Alexander T. Yahanda

BACKGROUND: Given surgery's inherent risks, a patient should be able to make the most informed decisions possible in selecting surgical treatment. However, there is little information on what factors patients deem important when choosing a surgeon. We performed a systematic review of the literature focused on how patients select surgical care, focusing on identification of factors that influence patient choice as well as important sources of information used by patients. METHODS: A search of all available literature on factors associated with choice of surgeon/surgical care, as well as sources of information used by patients before undergoing surgery, was conducted using the MEDLINE/PubMed electronic database. RESULTS: Of the 2315 publications identified, 86 studies met inclusion criteria. Overall, patients draw upon a wide range of factors when choosing surgical care. Surgeon reputation and competency stood out as the most valued professional attributes. Patients also often selected surgeons based on their interpersonal skills. Many patients chose surgical care using hospital, rather than surgeon, characteristics. For these patients, hospital reputation and hospital distance were factors of primary importance. Importantly, most patients relied on word-of-mouth and physician referrals when choosing a surgeon. Patients also expressed interest in quality information on surgeons, indicating that these data would be useful in decision-making. CONCLUSIONS: Patients draw upon a myriad of factors when choosing a surgeon and the circumstances surrounding patients' decisions maybe differ based on sociodemographic, cultural, as well as other factors. Additional information on how patients choose surgeons or hospitals will help providers assist patients in finding their preferred caregivers.

Spinal metastases are common in patients with cancer. As cancer treatments improve and these patients live longer, the number who present with metastatic spine disease will increase. Treatment strategies for these patients continues to evolve. In particular, since the prospective randomized controlled study in 2005 by Patchell et al . showed increased survival with decompressive surgical treatment of spinal metastases, there is a growing body of literature focusing on surgical management and complications of surgery for this disease. Surgery is often one component of a multimodal treatment approach with chemotherapy and radiation, which makes it difficult to parse the benefits of each individual treatment in outcome studies. Additionally, there has been more recent emphasis placed on patient-reported outcomes (PRO) after treatment for metastatic spine disease. In this review, we summarize treatments of metastatic spinal disease, possible perioperative complications, and validated tools used to assess outcomes for these patients.

Shared decision making (SDM) is a desirable process and outcome of patient-clinician relationships. Ideally, patients and clinicians have sufficient time to engage in SDM. In reality, time is often insufficient. This article explores time as a barrier to SDM, alternative ways clinicians can think about time, and steps they can take to have fulfilling SDM interactions despite time constraints. Although discussions of time typically focus on time quantity, redirecting attention to the ethical significance of time in establishing patient-clinician relationships suggests the importance of also considering time quality. Time as a Barrier Shared decision making (SDM)-the process by which clinicians and patients work together to make health care decisions that align with patients' goals, preferences, and values-is an ideal outcome of patient-clinician relationships. 1 Yet multiple potential barriers obstruct SDM in real-life clinical practice. Chief among these is time, particularly the amount and quality of face-to-face time clinicians and patients spend together. Studies have shown that both patients and clinicians view time constraints as a frequent and substantial barrier to SDM.

OBJECTIVE: Augmented reality (AR) is an emerging technology that has great potential for guiding the safe and accurate placement of spinal hardware, including percutaneous pedicle screws. The goal of this study was to assess the accuracy of 63 percutaneous pedicle screws placed at a single institution using an AR head-mounted display (ARHMD) system. METHODS: Retrospective analyses were performed for 9 patients who underwent thoracic and/or lumbar percutaneous pedicle screw placement guided by ARHMD technology. Clinical accuracy was assessed via the Gertzbein-Robbins scale by the authors and by an independent musculoskeletal radiologist. Thoracic pedicle subanalysis was also performed to assess screw accuracy based on pedicle morphology. RESULTS: Nine patients received thoracic or lumbar AR-guided percutaneous pedicle screws. The mean age at the time of surgery was 71.9 ± 11.5 years and the mean number of screws per patient was 7. Indications for surgery were spinal tumors (n = 4, 44.4%), degenerative disease (n = 3, 33.3%), spinal deformity (n = 1, 11.1%), and a combination of deformity and infection (n = 1, 11.1%). Presenting symptoms were most commonly low-back pain (n = 7, 77.8%) and lower-extremity weakness (n = 5, 55.6%), followed by radicular lower-extremity pain, loss of lower-extremity sensation, or incontinence/urinary retention (n = 3 each, 33.3%). In all, 63 screws were placed (32 thoracic, 31 lumbar). The accuracy for these screws was 100% overall; all screws were Gertzbein-Robbins grade A or B (96.8% grade A, 3.2% grade B). This accuracy was achieved in the thoracic spine regardless of pedicle cancellous bone morphology. CONCLUSIONS: AR-guided surgery demonstrated a 100% accuracy rate for the insertion of 63 percutaneous pedicle screws in 9 patients (100% rate of Gertzbein-Robbins grade A or B screw placement). Using an ARHMS system for the placement of percutaneous pedicle screws showed promise, but further validation using a larger cohort of patients across multiple surgeons and institutions will help to determine the true accuracy enabled by this technology.