Considering the whole patient before spinal surgery

Obesity, osteoporosis or poorly controlled diabetes are factors that can carry risks for spinal surgery.

Even though I’m a neurosurgeon specializing in spine, I spend a lot of time talking to my patients about issues other than their backs. Rarely do I see back pain in isolation.

Before they undergo spinal surgery, patients who are obese or who have osteoporosis or have poorly controlled diabetes all have risks we need to take into account.

For example, studies have shown patients with diabetes who undergo spinal surgery have an increased risk of postoperative mortality, surgical site infection, deep venous thrombosis and prolonged hospitalization.

To address that, Norton Leatherman Spine has developed a successful endocrinology fast-track program to help patients improve their blood sugar control. The program includes counseling, education and medical management.

Patients who do well in the program at the two-week checkpoint are scheduled for surgery an additional four weeks out. As a sign of the program’s efficacy, a study we did found patients’ improved blood sugar control was maintained at follow-up.

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Osteoporosis and degenerative spinal disease are both common among older patients. We follow evidence-based guidelines and give patients with suspected osteoporosis a preoperative assessment with a bone density scan.

If osteoporosis is confirmed, we offer counseling on the risk of postoperative events and treatment with teriparatide, which increases bone mineral density and induces earlier and more robust fusion.

Before elective spinal reconstruction, we also want to evaluate bone density for younger patients with risk factors including chronic glucocorticoid use, high fracture risk or previous fracture, and limited mobility.

Obesity is another common condition. One of the many health risks associated with obesity is low back pain.

If an obese patient is unable to lose weight, we might refer them to a bariatric surgeon. Sometimes, weight loss surgery and the accompanying weight loss are enough to make the back pain tolerable.

Spine surgery also can help. A retrospective study of 270 patients who underwent a lumbar fusion at Norton Leatherman Spine found both obese and nonobese patients demonstrated similar, significant improvements in back pain and leg pain.

Coronary artery disease, peripheral vascular diseases, nicotine and/or illicit drug use, and chronic opioid therapy are other conditions we want to address before surgery to lower the risks of complications and improve the odds of a successful recovery.

My colleagues and I take a multidisciplinary approach across the Norton Healthcare system — leveraging the full range of our health care capabilities to address issues before surgery.

Maybe the patient needs to see a cardiologist perioperatively for coronary artery disease, or a physical therapist to get in better shape, or a neurologist for an associated neurological condition such as multiple sclerosis.

Taking the time before surgery helps set expectations, gets the patient’s buy-in and goes a long way toward optimizing spine outcomes. Our goal is always to see the patient as a whole person to achieve the best outcome.

Taking a history, showing patients the imaging and telling them: “Here’s the issue, and here’s what we’re going to do to fix it” isn’t enough. It’s almost always more complicated than that.

By considering the whole person before surgery, my colleagues and I are able to optimize spine outcomes.

Duane W. Densler, M.D., is a neurosurgeon with Norton Leatherman Spine.

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