Seminars in Spine Surgery最新文献

Purpose

Methods

Results

Conclusions

The artificial intelligence (AI) revolution is underway. AI has become omnipresent in medicine, and its broad capabilities have permitted significant developments in many subspecialties including spine surgery. With AI, spine surgeons have been able to perform advanced computational analytics on vast amounts of data, allowing for solutions in each step of patient care from preoperative evaluation and planning, intraoperative execution, and postoperative evaluation. The tremendous potential of AI in medicine is clear and exciting. However, as the utility of AI in clinical practice expands, the medicolegal implications of this technology are poorly understood. In this chapter, we explore the existing technology, ethical considerations, legal challenges, and risk management strategies as it relates to AI in the field of spine surgery.

This article explores the transformative impact of telemedicine on spine surgery, tracing its evolution from historic roots to its expansion during the COVID-19 pandemic. The widespread adoption of telemedicine is discussed, highlighting some of its benefits such as increased patient accessibility and satisfaction. Despite its advantages, telemedicine introduces complex legal considerations, specifically concerning licensure, malpractice and data security. The article examines the challenges spine surgeons face when practicing telemedicine across state borders, the nuances of malpractice liability in virtual settings, and the importance of maintaining high standards of care. It also highlights the importance of adhering to HIPAA regulations, ensuring secure data transmission, and navigating reimbursement complexities. This article should serve as a thorough guide for spine surgeons navigating the evolving telemedicine landscape, balancing innovation with patient safety and legal accountability.

Medical malpractice is defined as an omission or act that deviates significantly from the norms of medical practice and leads to harm or injury to the patient. The key legal elements of medical malpractice are 1) the presence of a patient-doctor relationship, 2) failure to meet a standard-of-care, 3) evidence of injury relating directly from sub-standard care, and 4) harm relating to that injury. If a patient feels as though they have been a victim of a medical error, the first step in the process of beginning a claim is that the patient/plaintiff will consult with an attorney who specializes in malpractice. If the case is determined to be valid, a suit can be filed to initiate a pre-discovery and deposition process. During the discovery process, information is gathered through interrogatories, requests for disclosure, requests for production, requests for admission, expert reports, and depositions. The pre-trial process generally culminates in a deposition. This step involves a formal proceeding whereby the physician provides a recorded testimony under oath, which may be used in the future if the suit is brought to court. Following this process, suits can be dropped, settled, or end in the pursuit of a trial. When a defendant is found liable in a medical malpractice case, the plaintiff is entitled to indemnity payments in proportion to the harm and damages associated with the malpractice case. Indemnity payments are expected to cover various damages, including economic, non-economic, and less often punitive damages. Economic damages include tangible medical costs, like medical bills, future medical care, lost wages, and future lost wages associated with the injury or disability resulting from the malpractice event.

Spine surgeons face significant medicolegal risks over the course of their careers. Malpractice law is fragmented with an extensive variety of regulations depending on the individual state. The political environment in the United States is unlikely to address tort reform in the foreseeable future. Therefore, it is incumbent on spine surgeons to be familiar with the medicolegal framework and the strategies to mitigate risk. Additionally, with the growing use of enabling technology including navigation, robotics, and artificial intelligence, many questions remain about the impact of these systems on patient care and the responsible parties when the machines become more autonomous.

Study Design

Retrospective cohort

Background

The addition of an anterior cervical plate to a structural allograft during ACDF is thought to provide extra stability and enhance fusion, but it may increase the risk of complications like dysphagia. Stand-alone cages were designed to provide this extra stability without the need for the plate, but these may increase a patient's risk of subsidence, cervical dislocation, and cervical kyphosis. The purpose of this study was to assess reoperation rates and radiographic outcomes during follow-up longer than 6 months for patients who underwent ACDF with a cage and plate compared to stand-alone cage.

Methods

ACDF cases were retrospectively identified for four fellowship trained spine surgeons from 2016 – 2020 from two academic hospitals. A total of 57 stand-alone structural allograft constructs were matched via propensity scoring with a cohort of 65 patients with plate-secured structural allograft constructs. The primary outcome was reoperation rate within the follow-up period and secondary outcomes included complications, operative characteristics, readmission within 30 days, reoperation within 30 days and within follow-up, and radiographic outcomes. Immediate post-operative radiographs were compared to final follow-up radiographs at least 6 months post-operation to assess for evidence of subsidence, fusion, and change in cervical kyphosis using the Cobb angle technique.

Results

There were 5 patients (5.26 %) in the stand-alone cohort and 4 patients (3.15 %) in the plate cohort that had cervical reoperation at any time in follow-up (P = 0.83). At final follow-up, 58 patients (92.1 %) in the plate group and 37 patients (75.5 %) in the stand-alone group had radiographic evidence of fusion (P = 0.015). There were 38 patients (77.6 %) in the stand-alone group and 29 patients (46 %) in the plate group with evidence of subsidence (P = 0.0007). Patients with subsidence had a greater change in kyphosis angle at final follow-up and this change was significantly decreased in the plate group compared to the stand-alone group.

Conclusion

The use of anterior cage-plate constructs in ACDF produces higher rates of fusion and lower rates of subsidence than stand-alone cage constructs. Subsidence significantly increases the change in kyphosis angle between post-op and final follow-up, and the presence of a spanning plate significantly reduces this angle change compared to stand-alone cages. There were no statistically significant differences in reoperation rates, regardless of radiographic evidence of subsidence.

Professional athletes are prone to spinal injuries, and the treatment of this distinct patient population involves additional medicolegal challenges that must be considered. Catastrophic complications and delay in treatment of complications are linked with plaintiff verdicts in legal claims. Clear communication, thorough informed consent, and prompt disclosure of errors or complications can mitigate litigation risks. Effective collaboration with the athletic team is important in optimizing a safe return to competitive play.

Robotic assistance for spine surgery has seen a resurgence in the last decade, with numerous navigation-integrated robotic systems now available for commercial use. This paper briefly reviews the historical context of robotic surgery, summarizes the current robotic spine surgery platforms, and outlines medicolegal implications and general trends of litigation for spine surgery as they relate to robotic navigation. The focus of this review is on pedicle screw instrumentation, complications, and the learning curve for robotic navigation, and how these aspects relate to medical malpractice claims.

Spinal surgery is recognized as one of the most legally challenging specialties in the medical profession, with a history of complex and enduring issues related to medical malpractice. Spinal surgeons must be knowledgeable about common causes of medical malpractice in spinal surgery, such as intraoperative adverse events, wrong-level surgery, and neurologic surgery. Surgeons must stay informed about tort reform legislation in their respective states and their potential implications for their practices.