Perioperative considerations in spinal deformity surgery

Spinal deformity correction remains one of the most challenging surgical procedures in spine surgery. Historically, it has been associated with high complication rates. Despite advances in surgical approaches, modern instrumentation, and innovative technology, surgical correction of adult spinal deformity (ASD) continues to present a challenge in the preoperative, intraoperative, and postoperative period for spine surgeons. While the technical aspects of ASD surgery are often the primary focus during residency and fellowship training, perioperative considerations are sometimes not emphasized. Multimodal planning to address perioperative concerns in ASD surgery is critical to not only optimize clinical outcomes, but also to minimize perioperative complications and associated costs. In this review, we present articles published within the past 2 years to highlight the importance of five considerations in perioperative planning for ASD surgery: preoperative risk stratification, blood loss management, intraoperative safety, infection risk, and cost effectiveness. Preoperative risk stratification can be performed using assessment tools such as the American Society of Anesthesiologists (ASA) classification and the Modified Frailty Index. Blood loss management strategies include intraoperative blood salvage as well as the use of antifibrinolytic agents. Intraoperative safety encompasses intraoperative neuromonitoring and radiation exposure. Risk stratification can help identify patients at high risk for infection, and strategies to reduce surgical site infections include the use of vancomycin powder. Last, the cost effectiveness of ASD surgery remains a topic of interest for future studies as comprehensive cost-benefit analyses are still lacking in the current literature.