Predictors of variability in the length of surgery of posterior instrumented arthrodesis in patients with adolescent idiopathic scoliosis

Abstract

The most common corrective surgery for adolescent idiopathic scoliosis (AIS) is posterior instrumented spinal fusion, which is a relatively lengthy procedure. Longer procedures are known to have higher rates of negative outcomes and higher economic costs across the surgical specialties. The purpose of this study is to identify the factors that influence the length of this operation in AIS patients. This was an institutional review board-approved, retrospective cohort study. All primary posterior instrumented arthrodesis procedures in 2011-2013 performed by three surgeons on AIS patients at a tertiary care hospital were included. Age, race, sex, BMI, Cobb angle, curve flexibility, Lenke classification, number of levels fused, number of screws used, osteotomy use, intraoperative O-arm use, and length of surgery (time from incision to closure) were obtained from the electronic medical record. Multivariable linear regression analysis was used to determine independent predictors of length of surgery, and standardized regression coefficients were calculated to compare the relative magnitude of significant variables. A total of 95 procedures were included. The average length of surgery was 375 ± 72.7 min. The multivariable linear regression analysis contained the variables Cobb angle, number of screws used, osteotomy use, Lenke curve type, surgeon, patient age, and sex. The regression identified the number of screws used [β=4.72, P=0.003, 95% confidence interval (CI) 1.7-7.8], osteotomy use (β = 50.2, P = 0.004, 95% CI 16.2-84.1), Lenke type 3 curve (β = 77.9, P = 0.001, 95% CI 31.7-174), male sex (β=62.5, P=0.003, 95% CI 21.5-103), the Cobb angle (β=1.04, P=0.045, 95% CI 0.02-2.1), and the surgeon (β = 75.2, P < 0.0001, 95% CI 40-110) as independently associated with the length of surgery. The most significant factor associated with operative duration was the surgeon performing the case. We identified male sex, number of screws used, Lenke type 3 curves, osteotomy use, Cobb angle, and the surgeon variable as significantly associated with increased length of surgery in posterior arthrodesis of AIS patients.

Pediatric Scoliosis Surgery—A Comprehensive Analysis of Treatment-Specific Variables and Trends in Latvia

“…As expected, the ratio of female patients for AIS correction outweighed the males-in Latvia by 86%-a number that reflects the asymmetry in incidence and is similar to the results from Missouri, where females made up 91.6% of the surgical AIS corrections [25]. Furthermore, Heller et al reported a mean of 10.2 ± 2.1 fused vertebral levels similar to the data from Latvia with a mean of 9.7 ± 1.9, suggesting that the extent of vertebral instrumentation did not vary much among the two centers.…”

“…This learning curve has been reported in other studies, which showed that the number of previously operated surgeries had a greater effect on the operation length than, for example, the amount of vertebral levels fused [29]. Although there are many variables that influence the length of the surgery, such as the Cobb angle or the curve type, the experience operating surgeon has been shown to be most predictive [25]. Our results suggest that gained experience has led to decreasing durations of the surgical procedures.…”

“…In comparison, two hospitals in Atlanta described a mean age at operation of 14.4 ± 1.9 years and 14.7 ± 2.3 years for their AIS patient groups between 2006 and 2008 [20]. A similar study by Heller et al in Kanas City, Missouri, which analyzed data of 95 AIS posterior fusion surgeries from 2011-2013, found a mean age at operation of 14.2 ± 1.8 years [25]. To partly explain the comparatively late operative intervention, it has to be kept in mind that there is currently no uniform screening program for the early detection of scoliosis in Latvia.…”

Feasibility of Episode-Based Bundled Payment for a Pediatric Surgical Condition: Posterior Spinal Fusion

“… 7 , 8 Multiple targets for reducing costs have been identified, including selecting less expensive types of fixation, negotiating among implant suppliers, reducing operative time, reducing payments to providers, and reducing hospital length of stay. 10 , 11 In addition, many centers successfully care for routine AIS–PSF patients on the acute care unit, avoiding the intensive care unit. Thus, centers that routinely utilize the intensive care unit postoperatively could achieve additional savings by modifying this practice.…”

Operative time in adolescent idiopathic scoliosis surgery: a need for a standard definition

“…Surgical advancements have improved operative correction of adolescent idiopathic scoliosis (AIS) patients. Amid the evolving surgical procedures and techniques, operative time has been identified as an important measure for comparing operative risks, assessing surgeon learning curves, and evaluating surgical team efficiency [1][2][3][4]. Despite the wide utilization of operative time as an outcome measure in medical records, comparative studies, and surgical registries, no standardized definition has been provided in the literature [1].…”