Revision Deformity Surgery

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: October 1, 2025
Expiration Date: September 30, 2026

Estimated Time of Completion: 30 minutes

Revision Deformity Surgery
Jason Savage, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience
Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

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CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director
Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer
Cindy Willis, DNP

Faculty
Jason Savage, MD
Center for Spine Health

Host
Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Revision Deformity Surgery
Jason Savage, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen H Stevens, DO	DynaMed Consulting
Jason Savage, MD	Stryker Consulting Highridge Medical Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast October 1 , 2025 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neurorehab, and psychiatry.

Glen Stevens, DO, PhD: Spinal revision deformity surgery represents one of the most technically demanding and clinically nuanced areas in spine care. In this episode, we're taking a deep dive into the complexities of spine revision deformity surgery, a field where surgical precision, multidisciplinary coordination, and evolving technology converge to address some of the most challenging cases in spine care. I'm your host, Glen Stevens, neurologist, neuro-oncologist, in Cleveland Clinic's Neurological Institute. Joining me for today's conversation is Dr. Jason Savage, orthopedic spine surgeon and director of the Spine Deformity Program at the Cleveland Clinic. Jason, welcome to Neuro Pathways.

Jason Savage, MD: Glenn, thanks for having me.

Glen Stevens, DO, PhD: So Jason, as a means of introduction, tell us a little bit about yourself, where you trained, how you made it here, and what you do surgically on a daily basis.

Jason Savage, MD: Sure. So I did my orthopedic surgery residency at Northwestern in Chicago. I did my spine surgery fellowship at the University of Wisconsin. I returned to Northwestern for three years, worked there was on staff and then joined the Cleveland Clinic staff in 2015. So I've been here for 10 years now. I have a busy clinical practice, about 40 to 50% of that takes care of adult spinal deformity and complex revision surgery. The rest is everything else in spine. I am the director of the Spine Surgery Fellowship program here. That's a combined ortho and neuro spine program and also the program director of the adult spinal deformity program.

Glen Stevens, DO, PhD: Great. Yeah, I think that's one of the great things about the program, right? It's orthopedic spine surgeons, neurosurgeons combined together and you run multidisciplinary clinics and tumor boards or spine boards as it goes through.

Jason Savage, MD: Yeah. It's one of the only truly combined fellowship programs in the country and we're very proud of that and I think it really is an outstanding training program.

Glen Stevens, DO, PhD: So, when someone's out here listening to this and we say revision deformity surgery, tell our audience what you're talking about.

Jason Savage, MD: Yeah, so revision surgery in general just means that you're having spine surgery and you've had spine surgery before. That's what the reward revision means obviously, but a lot of our deformity patients are patients who have had multiple operations before and then come to us and we're correcting a postural problem. Oftentimes they have a lot of back pain, they have the inability to stand up straight and they oftentimes have neurologic symptoms as well.

Glen Stevens, DO, PhD: In the disease entities we're looking at, we're talking, I assume about scoliosis, kyphosis, failed fusions, that type of thing. Is there anything else?

Jason Savage, MD: No, that's right. There's a variety of different types of deformities that we see and treat. Degenerative scoliosis or what we call de novo scoliosis is basically an arthritic problem and the spine tends to kind of curve over time. There's idiopathic scoliosis, which is more of the scoliosis that develops in childhood. We have iatrogenic deformity and that's basically when patients have surgery before and they develop a postural problem potentially as a result of that other spine surgery, and that's what we call iatrogenic deformity.

Glen Stevens, DO, PhD: So I'm getting older. If you notice, you think I got some kyphosis, let me know.

Jason Savage, MD: Sounds good.

Glen Stevens, DO, PhD: We'll see if we can figure that out. So somebody comes in to see you. I've had scoliosis surgery, I come in to see you, I'm having a lot of additional problems. What are the indications for when you would decide that I need some type of revision surgery?

Jason Savage, MD: Yeah, that's a great question and I think it really depends on the symptoms. So most patients who come to see us are complaining of some sort of pain. They could be complaining of postural problems, but most of the time it's pain. Is it back pain? Is it leg pain? Is it sciatica pain? Are they having weakness in their legs? Patients who complain of postural problems complain of the inability to stand upright, complain of a lot of back pain as a result of not being on the stand wrap. Those are the candidates there. Those are the people we tend to look towards doing a deformity correction surgery on.

I tell patients you want to try to avoid deformity surgery like the plague unless you can't. And then if your symptoms kind of warranted and you're really having a lot of trouble and you're having a hard time standing up, those are the people we tend to offer these relatively large surgeries to take care of their deformity.

