In This Article
- Neurosurgery spine surgeons at Massachusetts General Hospital are treating the most challenging cervical spine deformity cases in the world by using intraoperative technology
- Cervical spine reconstructions are complex operations associated with high complication rates, and may require more than one type of surgical approach for patient safety
- Current research seeks to predict which patients will have successful surgeries using patient imaging data and predictive algorithms to anticipate, minimize and prevent early and late surgical complications
- John H. Shin, MD, has developed a multidisciplinary team that consists of experts in nursing, plastic surgery, neurology, and pain medicine to optimize outcomes and navigate recovery from cervical spine deformity surgery
Cervical spine deformities are debilitating neck conditions involving severe spinal cord compression that can lead to disability. For many patients, it may be difficult to keep their head up and conduct everyday tasks such as walking, eating and driving due to the pain associated with looking straight ahead. Surgeons in Massachusetts General Hospital's Neurosurgical Spine Service use a multidisciplinary approach to treat cervical spine deformities that improve patient outcomes using innovative technology including artificial intelligence (AI).
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"These are complicated surgeries that involve reconstructing and reconfiguring the alignment of the spine while delicately decompressing the spinal cord and nerve roots," says John H. Shin, MD, director of Spinal Deformity & Spine Oncology Surgery at Mass General. "Safely navigating these surgeries relies on sophisticated spinal instrumentation systems, intra-operative imaging, and the expertise of nurses, anesthesiologists, neurologists, and plastic surgeons. We can help patients with these severe conditions because we have the expertise and the technological and surgical innovations to do so. Most importantly, we have a culture of communication here that facilitates teamwork in the operating room."
Treatment Challenges for Cervical Spine Deformity
Severe cases of degeneration in the cervical spine can lead to scoliosis and kyphosis. Without treatment, these conditions can become severe, leading to pain and neurological and musculoskeletal issues. Problems also arise when patients experience poor outcomes from previous surgeries, such as inadequate spinal cord or nerve decompression, when too much bone and soft tissue is removed during decompression and with failure to fuse the spine together.
"If not carefully planned, surgery may not go well and that can lead to more pain and possibly revision surgery," says Dr. Shin. "Patients with these type of deformities come to Mass General because they have exhausted other medical treatment options and are looking for solutions to improve their function and quality of life. For many patients, these symptoms can even affect the way they eat and walk. They fall and lose balance. They can't look up. They can't drive."
Complexities inherent in spinal reconstruction procedures require expertise that many hospitals cannot incorporate into one center. Dr. Shin's team is able to treat challenging cases through a combination of clinical collaboration and utilization of advanced imaging systems available at Mass General.
Real-Time Imaging and Operative Navigation Improves Spinal Reconstruction Outcomes
Spinal reconstruction surgeries for cervical deformity often involves performing spinal osteotomies, in which bone is broken up to mobilize and loosen the spine. Surgeons need to be able to manipulate and re-contour the spine to the desired alignment and curvature. But they are limited by what they can directly see, especially deep within a body cavity,
Maintaining the precision needed to avoid harming nearby body structures—including the spinal cord, the nerve roots, major blood vessels, the esophagus or the aorta in the heart—can be challenging. "There are a number of landmines we have to deal with. The last thing any surgeon wants to do is cause damage to an important nerve or blood vessel," says Dr. Shin.
Mass General spine surgeons utilize sophisticated intra-operative imaging, including ultrasound and computed tomography–based computer navigation capabilities, to visualize and plan procedures in real-time. The O-arm imaging system allows surgeons to register and confirm anatomic landmarks, identify targets and rehearse trajectories, and verify accuracy throughout the operation in three dimensions. Dr. Shin's experience with applying this technology for cervical deformity has helped make these surgeries safer for patients at Mass General and beyond.
Minimizing Complications Through Multidisciplinary Collaboration
To minimize potential neurologic, medical and surgical complications during these lengthy surgeries, Dr. Shin works with a team of specialists in the operating room including neurologists and plastic surgeons. The neurophysiologist monitors nerve, spinal cord and brain function during the most critical portions of surgery. By leveraging this neurology expertise, Dr. Shin is able to detect and anticipate any changes in spinal cord or nerve function in real time, thereby preventing injury to these structures.
"The neurologists are integral to the operation and are constantly providing feedback to me and the anesthesiologist. Having them in the room is invaluable," says Dr. Shin. "If at any time during the surgery there is a change in the monitoring, I know to make adjustments in real time as it can make a difference in outcomes."
Plastic surgery also plays a vital role in these spinal reconstruction surgeries as meticulous closure of these incisions is critical to decreasing the chance of infection. If the soft tissues do not heal adequately, this can lead to additional operations that repeat skin closures. To combat these kinds of complications, Dr. Shin started a program where he works with plastic surgeons at the time of surgery—before complications arise. Bringing in plastic surgeons earlier allows them to perform the complex reconstruction required to prevent wound failure.
"The worst thing for a patient is to have an operation and then have to come back after rehab because the incision opened," says Dr. Shin. "These wound healing issues can delay the recovery process and prolong their hospitalization. Having our plastic surgery colleagues involved in the cases upfront has dramatically improved our results."
Postoperatively, spine surgeons collaborate with Mass General's Pain Management Center to minimize discomfort. Together, they developed specific protocols that maximize pain relief and limit narcotic use.
"This multidisciplinary nature is important, it is a key feature for why patients come to Mass General for evaluation and why those patients are referred here. Many referrals are from other spine surgeons – neurosurgery and orthopedics - and primary care physicians who defer to us, as these cases fall beyond the scope of the typical medical practice."
Leveraging Predictive Analytics and AI to Improve Success
Dr. Shin's research team focuses on developing predictive analytical tools for spine surgery. They have developed machine learning algorithms to help predict complications and failures associated with cervical deformity surgery. Using these decision making tools, Dr. Shin and his team seek to provide patients with better resources to make informed decisions about surgery and how to prevent spinal reconstruction failures.
"Spinal deformity correction redistributes biomechanical forces throughout the spine. Complications from the redistribution of these forces can be a major problem," says Dr. Shin. "If we can predict which patients or which types of constructs are more likely to fail given various biomechanical characteristics, then perhaps the operation can be designed in a way to account for that potential failure."
To try to predict and avoid these complications, his research team analyzes data from national databases along with their own, including imaging data from Mass General's EOS low-dose 2D/3D imaging system. Mass General is one of few facilities in the United States with this full-body scanner. These scanners provide full-body X-rays that allow surgeons to see a patient's spine, alignment and balance from head to toe. Dr. Shin uses it to plan surgeries for cervical spinal deformity patients, and his research team works to code this data so that artificial intelligence processes can eventually correlate the data with patient outcomes.
"These are some of the most maximally invasive operations," says Dr. Shin. "We are putting the patients through a lot to improve their quality of life. So it's key to take the guesswork out of surgery. Part of that is developing software and algorithms that can gather information from X-rays and CT scans. It will take a year or two to get some real data, but it's an exciting avenue."
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