spinal fusion Archives

Transformative surgery: A catalyst for a girl’s future career aspirations

February 14, 2024

“I knew something was wrong because Gabi couldn’t walk in a straight line or ride a bike,” said Gabi’s mom, Petrice Young. “Since the surgery, she’s a different person. Dr. Oetgen literally changed her life.”

When Gabi, 17, went for her 12-year checkup, her pediatrician noticed a deformity in her spine. He quickly recommended Gabi make an appointment at Children’s National Hospital with Matthew Oetgen, M.D., chief of Orthopaedic Surgery and Sports Medicine. The X-rays indicated Gabi had a very large, 73 degree thoracic and 77 degree lumbar, double-S curvature in her spine and it was likely that as she continued to grow, the curve would get bigger.

Surgery was the best next step. The news came as a surprise to Gabi and her family, especially since she wasn’t experiencing any pain at the time.

“I knew something was wrong because Gabi couldn’t walk in a straight line or ride a bike,” said Gabi’s mom, Petrice Young. “Since the surgery, she’s a different person. Dr. Oetgen literally changed her life.”

Gabi was discharged just four days after her spinal surgery.

As a junior in her high school’s biomedical magnet program, Gabi actively participates as a cheerleader and is currently in her third year as a member of the softball team – something she’d never done before. She maintains a 4.0 GPA and participates in community service regularly.

Her dream career? Becoming an orthopaedic surgeon one day, expressing that her personal experience with the surgery will contribute to fostering a unique and meaningful patient-doctor relationship. She is extremely grateful to Dr. Oetgen for performing the surgery and influencing her career goals.

A program developed to treat the wide range of pediatric spine patients

Since 2015, patients undergoing spinal fusion at Children’s National have been part of the first-of-its-kind pediatric Spinal Fusion Surgical Home care model. This model was developed by a multidisciplinary team with the goal to streamline care for adolescent idiopathic scoliosis (AIS) patients with an emphasis on increasing quality outcomes.

The team’s coordinated approach means they can deliver care more efficiently, resulting in shorter hospital stays and allowing children to come home as soon as it is medically safe. As a leader in this care concept, Children’s National has standardized the infection-control process, pain-management pathway and physical-therapy program for AIS patients who require spinal fusion.

What is AIS?

Gabi actively participates as a cheerleader and is currently in her third year as a member of the softball team – something she’d never done before.

AIS is a condition of the spine, which typically affects children between the ages of 10 and 14 years old, marked by an abnormal side-to-side shaped curve that measures 10 degrees or greater. There are two types of curves associated with idiopathic scoliosis – C-shaped (one curve) and S-shaped (two curves). Along with the curve, the spine also rotates or twists, pulling the ribs along with it. Children with idiopathic scoliosis may experience uneven hips and shoulders and the head may not be centered with the rest of the body.

The period of rapid growth poses the greatest risk for the progression of a child’s spinal curve. Even after reaching skeletal maturity, a child with a curve exceeding 50 degrees may continue to progress at a rate of one to two degrees per year throughout their lifetime.

Treatment of early onset scoliosis

Early onset scoliosis (EOS) is a curve in the spine present before the age of 10. Diagnosing and addressing spinal deformities in children before the age of 10 can significantly impact the long-term outcomes. Close monitoring allows healthcare professionals to intervene promptly if necessary, preventing the progression of the spinal curve.

Minimally invasive techniques are particularly advantageous in pediatric cases, as they often result in shorter recovery times, reduced pain and minimized disruption to a child’s normal activities. This approach aligns with the goal of returning the child to a normal, active life as quickly and seamlessly as possible. Some minimally invasive techniques for EOS include:

Casting – young children may be placed in what is called Mehta casting. In this advanced casting technique, the child’s chest and abdomen are casted. Every two to four months the cast is replaced as the child grows.
MAGEC™ (MAGnetic Expansion Control) spinal growing rods – these rods are surgically attached to the spine and doctors use an external remote control outside of the body to lengthen the magnetically controlled rod as the child grows. Traditional growing rods require multiple surgeries.