Glen Stevens, DO, PhD: And I'm sure it doesn't happen here, but statistically nationwide, what's the failure rate for deformity surgeries that people would have to have something else done?

Jason Savage, MD: Yeah, it's a good question. I think if you're looking at relatively smaller surgeries that we do, I think the revision rates are relatively low. They're probably less than 10, 15%. When you start getting into the more complex procedures, the deformity corrections, revision rates can be as high as 20, 25% even when we try everything humanly possible obviously to avoid those issues.

Glen Stevens, DO, PhD: And I'm sure that a lot of the issues are wherever somebody is structurally fused or however you do it, the segments above it and below it are at risk because they're not part of the whole thing and you don't want to fuse the entire spine. Are their specific ways the pain presents that helps tell you if they're not fused, they're not solid, those types of things? How do you tell?

Jason Savage, MD: Yeah, that's a good question.

Glen Stevens, DO, PhD: Other than just imaging.

Jason Savage, MD: Yeah, that's a good question. So, if people have had prior fusion procedures and they present to us complaining of relatively newer onset pain, what we call mechanical pain, they're having a lot of pain with activity with upright activities, that kind of gets us wondering, okay, what's going on here? We call it a little bit of a honeymoon period, which means that if people have spine surgery and they say, "Hey, I was doing really well for one year, two years, three years or whatever, then all of a sudden something kind of new happened." That to us says, "All right, something new is going on," and then we start to work up with usually with imaging studies and figuring out what's going on.

Glen Stevens, DO, PhD: So, what factors do you consider when you are determining whether a patient is a good candidate or a bad candidate for surgery?

Jason Savage, MD: Yeah, that's a good question and there's a lot that goes into that as you can imagine. It's a lot of the overall health of the patient. Can they tolerate surgery? Can they tolerate a relatively big surgery? If it's a deformity surgery, what are their comorbidities? Can we optimize these patients preoperatively? And that's why we're lucky here at the Cleveland Clinic, because we have a very talented multidisciplinary program that we use to try to really optimize patients prior to surgery.

I always tell patients, "Look, we're going to try to do those smallest surgery can take care of your problems." The problem with some of these deformities is that there's no small surgery that takes care of that problem, and that's when we start talking about potentially bigger operations. But I think it all goes about preoperative assessment, perioperative optimization in the preoperative period. Then obviously the surgery itself, and then trying to get people through these big surgeries as best we can postoperatively.

Glen Stevens, DO, PhD: And I imagine some patients, if you have a lot of thoracic scoliosis, kyphosis is going to affect your lung capacity and really limit your ability to function just by decreasing your pulmonary output.

Jason Savage, MD: Yeah, it could. The idiopathic curves that tend to develop earlier in life, really severe idiopathic curves, curves that are greater than 89 degrees can sometimes affect your cardiopulmonary function. It's actually rare in adults in degenerative scoliosis. So the scoliosis that develops later in life to actually have a negative impact on GI system, on lung system, on cardiovascular system, which is a good thing.

Now the problem is that as patients age, as you know, we develop other problems, and that's really what we're trying to optimize around the time of surgery. People with diabetes, we're trying to get their blood sugars better controlled. People have osteoporosis, we're trying to get them on better medications to build their bone up prior to these surgeries. Those are the sorts of things we're really focusing on to try to decrease mechanical failures and also decrease medical complications associated with the surgery.

Glen Stevens, DO, PhD: Are there nomograms out there that you can put in data from patients that can help? Again, it would be complicated, lots of different deformities, and then there'd be lots of different things. But does that exist or no?

Jason Savage, MD: That's a great question. It's starting to exist and I think that's really the future honestly, of where we're going. Here we've been collecting data on patients for probably 15 years, so we have a huge registry of outcomes data that we can dive into to get a better sense. But I think looking at AI, looking at bigger data and clustering these patients in terms of, there's their age or the age of this patient, these comorbidities, this type of deformity, this is their bone health, what are the potential risks associated with surgery and what's the chance that they're going to do better with this surgery? I think that's where the future is. It's not there yet, but I think we're close.

Glen Stevens, DO, PhD: I mean, I assume most of these patients aren't flying into the ED on a Friday night and get surgery on a Saturday that there's time to risk stratify and decide what the best options are for these people. I'm always curious about the role of smoking. Tell our audience why nicotine's an issue.

