AO Spine Clinical Expert Advice Forums—Placing focus on situations where an expert opinion crucially matters

The AO Spine International Board Chairperson S. Rajasekaran refers to rare complications such as intraoperative vertebral artery injury, or the more frequent but alarming complications such as post-operative Cerebrospinal Fluid (CSF) leaking wound, or a dangerously positioned but asymptomatic pedicle screws. "These topics are not adequately covered in literature, and there is wide variation in the way they are currently managed across the world," Rajasekaran says.

These are exactly the situations Rajasekaran wanted to address by initiating the AO Spine Clinical Expert Advice Forums for six vital clinical scenarios. Each forum is comprised of five to seven international surgeons, most experienced in their respective fields, representing regions around the world. An international spread was ensured to prevent regional bias in the choice of treatment.

The six topics are:

1. Accidental tears in the dura mater that result in leakage of cerebral spinal fluid
2. Accidental laceration of the vertebral artery during surgery
3. Pedicle screws that are dangerously positioned but asymptomatic
4. L4–L5 instability with asymptomatic disc disease
5. Post-operative spinal infection in the presence of implants, interbody cages
6. Loss of signals during neurophysiological monitoring during surgery

These six expert advice forums resulted in six papers produced in a journal format, which will be published by AO Spine in a single collection. Altogether, the papers provide detailed advice derived from discussions involving 47 expert surgeons, practicing on 5 continents, in 15 countries, in more than 35 institutions.

"This process documents areas with high agreement amongst surgeons, but also areas where considerable difference of opinion and variations in preferences for management remain."

"These papers do not represent a formal randomized study and, understandably, have not gone through a formal peer reviewed process," Rajasekaran reminds. "But they represent a crystalized summary of the experience and expertise of the most respected spine surgeons across the world."

Variable expert responses through challenges in management

The challenges in the management of these difficult clinical scenarios is obvious. The experts were able to reach consensus on the overall goal and treatment strategy on a few topics, while in some other scenarios, the goal was the same but surgical approaches differed widely. In some scenarios, the management options from surgeons differed radically, exposing the need for a thorough study into the topic.

A significant pearl from the process are the tips and tricks provided by the experts, and the situations they identified as potentially requiring a change in treatment strategies. Additionally, in scenarios like the vertebral artery injury, the discussion detailed steps that should be taken preoperatively to avoid a potentially catastrophic event.

The surgeon responses were perhaps most variable for neuro physiological monitoring during surgery, which is used to identify potentially harmful changes in nerve function before irreversible damage occurs. Some aspects of the case studies produced widely different responses, with some surgeons indicating that a particular modality was part of standard guidelines, while others would use it if available, and some would not use it at all. The differences revealed by these forums highlight areas that require further research to develop a consensus among experts.

"The AO Spine Expert Advice Forums address clinical scenarios that pose problems to the practicing surgeon, but where randomized clinical trials are not possible."

AO Spine believes the AO Spine Clinical Expert Advice Forums can bring significant value to any surgeon’s daily practice, as it offers first-hand experience from world-renowned surgeons with a hands-on, practical approach. We thank the experts for their valuable contribution and the considerable time they spent on this endeavor.

We also invite you—our readers—to identify further areas of knowledge gaps where documented experience could be of help and reach out to us with your ideas.