As part of the Growing Spine Study Group, Children’s National collaborates with other hospitals around the world to enhance care for EOS and related deformities.

The right facility

Children’s National is equipped to treat the most severe and high-risk cases of scoliosis. In rare cases, severe spinal curves can require month-long inpatient spinal halo-gravity traction prior to surgery. This can impede a child’s quality of life just as severely as the condition itself, often making eating, breathing and moving difficult.

Spinal halo-gravity traction can reduce the degree of surgical intervention necessary by accomplishing some gradual straightening of the spine prior to spinal fusion procedures. For severe spinal deformities, this has been shown to improve the safety and effectiveness of the final surgical procedure.

Recognizing the challenges posed by both the condition and its treatment, the surgery team at Children’s National endeavors to coordinate cases, providing patients with mutual support throughout the traction process.

Read more about our advances in Orthopaedic Surgery and Sports Medicine.

Advancing care: Innovations and learning in Spinal Fusion Surgical Home

December 23, 2023

“We are committed to discovering methods that eliminate variability in the care process and enhance the quality of care for pediatric orthpaedic patients,” says Matthew Oetgen, M.D., M.B.A., chief of Orthopaedic Surgery and Sports Medicine at Children’s National Hospital.

“We are committed to discovering methods that eliminate variability in the care process and enhance the quality of care for pediatric orthpaedic patients,” says Matthew Oetgen, M.D., M.B.A., chief of Orthopaedic Surgery and Sports Medicine at Children’s National Hospital. “The Spinal Fusion Surgical Home model is specifically designed for young patients with adolescent idiopathic scoliosis (AIS), laying the foundation for numerous other children undergoing various surgical procedures.”

The first-of-its-kind for pediatric patients, the Children’s National Spinal Fusion Surgical Home continues to streamline care with an emphasis on increasing quality outcomes for patients. At its inception, the program implemented a newly developed model of care to optimize the spinal fusion process for AIS patients. As a leader in this care concept, Children’s National has standardized the infection-control process, pain-management pathway and physical-therapy program for patients undergoing spinal fusion.

The patient benefit

A patient with a right thoracic deformity of approximately 33 degrees and a left thoracolumbar deformity of 54 degrees was treated with an instrumented posterior spinal fusion from T4-L3 and was admitted for 5 days post-operatively.

Children’s National has implemented standardized protocols and ongoing enhancements, including the establishment of a specialized surgical team and the integration of a Lean process analysis. This has led to a notable decrease in the average length of stay for spinal fusion patients from about five days to three days. The surgical home has also reduced the transfusion rate from 30% to 12% and patient pain scores have decreased. Additionally, the number of patients who have returned to the emergency department due to complications has also decreased.

In a case prior to the surgical home model being established, a patient with a right thoracic deformity of approximately 33 degrees and a left thoracolumbar deformity of 54 degrees was treated with an instrumented posterior spinal fusion from T4-L3 and was admitted for 5 days post-operatively. Per standard protocol at the time, this patient stayed in the intensive care unit (ICU) immediately after surgery for a day and a half.

In another case, a patient with a right thoracic deformity of 58 degrees and left thoracolumbar deformity of 67 degrees was treated with a similar instrumented posterior spinal fusion from T4-L3 and admitted for 2.5 days post-operatively. With the new model in place, this patient did not need any time in the ICU, required less length of stay and had less loss of blood.

“By working together with all our care givers, we have been able to standardize our care and decrease care variability. This has proven effective at improving outcomes allowing our patients to recover faster and avoid complications. These cases are an example of our system being primed to treat children with ever increasing complexity with better and better outcomes,” says Dr. Oetgen.

x-ray of a patient with a right thoracic deformity

A patient with a right thoracic deformity of 58 degrees and left thoracolumbar deformity of 67 degrees was treated with a similar instrumented posterior spinal fusion from T4-L3 and admitted for 2.5 days post-operatively.