Jason Savage, MD: Yeah, it's a really good point. So here at the Cleveland Clinic, and I think a lot of centers are doing this obviously nationwide now probably worldwide, is that if you're having an elective fusion procedure, which most of these procedures outside of cancer infection potentially traumas, acute spinal cord injuries, most of these procedures are elective. We really counsel patients on the importance of quitting smoking. We'll actually test them preoperatively and get a negative nicotine test if they have a history of smoking before we even schedule them for surgery, and then we'll actually check them again, not because we don't believe them, but we just want to make sure that they're not smoking around the time of surgery. That's so important.

People who smoke basically have a significantly increased risk of wound complications, a significantly increased risk of not healing or developing a non-union or what's called pseudoarthrosis, have mechanical failures, need revision surgery. So that's why it's so important to get these people to really understand why we're torturing them and saying, "Look, we need to get you to quit smoking." I tell all my patients, "Look, you should stop smoking for a lot of reasons, but selflessly speaking from my standpoint, I want you to quit smoking to really decrease the risk that you have problems with this big operation."

Glen Stevens, DO, PhD: For those listening that aren't part of this field, pseudoarthrosis just refers to non-union of bone.

Jason Savage, MD: That's exactly right. So if you're attempting to do a fusion, it doesn't heal, the screws can loosen, you need another surgery.

Glen Stevens, DO, PhD: We're really not talking about cancer affecting bone. We're really talking about other things, correct?

Jason Savage, MD: Yeah, correct.

Glen Stevens, DO, PhD: For the most part.

Jason Savage, MD: Yes, for the most part, for this particular type of discussion for deformity patients, we're really thinking about osteoporosis and bone health, which there's obviously a lot of good ways now to improve bone health prior to surgical intervention.

Glen Stevens, DO, PhD: I come to see you. I had scoliosis as a child, they put a brace on me, and then I had surgery and I got some screws and rods and all that sort of stuff in me, and I'm having pain and I'm looking like I'm having some issues. As an aside, can you do flexion extension films on me to see if things are moving or if I'm fused, it's not very helpful, I can't move enough or?

Jason Savage, MD: Yeah, good question. So there's different imaging modalities that we can use to assess flexibility deformity, whether or not people have a non-union or people are solidly fused. Supine X-rays are actually really helpful. You can get flexion and extension films, which is basically just bending right forward backwards. You can get films bending sideways and specific type of curve patterns. I actually think it's really helpful looking at a scout CT scan of someone.

So a lot of times we'll get a CAT scan, as you know, to look at the bone, to look at the fusion, and that really tells us about the screws. Is anything loose, is anything not healed? But the supine scout on the CT scan really helps to say, all right, how flexible is this thing? What happens when they're laying down versus when they're standing up?

Glen Stevens, DO, PhD: And I think the question the audience is dying to know is, do you carry a protractor with you?

Jason Savage, MD: No, no, I haven't seen a protractor in a long time.

Glen Stevens, DO, PhD: I've gone by occasionally, and I'll see in the old days when they used to put the films up in the light box and they would have a plain film x-ray on there with lots of angles on it, and people have their out and they're drawing angles and figuring out what the angle is and this type of stuff, do you still do that? Is it all done on the computer? It's easier. There are programs for that.

Jason Savage, MD: Yeah, good question. Fortunately, fortunately it's all digital now. When I was training in 2006, 2011, we were still doing some of that stuff manually, but now it's all digital. They do have some smart software platforms that basically help essentially do all the important measurements, get a sense of, all right, where's the deformity coming from? What's the magnitude of deformity? If we want to achieve this correction, how's it going to look intraoperatively? So I think the planning software has come a long way over the past probably 5 to 10 years.

Glen Stevens, DO, PhD: Well, in the field of dentistry, it's really quite impressive that they can... And I'm not sure exactly what the technique is, but they'll do ultrasound or some type of thing in the mouth for people that are going to correct their dental appearance and it will show what it looks like by just doing that. They can mold from it and then they can predict how they can move and how it can change. Now, I'm not sure that you guys can necessarily do that same thing, but potentially it's getting there, right?

Jason Savage, MD: I think we're getting there. The navigation systems and the technology we can use in the OR now is getting really savvy, so to speak. You can get a sense of what the spine's doing real time, which is great. Robotics is a really big thing right now that people are talking about. The robots right now are helpful. I think the next generation of robots are even more helpful to help us do some of these complex procedures.

Patient specific implants, patient specific rods are coming out. We're not using them too much yet here at the clinic, but I think over the next few years to 5, 10 years, we're going to have a lot more data and saying, all right, are these patient specific implants based on this planning software really helping achieving the correction we need, achieving the outcomes we need, improving the patient outcomes. We're just not sure yet. It's out there, but we're not sure yet.

