The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases

Abstract

Introduction: Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA). Methods: This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed. Results: Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m2. Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates. Conclusions: These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Oblique anterior column realignment with a mini-open posterior column osteotomy for minimally invasive adult spinal deformity correction: illustrative case

“…To this end, a recent series on 312 patients published by Lee et al. 25 noted the 2-year complication rate to exceed 60% for PSO. By comparison, minimally invasive deformity correction techniques have been correlated with lower perioperative complication rates and thus may be preferrable in high-risk patients such as the present case, and we proceeded with this strategy.…”

“…24 The combination of an L4 PSO with the L5-S1 lateral ALIF was considered; however, it was believed that the PSO would carry with it significant morbidity especially in a higher risk patient such as ours. To this end, a recent series on 312 patients published by Lee et al 25 noted the 2-year complication rate to exceed 60% for PSO. By comparison, minimally invasive deformity correction techniques have been correlated with lower perioperative complication rates and thus may be preferrable in high-risk patients such as the present case, and we proceeded with this strategy.…”