Children’s National leads the way

Over the years, the Spinal Fusion Surgical Home has continuously fine-tuned its approach, resulting in greater success outcomes and better patient care. Children’s National orthopaedic experts have published many articles highlighting this evolution:

Lean process mapping: Implementation of a standardized care pathway developed with the use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative and post-discharge care. Since 2015 our program has demonstrated effective and sustained improvements to the care of patients and decreased postoperative length of stay.
Significant decrease in perioperative blood transfusions: A study published in Pediatric Anesthesia details team findings that implementation of blood-conservation strategies as part of a perioperative surgical home for patients with AIS undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.
Reduced patient length of stay: An in-depth Lean process mapping technique improved outcomes and decreased length of stay of patients, as outlined in an article in Spine Deformity, through use of a standardized care pathway. Work to improve surgical efficiency, intraoperative fluid and blood management, and postoperative pain management continues to further improve effectiveness.
Standardization of intraoperative pain control: A study published in the Journal of Anesthesia on the implementation of the medical home model for AIS-improved pain control and decreased opioid consumption and hospital stay. Through pathway standardization, consistent multi-modal analgesia and early mobilization, the medical home model improved outcomes and is our standard of care.
Reduction in perioperative outcome disparities: Acknowledging the well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients across healthcare, the team documented and published findings that this model was able to reduce racial and ethnic disparities in length of stay and pain scores.
Dedicated surgical team: Having dedicated spine personnel in the operating room decreases surgical time and improves clinical outcomes, as detailed in a study on Spine Deformity.

Read more about our advances in Orthopaedic Surgery and Sports Medicine.

2020 at a glance: Orthopaedic Surgery and Sports Medicine at Children’s National

July 20, 2020

The Children’s National Division of Orthopaedics is consistently recognized by U.S. News & World Report as one of the top programs in the nation.

Surgical home program for spinal fusion achieves long-term success

November 9, 2018

“Our primary goal was to improve the value of care for children with scoliosis and their families,” says Dr. Oetgen. “Even better, we’ve shown that this model can be used consistently over time to maintain the benefits it delivers to this patient population.”

“Creating an effective process that benefits patients, is sustainable long term and doesn’t increase costs is one of the most challenging parts of any new procedure, both in health care and beyond,” says Matt Oetgen, M.D., chief of Orthopaedic Surgery and Sports Medicine at Children’s National.

Dr. Oetgen’s team accomplished this feat when building the Children’s National Spinal Fusion Surgical Home. The team used LEAN process mapping at the outset to engage a broad group of care providers who established a collaborative environment that empowered and engaged everyone to take ownership over a new care pathway for every patient who undergoes posterior spinal fusion surgery at the hospital.

This unique model designed using proven business process development tools has allowed patients require fewer pain medications after surgery and have shorter stays in the hospital. Even better, the team has maintained the integrity of the pathway consistently over a longer period of time than any other pediatric spinal fusion care model to date.

“Our primary goal was to improve the value of care for children with scoliosis and their families,” says Dr. Oetgen, who was the study’s lead author. “Even better, we’ve shown that this model can be used consistently over time to maintain the benefits it delivers to this patient population.”

The team conducted a retrospective analysis of prospective data from all patients (213) undergoing posterior spinal fusion at Children’s National Health System from 2014 to 2017, a period of time that captures nearly one year before implementation of the new pathway and 2.5 years after implementation. The outcomes were reported in the Journal of Bone and Joint Surgery.

As pressure builds to increase the value of care, many hospital systems are trying standardized care pathways for many complex conditions, in an effort to decrease care variability, improve outcomes and decrease cost. Previous research has shown the effectiveness of a variety of standardized pathways with wide ranging goals for spinal fusion procedures, however, most published studies have focused only on the initial success of these pathways. This study is the first to look at the implementation over a period of 2.5 years to gauge whether the process and its effectiveness could be maintained long term.

