119. Indications conference for surgical decision-making in complex spine surgery: creating consensus when the stakes are high

Abstract

<h3>BACKGROUND CONTEXT</h3> In complex spine surgery, indications and approaches are challenging and stakes are high. There is little data on how these surgical decisions are made. There is growing concern that decision-making variability and poor planning lead to suboptimal short- and long-term outcomes. Complex spine surgery has an approximated risk of major complication of 19%, an overall complication rate of up to 55%, and a readmission rate of 7.5% (Friedman et al 2020). Multidisciplinary spine conferences have been shown in prior case series to alter surgical plans in 19%-28% of cases (Benton et al 2021, Chan et al 2016). Multidisciplinary planning conferences have also been shown to improve perioperative optimization. <h3>PURPOSE</h3> The goal of our study was to determine the effect of spine indications conferences on surgical decision-making and planning in complex spine patients at our institution. Additionally, we wanted to better understand how this process might aid in addressing difficult decisions in high-risk patients. <h3>STUDY DESIGN/SETTING</h3> To answer our questions, we collected data on patients presented at our weekly indications conference. The study had Duke University IRB approval. <h3>PATIENT SAMPLE</h3> Patient sample included patients presented at the Duke Spine Center weekly indications conference in a 6-month period in 2020. Primary surgeons chose patients to present and there was no presentation requirement. <h3>OUTCOME MEASURES</h3> We assessed primary surgeon plan vs consensus plan vs implemented plan to determine the role of indications conference on surgical planning and decision-making. We then assessed correlations between demographic, clinical, and complication data on this population. Complication data assessed was specifically, our preoperative Pythion risk calculator (Corey et al 2018) as well as our morbidity and mortality report. <h3>Methods</h3> The primary surgeon's preconference plan and the conference consensus plan were recorded following each indications conference. The actual surgical plan implemented was obtained from chart review. We performed a chart review for demographic and clinical factors. Complication data were obtained from the Pythion Risk Calculator (Corey et al 2018) and the morbidity and mortality conference list. Preliminary summary statistics were performed. <h3>Results</h3> Our analysis included 143 patients over a 6-month period. Orthopedic and neurosurgery spine surgeons attended conferences and a range of 10 to 26 surgeons attended weekly during the study period. Eighty-two (57%) patients identified as male and 62 (43%) female with an average age of 59 years. For 64 of the patients presented, the consensus plan agreed with the surgeon's initial plan without change. Seventy-six of the surgical or nonsurgical treatment plans were new and/or different from the primary surgeon's initial plan after group consensus. One patient was excluded as the primary surgeon did not attend the conference and for 2 patients, the group did not reach consensus. Additional therapies such as injections, neurology consultation, management of osteoporosis, medical optimization, and weight loss were recommended for 36 patients. In 70% of cases, the primary surgeon implemented the plan suggested in conference. The average estimated risk of a surgical complication for this patient sample by the Pythion calculator was 40%. Seven patients (4.9%) had complications presented at the morbidity and mortality conference. Of the patients with complications, the group agreed with the primary surgeon's plan for 4 patients, no consensus plan was reached for 2 of the patients, and a new surgical plan was suggested for 1 of the patients. The implemented plan was consistent with the conference plan in all of these cases. <h3>Conclusions</h3> This abstract presents summary statistics from an in-depth evaluation of our institution's spine indication conference and its association with surgical plan as well as the role it plays in complication avoidance in high-risk patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.