Editorial

Abstract

The issue of complications in surgery—in spinal surgery in particular—is a highly important topic especially in the current climate of healthcare reform. Surgeons are constantly striving to improve their practice and quality of care, and now patients and healthcare administrators are also demanding improvement in outcomes and accountability.6 Policy makers anticipate that the practice of evidence-based medicine will lead to safe, high-quality care with reduced costs.8 A critical aspect in quality analysis of a specific procedure is the epidemiology of complications occurrence associated with that procedure. Theoretically, if one can identify the epidemiology of complications in spinal surgery, one can use this knowledge to prevent and reduce the occurrence of these negative sequelae. Logically, this is the critical first step in the process to quality improvement and is the stimulus behind the review on complications in spine surgery by Nasser et al.10 in this issue of the Journal of Neurosurgery: Spine. Spinal surgery is a highly scrutinized specialty and thus is heavily driven by outcomes.5,15 Intuitively, it is exceedingly difficult to justify invasive procedures in an area—the spine and spinal cord—in which the stakes can be so high if the associated outcomes are not positive. There is therefore a growing requirement for evidence and numbers to support not just the ever-evolving new technologies and procedures, but also the so-called tried and true methods that have become traditions in the specialty. This pressure is coming from the surgeons, the administrators, and the insurance providers as well as, increasingly and justifiably, from those with the most at stake—the informed patient. Nasser and colleagues10 have undertaken a careful literature review to identify reported complication rates in spinal surgery. This systematic review incorporated 105 articles containing a 79,471 patients with 13,067 complications, for an overall complication incidence of 16.4%. The literature showed a bias towards thoracolumbar procedures (80 studies) as opposed to cervical procedures (25 studies). There was also a much greater number of retrospective studies (84 studies) than prospective studies (21 studies). These factors became significant because complications were reported to be higher in thoracolumbar (17.8%) compared with cervical (8.9%) procedures and in prospective (19.9%) compared with retrospective (16.1%) studies. Based on these findings, Nasser et al. concluded that retrospective studies significantly underestimate the overall incidence of complications in spine surgery, which is sobering although not surprising. A cause for concern is the revelation by Nasser and colleagues10 that there is no uniform standard for reporting complications. This is an issue that has been previously flagged by our clinical research team, which proposed a standardized classification system for intraoperative adverse events.14 Currently there is no consensus definition of what actually constitutes a complication in the spine surgery literature. This fact is perhaps responsible for the noted wide variance in the methodologies used to report and evaluate complications. Duration of follow-up also plays a significant role in the incidence of complications, as was revealed in the Nasser et al. review in which a longer follow-up was associated with increased complications. Not surprisingly, given the current limitations of the available literature, Nasser and colleagues10 acknowledge J Neurosurg Spine 13:141–143, 2010 See the corresponding article in this issue, pp 144–157.