The SSTP calls for a live, in-person preoperative multidisciplinary evaluation and discussion of all complex spine patients [13]. This comprehensive multidisciplinary medical review and consultation is aimed at ensuring that the patient receives optimal treatment, whether surgical or nonoperative. The discussion is focused on the potential risk of complications and the steps to mitigate these risks should spine surgery be deemed necessary.

Once a patient has been deemed as a potential operative candidate for the correction of a major lumbar kyphoscoliotic deformity based on the surgical evaluation, their case progresses to the multidisciplinary review conference. These conferences are conducted on a monthly basis. These conferences involve representatives from many medical and allied health specialties, including cardiologists, physiatrists, specialized complex spine anesthesiologists, neurologists, intensivists, internists, neurosurgeons, and orthopedic surgeons. Allied health specialists involved in the conferences include physiotherapists, nurses, physician’s assistants, and clinical researchers. At least two members of the dedicated complex spine anesthesiology team play an integral role in the review of each case. The spine clinic nurses who coordinate the preoperative complex spine patient education class are also in attendance.

The anesthesiologists and an internist review each patient’s history and medical issues before the conference. A written summary of the patient’s past medical history, their spine clinic evaluation summary note, relevant laboratory values, and screening tests (electrocardiogram, echocardiogram, etc.) is then generated and sent to the conference participants a week prior to the conference date for review.

For each patient, discussion focuses on both the proposed surgical correction, the correction process, and the preoperative and postoperative medical issues relevant to the patient. One hallmark of the conference discussion is that both non-surgeon members (e.g., internal medicine, anesthesia) and surgeon members of the committee have equal power to decide the suitability of a case for surgery. The views of all attendees are taken into account and seriously considered.

This “equal voice” setup differs from traditional approaches taken at other institutions. It has been our experience that in most academic institutions and spine surgery practices, the surgeons wield the primary decision-making power. They are the ones who, often without involvement of other clinicians, make the decision when it comes to determining whether or not to move ahead with surgery. In these situations, the non-surgeon members of the patient care team are often left to attempt to prepare patients as best as possible preoperatively and care for them postoperatively, all the while wondering why a particular patient was ever selected for surgery in the first place. Because of differences in training, patient exposure, and experience, these stakeholders may be more acutely aware of factors that may be critical in the preoperative decision-making process to maximize patient safety and decrease the risk of complications. With the increasing specialization of medical care, we believe that it is not realistic to expect that a complex spine surgeon can nowadays fully understand and effectively manage the various cardiac, pulmonary, hematologic, and renal risks and complications that may arise for every patient under time pressure.

The SSTP requires that each surgical patient has majority, although not unanimous, support from all interested parties mentioned above who are involved in the conference. This protocol requirement does mean that patients who might appear to be surgically viable based on radiographic imaging, physical examinations, and clinical history can be deemed unsafe for surgery due to factors or concerns raised by the non-surgeon members of the conference review team. The developers of the SSTP [13] firmly assert that this focus on removing the influence of potential biases driven by politics and economic incentives in the decision-making process is critical to ensuring that an appropriate and safe decision is made for every patient.

A significant proportion of potential complex spine surgery patients is rejected as a result of the multidisciplinary conference review process. Over the past 5 years, the multidisciplinary medical team involved in the SSTP conference review process came to the decision that approximately 25 % of patients initially presented at the conference had medical conditions that rendered them unsuitable for the extent of complex surgical treatment that was being proposed. When this outcome occurs, the case may be deferred until further workup is completed or a nonoperative plan is proposed and pursued for these patients [25]. In some instances, a patient may require medical optimization or further studies before a reliable final decision can be made. These delayed patients are exposed to further in-depth evaluation and pretreatment processes based on the conference discussion and are then brought back for re-review at a later date.

The result of each patient’s conference discussion is summarized and placed into the medical record. The primary surgeon also discusses the results of the conference review directly with the patient. This discussion facilitates a shared decision-making process, which values and takes into account the concerns, views, and preferences of the patient.

The preoperative multidisciplinary conference is designed to reduce a multitude of potential short- and long-term postoperative complications through appropriate patient selection and preoperative optimization. Figure 6.2 links the preoperative multidisciplinary conference process with each main risk it is designed to address.

Osteoporosis can substantially impact outcomes associated with complex spine surgery [26]. A patient’s bone quality is therefore an important consideration in the preoperative evaluation and decision-making process. All patients receive a preoperative DEXA scan. The T-score at the femoral neck is the primary bone quality measure that is taken into account. Any patient classified as being osteopenic (T-score between −1 and −2.5) is considered for cement augmentation at two locations at the time of surgery: the upper instrumented vertebra (UIV) and the vertebra above the UIV. Low bone mineral density is significantly associated with proximal junctional kyphosis in patients with adult scoliosis [26]. For any patient with a T-score less than −2.5, the team is unlikely to recommend surgery as an appropriate course of treatment except in rare cases of severe neurologic compromise or decline. These osteoporotic patients are referred to endocrinology and are evaluated for appropriate treatment with teriparatide by the endocrinology team.

Once a patient has been cleared by the conference and has been deemed eligible for surgery, they enter the next phase of the SSTP. All surgical patients attend a 2-h education class run monthly by clinic nurses and one of the spine deformity surgeons. This class focuses on the postoperative recovery period and involves a question-and-answer session and the distribution of printed materials to foster understanding. All patients are then engaged in a lengthy informed consent process that includes a discussion of risks. Risks discussed include the likelihood of severe bleeding, infection, proximal junctional kyphosis, implant failure, postoperative neurologic injury, blindness during spine surgery, stroke, and death [3, 27–30].

At this point, an internist performs a more detailed preoperative evaluation. Depending on the patient’s needs and the conference discussion, further cardiac evaluation for these patients is obtained based on the guidelines of the American College of Cardiology and American Heart Association for perioperative risk stratification [31]. Pulmonary function tests are obtained if needed [32]. If the patient has normal preoperative hematologic and coagulation panels, they have four units of packed red blood cells and four units of thawed plasma crossed and typed. If the evaluation team discovers abnormalities in hematocrit or coagulation, an additional workup is completed involving both internal medicine and hematology.

Members of the acute pain service team in the Department of Anesthesiology also evaluate all patients to further assess their baseline pain and current pain regimen. This analysis informs the development of a tailored individual perioperative pain regimen for each patient. The attending anesthesiologists who direct the pain service and supervise the resident and fellow team are closely involved with the complex spine surgery team. These pain anesthesiologists are therefore keenly aware of the unique issues and problems that may be faced by these patients. They understand the importance of early mobilization and frequent communication with members of the daily rounding primary spine care team.

Figure 6.3 presents an activity diagram that synthesizes the entire preoperative evaluation process. This diagram illustrates the process steps and key decision points for (1) the preoperative medical evaluation, (2) the multidisciplinary review conference, and (3) further post-conference preoperative evaluation activities. The preoperative evaluation process is multifaceted, systematic, comprehensive, and structured.

Recently published data suggested that the processes of the SSTP have significantly reduced complication rates even in an institution where baseline complication rates were lower than published practice benchmarks [13]. Outcomes of complex spine surgery patients who were exposed to the full SSTP process were compared to the outcomes of patients who underwent complex spine surgery prior to the implementation of the SSTP. The overall complex spine surgery complication rate of 16 % in the SSTP group was significantly lower than the total complication rate of the non-protocol group (52 %). The SSTP group was less likely to return to the operating room during the postoperative 30-day period (0.8 % vs. 12.5 %) and showed significantly lower rates of urinary tract infection requiring antibiotics (9.7 % vs. 32.5 %) [13].