Introduction: Overlapping surgery has come under increasing scrutiny, but there is little evidence to support or refute the safety of this practice.
Methods: A retrospective cohort study for patients who underwent spinal surgery at Emory University Hospital Midtown, a large academic referral hospital, between January 1, 2015, and December 31, 2017 for a single surgeon (DR). Cases were categorized as overlapping surgery (OS) if the attending surgeon had a separate case with overlapping in-room time; otherwise, surgeries were categorized as non-overlapping surgery (NOS). Investigators were blinded to study cohorts during data collection and analysis. Preoperative risk stratification used the American Society of Anesthesiologists (ASA) score. The primary outcome measure was complications in the perioperative and 90-day windows stratified as major, minor, and durotomies. Overlapping vs non-overlapping cohorts were compared using Fisher exact test for categorical data and analysis of variance for continuous variables.
Results: A total of 520 patients were included. A total of 311 (60%) surgeries were NOS while 209 (40%) were OS. The preoperative risk stratification was similar between both cohorts (p=0.85). Overlapping cases had significantly longer mean in-room time (OS 208 vs NOS 192 minutes, p=0.023) and mean surgical time (opening to closure) (OS 144 vs NOS 132 minutes, p=0.041). There was no difference in major complications between cohorts (NOS 2.9% vs OS 2.1%, p-value 0.84), and no difference in minor complications between cohorts (NOS 3.5% vs OS 3.9%, p-value 0.12); however, there were more durotomies in the overlapping cohort (NOS 3.3% vs OS 4.2%, p-value 0.041). Examples of major complications included new permanent neurologic deficits and reoperations for CSF leaks, infection, or hardware failure. Examples of minor complications included urinary tract infection, transient urinary retention requiring discharge with catheter, or wound infection not requiring revision. There was no difference between groups for return to OR or need for lumbar drain.
Conclusions: These data suggest that OS can be safely performed if appropriate precautions and patient selection are followed. Data such as these will help determine health care policy to maximize patient safety.
Patient Care: Suggest guidelines for safe overlapping surgery
Learning Objectives: 1. Review definitions of in-room time, skin-to-skin surgery time, and critical stages, and surrounding controversy
2. Describe factors that are affected and not affected by overlapping surgery
3. Discuss recommendations for planning overlapping surgeries