negative connotation,” Lawton told Orthopedics Today, noting overlapping surgery is a more appropriate term. “Overlapping surgery is two simultaneous cases where the critical parts do not occur simultaneously, whereas concurrent surgery is two simultaneous cases where the critical parts do occur simultaneously. Our cases were overlapping surgeries,” he said. – by Casey Tingle

Disclosures: Guan reports no relevant financial disclosures. Lawton reports he receives consulting fees from Zeiss and Stryker.

    Perspective
    Scott D. Boden

    Scott D. Boden

    It is important to distinguish concurrent surgeries from overlapping surgeries. In the latter, non-critical portions of the surgery, such as anesthetic induction, positioning, draping, superficial dissection, wound closure and emergence from anesthesia, are occurring simultaneously in two rooms. One case is winding down while another case is starting. This practice allows a surgeon to achieve higher proficiency and volume which can often be associated with fewer complications. However, overlapping cases must be carefully chosen, planned, timed and staffed to ensure maximal safety. These studies highlight the point that overlapping surgeries can be performed safely without increased risk of complications in experienced hands.

    • Scott D. Boden, MD
    • Orthopedics Today Section Editor, Spine

    Disclosures: Boden reports no relevant financial disclosures.