The authors attribute physician buy-in across disciplines and strict adherence to pathway processes as key to the success of this model. In addition, the team created standardized educational procedures for onboarding new care providers and implemented standardized electronic order sets for both orthopaedic and anesthesia services to make the pathway easy to maintain with little deviation over time. Lean process mapping at the outset included a broad group of care providers who established a collaborative environment that empowered and engaged the entire team to take ownership over the new process.

“We used proven business models for culture change that were critical to the success of this program,” Dr. Oetgen says. “We’re proud of the model we have created and think it would work well in other pediatric hospitals with similar patient populations.”

Improved procedures, reduced harm: Moving the needle on spinal fusion

January 29, 2018

In many cases of pediatric scoliosis, a surgical posterior spinal fusion – a life-changing yet complicated process – is needed to straighten the spine.

As part of its ongoing transition to value-based care, Children’s National is constantly reevaluating systems and processes across specialties and proactively seeking ways to deliver the highest quality care. This includes treatments for everything from the rarest of diseases to more frequent conditions, such as pediatric scoliosis.

In many cases of pediatric scoliosis, a surgical posterior spinal fusion – a life-changing yet complicated process – is needed to straighten the spine. The procedure involves permanently fusing bones over the curved part of the spine and requires expert coordination among physicians, nurses and therapists. To improve the procedure and make it as safe and efficient as possible, experts at Children’s National developed a first-of-its-kind pediatric spinal fusion surgical home, an innovative, family-centered approach that is making a real impact.

Prior to this initiative, patients who underwent posterior spinal fusion to treat scoliosis spent multiple days across multiple units in the hospital. Thanks to a comprehensive care pathway with input from all care providers treating these patients, overall recovery time has been reduced as well as days in the hospital. This in turn decreased the costs to both the families and Children’s National.

In the first six months of implementation, changes included decreasing the average length of stay from approximately five days to three and a half days, decreased blood transfusion rate and less use of opioid pain medications. Each of these pieces directly contributes to the safety of a child and decreased costs across the board. Ultimately, implementing cutting-edge practices like these brings the organization closer to zero harm and helps move the needle on patient care across the industry.

Spinal fusion surgical home helps kids go home sooner

September 28, 2016

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The first of its kind for pediatric patients, the Children’s National Spinal Fusion Surgical Home implements a newly developed model of care to streamline and optimize the spinal fusion process for adolescent idiopathic scoliosis patients.

Using frameworks of care used in adult models, along with best practices and literature reviews, a multidisciplinary team developed the first Spinal Fusion Surgical Home for pediatric patients. It standardizes the infection-control process, pain-management pathway, and physical-therapy program for patients undergoing spinal fusion.

“This model eliminates variability in the care process and increases the quality of care for pediatric patients,” said Matthew Oetgen, MD, MBA, Chief of Orthopaedic Surgery and Sports Medicine. “It’s just the start—by developing this model specifically for our young patients with adolescent idiopathic scoliosis, we are paving the way for a number of other kids that require different kinds of surgeries.”

Hallmarks of the spinal fusion surgical home
From pre-operative care through recovery, the Spinal Fusion Surgical Home streamlines care with an emphasis on increasing quality outcomes for patients. Children’s National provides an informational website and a single point of contact for scheduling procedures and pre-operative laboratory exams. Before surgery, patients and families attend an evening education class that features presentations from orthopaedic nurse practitioners, physical therapists, and anesthesiologists.

After surgery, a nurse follows up by phone to assess how the patient is handling pain and healing.

Increasing the quality of care
By implementing these standardized protocols, Children’s National has seen a decrease in the average length of stay for spinal fusion patients from about five days to three and a half days. The surgical home also has reduced the transfusion rate from 30 to 12 percent, and patient pain scores have decreased. “Patients are getting better faster with less pain, and are getting to leave the hospital sooner,” says Karen Thomson, MD.

Children’s National also is creating surgical homes for sickle cell disease patients, who need a variety of different types of surgery, as well as for children who need Nissen fundoplication and heart surgery.

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