Spine Division | Quality & Safety

Every year, we treat hundreds of patients with complex spine conditions that require surgery. Our goal with these patients is to perform the highest quality surgery while maintaining and fostering a culture of safety. In all aspects of care, at every stage of surgery, we adhere to a strict set of guidelines to ensure the highest standard of quality and patient safety.

Experience fosters quality

Surgical quality starts with a skilled clinical team, particularly for spine patients whose medical issues often require specific expertise. Our surgical team includes surgeons, anesthesiologists, and nurses, each with a dedicated role to safeguarding the patient’s safety.

• Our spine surgeons are responsible for ensuring that all surgical procedures meet scientific standards for safety and quality.
• Our anesthesiologists devote much of their practice to spine patients and have great experience managing the most complex medical conditions.
• Our nursing staff plays a large role in ensuring safety standards and making sure the surgical procedure is as efficient as possible.

Quality measures before spine surgery

Preoperative evaluation

All patients scheduled for spine surgery have a thorough review of their medical status one week before surgery. This includes an evaluation by the anesthesia team and a face-to-face meting with their surgeon to make sure all medical issues have been addressed. The family also has the opportunity to ask questions and be sure they understand the planned procedure at this time.

Surgical planning and consultations

Our team reviews the surgical plan for each patient with other clinicians several times before the day of surgery. This includes presentations at spinal education rounds, preoperative visits where up-to-date imaging is reviewed in consultation with radiologists if needed, and at surgical fellows conferences. This intense focus on planning ensures that when the day of surgery arrives, everything is in place and the surgical team is prepared to provide the best care for the patient.

Software-assisted surgical planning

Boston Children’s Hospital is one of the first and only pediatric hospitals to use a preoperative software program in conjunction with the Mazor X Stealth robotic navigation program. This software enables precise surgical planning for spinal instrumentation and spinal rod contouring, leading to improved safety and outcomes for patients.

High-risk spine surgeries

For patients with complex medical cases, our high-risk program conducts weekly multidisciplinary meetings of surgeons, anesthesiologists, and pediatric hospitalists from the Care for Children with Medical Complexity program. We review each case individually during these meetings to assure each child is ready for surgery. This innovative program has been shown to lead to better outcomes in patients with complex scoliosis. The program has also fostered research that has led to a significant reduction in the number of surgical site infections.

Quality and safety measures during surgery

Time out

At the start of every surgery, we take a time out in the operating room to review any and all patient safety issues such as allergies, antibiotic administration, and the size of the spinal instrumentation (the rods and screws that will be used to stabilize the spine). This standard procedure helps assure that every member of the surgical team is fully aware of any patient safety issues, has double checked the equipment, and has taken all necessary precautions to assure a safe procedure.

Neuromonitoring

Neuromonitoring is a routine part of every spine surgery at Boston Children’s that helps prevent any potential neurologic injury for the patient. Our surgical team routinely monitors the motor and sensory portion of the spinal cord as well as individual nerve roots throughout surgery. In addition, we have a dedicated team of neuromonitoring technicians who closely observe the electrophysiologic activity of the patient’s spinal cord during surgery.

Blood-loss prevention

Preventing blood loss is a top priority to avoid postoperative complications and prevent the need for transfusions after surgery. We recently performed a randomized prospective trial using a medication called TXA (tranexamic acid). The study showed the medication was associated with a lower blood loss and prevented the need for transfusions in patients with idiopathic scoliosis. The study was awarded the Hibb’s award at the Scoliosis Research Society meeting for the best basic science study.

Infection prevention

Surgical site infections can have devastating consequences for patients. Our quality and safety programs have demonstrated success in preventing surgical site infections in spine patients.

• Our high-risk program has shown to be effective in reducing surgical site infections in patients who present with unique medical problems that put them at risk for infection.
• Our time-out program has led to a 100 percent rate of antibiotic compliance in spine patients, one of the single greatest factors in reducing surgical site infections.

Quality-enhancing technologies

Robot-assisted surgery and navigation

Boston Children’s has a long, successful history of using surgical navigation techniques to assure safe, precise placement of spinal instrumentation (the screws and rods used to stabilize patients’ spines).

In 2019, the Spine Division became one of the first pediatric hospitals in the country to use the Mazor X Stealth robotic navigation system. During preoperative planning, the robotic system supports accurate, effective planning. During surgery, the system’s robotic arm and real-time imaging guide surgeons in finding precise locations and angles as they place spinal instrumentation in patients’ spines. In complex procedures in which precision is absolutely essential, this technology has been shown to improve accuracy and enhance patient safety.

Intraoperative CT scan

Since 2015, our surgeons have used an intraoperative CT scan, called the O-arm, which enables the surgical team to confirm the correct placement of spinal instrumentation, leading to higher accuracy and patient safety.

We recently published a series of case studies of complex cervical spine patients who underwent spinal surgery in which the O-arm was used. This series confirms that the use of O-arm in pediatric patients is an effective way to verify screw placement and can prevent incorrect positioning that could cause potential neurologic harm.

Quality and safety after surgery

Once a patient leaves the surgical area, a dedicated team of nurses, nurse practitioners, and physician assistants focus on opioid safety, discharge planning, post-discharge planning, and follow-up for continued safety. Through this team’s ongoing focus and intervention, we have been able to reduce our patients’ post-surgical length of stay, manage pain, and often reduce the duration and amount of opioid use for pain. This team-based strategy has reduced the number of patients readmitted after discharge, as well as led to higher patient and family satisfaction.