Surgical Co-piloting for Complex Spine Surgery

Many patients who come to UCSF needing surgery for spinal disorders get an unexpected benefit: two senior surgeons for a single operation.

In an uncommon model of care, but one that is increasingly gaining traction, neurosurgeons and orthopaedic surgeons at the UCSF Spine Center combine their expertise by operating side by side to maximize outcomes for complex cases.

“With two surgeons, operating times are much shorter, blood loss is much less, there are fewer complications, and patients recover faster from the surgery,” Vedat Deviren, MD, professor of orthopaedic surgery, said. “We have seen that these factors have a significant benefit to patients’ outcomes.”

Safer procedures, reduced stress for patients

Patients who are the best candidates for a two-surgeon operation are generally those with complex spinal tumors or deformities, those needing revision of a previous surgery, or those whose age or health status put them at increased risk for complications.

“For these difficult cases, having two surgeons makes the procedure safer and reduces stress,” Dean Chou, MD, professor of neurological surgery, said. “Patients who require complicated procedures also really appreciate that they have two experienced pairs of hands performing the surgery, versus an experienced surgeon and a trainee.”

This approach also alleviates confusion for patients who do not know if their condition is best treated by and orthopaedic surgeon or a neurosurgeon.  “When patients come to us seeking care, they are usually in significant pain and already have stress and anxiety around needing a big operation,” Deviren said. “When they find out that they will have both a neurosurgeon and an orthopaedic surgeon working together, it takes away the anxiety around having to choose who is the best specialist for their problem.”

Supported by clinical research

Deviren first partnered with neurosurgeon Christopher Ames, MD, on a complex tumor case in 2007. After achieving an outstanding result in half of the expected time, the two immediately knew that they were onto something. The clinical research they have conducted in the past decade has borne out their initial conclusions regarding the superior outcomes that can be achieved through collaboration. Other medical institutions, such as Brigham and Women’s Hospital in Boston, the Hospital for Special Surgery in New York City, and the University of California, San Diego, have since implemented dual-attending protocols with similar results.

At Virginia Mason Medical Center in Seattle, Rajiv Sethi, MD, has made the dual-attending surgeon approach, based on Ames and Deviren’s published research, a major part of the Seattle Spine Team protocol for managing complex adult scoliosis cases. “Patients from 47 states have been treated with this protocol over the past 8 years,” Sethi, who is a 2006 graduate of the UCSF complex spine and scoliosis fellowship, said. “The dual-attending surgeon approach is required for all three-column osteotomies and any surgery that is proposed to last greater than 6 hours.”

Clear value, payment hurdles

In a recent survey of the Scoliosis Research Society membership, the majority of respondents agreed that having two attending surgeons improves safety, decreases complications, and improves outcomes—especially for difficult cases like three-column osteotomies. However, 51 percent of the 199 respondents felt that despite having clear value, having a second attending surgeon was limited by reimbursement and access problems, and 72 percent reported difficulty in getting the second attending reimbursed. Ames and Deviren hope that with more institutions publishing high-quality comparative studies, the protocol will overcome payment hurdles.

Expanding access for high-risk patients

At UCSF, an additional and unexpected benefit to the two-surgeon approach has been the ability to treat an entire population of patients with debilitating conditions who were previously deemed unfit to undergo major surgery.

 “As a high-volume tertiary care facility, we routinely care for patients with multiple comorbidities, such as pulmonary issues, osteoporosis, or heart disease,” Chou said. “By reducing operating risk with two surgeons and working as a multidisciplinary group with our colleagues in anesthesia, neuromonitoring and pain management, we can offer more patients procedures that can dramatically improve their pain and quality of life.”

Further Reading 

Ames CP, Barry JJ, Keshavarzi S, Dede O, Weber MH, Deviren V. Perioperative outcomes and complications of pedicle subtraction osteotomy in cases with single versus two attending surgeons. Spine Deform. 2013 Jan;1(1):51-58.

Scheer JK, Sethi RK, Hey LA, et al. Results of the 2015 Scoliosis Research Society Survey on single versus dual attending surgeon approach for adult spinal deformity surgery. Spine (Phila Pa 1976). 2017 Jun 15;42(12):932-942.