Personalized Approaches to Spine Surgery

Abstract

Patient-centric decision-making has imbued all aspects of health care, including spine surgery. This review describes how spine surgeons can use evolving technologies and knowledge of disease and pain states to tailor their surgical approach to the individual patient. This includes preoperative screening for and optimization of low bone mineral density, intraoperative selection of implant material and customization of interbody cages and screws, and postoperative personalization of pain regimens and rehabilitation courses. By working in a multidisciplinary fashion, spine surgeons can avail themselves of these advances to provide individualized care.

Keywords: artificial intelligence; biologics; bone mineral density; outcomes; pain; personalized medicine; robotics; spine implants; spine surgery; surgical planning.

Figure 1

An 80-year-old man undergoing preoperative spinal imaging. (A) Lumbar dual-energy x-ray absorptiometry scan. (B) Hounsfield unit (HU) bone mineral density at a given level is calculated as the average HU of the superior endplate, middle of the vertebral body, and the inferior endplate. (C) Vertebral bone quality is calculated by dividing the median signal intensity of the medullary portions of L1–L4 vertebral bodies by the average signal intensity of the cerebrospinal fluid at L3.

Figure 2

Algorithm for optimization of preoperative bone mineral density. *At this time, starting bisphosphonates as a single agent to treat osteoporosis specifically for surgery optimization is not generally warranted. However, surgery is not contraindicated and does not need to be delayed in patients who are currently receiving bisphosphonates

Figure 3

A 78-year-old man with a history of prior lumbar laminectomy underwent a 2-stage lumbosacral fusion: L3–L5 anterior lumbar interbody fusion and L2-pelvic minimally invasive fixation for severe back pain, right leg pain, and chronic right foot weakness. (A) Preoperative anteroposterior and (B) lateral full spinal imaging generated from an EOS scan, revealing severe degenerative changes, spinal stenosis worst at L2–L3 and L3–L4, and scoliosis with a significant mismatch between lumbar lordosis and pelvic incidence. (C) Postoperative coronal and (D) sagittal full spinal imaging generated from EOS showing instrumentation.

Figure 4

Fifty-two-year old man who underwent a T7 corpectomy with en bloc resection of a grade 2 chondrosarcoma and T5–T9 posterior fusion. This is an example of a case in which a custom implant would have been advantageous given the irregular margins of the tumor resection cavity. (A) Preoperative T1-post gadolinium magnetic resonance imaging revealed a 1.4 cm bony destructive mass within the T7 vertebral body and left pedicle with expansile component to the left paravertebral space and also left epidural component abutting the thoracic cord without cord compression (inset). (B) Postoperative computed tomography scan demonstrating an expandable titanium cage flush to the endplates of T6 and T8. (C) and (D) Postoperative stitched standing scoliosis films demonstrating anterior and posterior instrumentation.

Figure 5

Sixty-eight-year-old man who underwent posterior C2–T6 fusions extension into prior fusion construct and C2–T2 laminectomy for progressive cervical myelopathy status post prior T7 corpectomy and T4–T9 fusion following T6–T7 pathologic fracture secondary to osteomyelitis. (A) Preoperative magnetic resonance imaging demonstrating severe stenosis from C2 to T2. (B) Preoperative anteroposterior (AP) and (C) lateral EOS scans demonstrating prior posterior hardware. (D) Postoperative AP and (E) lateral stitched scoliosis films highlighting a titanium rod construct spanning C2–T9.