Glen Stevens, DO, PhD: So you've decided after seeing me that my scoliosis needs repairs, so I go in to do surgery. What kind of things are going on intraoperatively of decisions that you need to make that maybe what you planned or maybe you have to take a turn?

Jason Savage, MD: Yeah, good question. There's a lot of things, and it really starts with your pre-operative discussion with your anesthesia team. We're lucky here. We have a wonderful neuro anesthesia team. It's not a kind of case to take care of these patients intraoperatively. I mean, there's a lot of potential blood loss, there's a lot of fluid shifts. So the anesthesia team is incredibly busy during these procedures, as busy as we are teams in the OR. So we're making sure that when we're doing these corrections that the spinal cord, that the nerves are not being irritated, not being God forbid, damaged or whatnot as a result of what we're doing.

I think a lot of the things that we're doing intraoperatively you can actually see with your eyes, which is wonderful in terms of, all right, how much correction am I getting? But that intraoperative radiographic assessment I think is super important. And we have the ability to get what's called scoliosis films in the OR. So films from head to pelvis looking at your entire spine and saying, "Okay, are we really where we want to be with this patient's deformity correction?" And that's come a long way over the last five or 10 years too.

Glen Stevens, DO, PhD: Time range of these surgeries.

Jason Savage, MD: Yeah, good question. If we're really talking about deformity surgery here, which we obviously are, most of these surgeries at minimum are four or five hours up to eight, nine hours sometimes.

Glen Stevens, DO, PhD: You mentioned it a little bit with the intraoperative robots and navigation, neuro navigation, those types of things. Tell me what the role of the robot is currently and what do you hope it will be?

Jason Savage, MD: Yeah, good question. So right now, the robot in my mind is a glorified navigation system. So we've had navigation to help us put screws in for a long time, probably greater than 30 years. Obviously, those systems have improved over time, but basically they are intraoperative guides, usually CT based to allow us to put screws in the right position in these deformed complex spines. The robot right now is a really good navigation system. So it's basically almost a tool or a drill guide to say, okay, this is where we need to put the screws.

Glen Stevens, DO, PhD: So it's not drilling. It's navigating.

Jason Savage, MD: It's not drilling. So not like [inaudible 00:16:44].

Glen Stevens, DO, PhD: People would have a concept that the robot's doing the surgery.

Jason Savage, MD: Yeah, it's a good question. It's a nuance. Some of these surgeries, surgeons, for example, the DaVinci robot, which is super common in the field of urology and prostatectomies or prostate surgery, surgeons are basically controlling the robot, but the robot is actually doing a lot of the surgery. The spine robots right now are not like that. They're essentially a guide for then us to do the surgery through their guides.

I think right now the robot is a useful tool. It helps us put screws in. There's other navigation systems that also allow us to do that very safely. I think what the robot's going to be really good for in the future is helping us do some of the more complex decompressive work, meaning taking the pressure off the nerve osteotomy work, meaning we have to cut the bone in a certain position to correct the deformity. I think that's really where the robot's going to help from an efficiency standpoint and a safety standpoint over the next 5, 10 years.

Glen Stevens, DO, PhD: My recollection from being involved in some spine surgeries many, many years ago was that everything else you need good exposure, which means you have to go through things to get to the exposure, which is usually a lot of muscle. I've always been a bit surprised when so much muscle is being moved, especially if you're doing a log segment. What happens to that? Does it reattach the fibrosis? I would've always thought there would be more risk of moving the musculature.

Jason Savage, MD: Yeah, that's a good question. I think most deformity surgeries still are done what I'd call open. And so basically you're making an incision, you're dissecting muscle, you're basically moving the muscle out of the way. You're doing whatever you need to do to take the pressure off the nerve to correct the deformity, to put the screws and rods in, and then essentially you're reattaching the muscle with suture, and that's what we call our closure. And it's in a multiple layers muscle fascia than skin.

Some of the minimally invasive techniques that we're doing now are a little bit less invasive, a little bit less disruptive of the muscles. Most of the bigger deformities though that we're taking care of are still done through a relatively open approach.

Glen Stevens, DO, PhD: And common pitfalls with revision deformity surgeries.

Jason Savage, MD: Yeah, good question. I think the pitfalls, if I think of my practice over the past 13 years, you really got to do the preoperative planning. You have to get the perioperative optimization. I think one of the pitfalls is not maybe focusing as much on that, getting their bone health better prior to doing their deformity surgery. There's nothing worse than doing what you think is a great operation on someone who's really going to help them and their bone isn't strong enough and the screws pull out and then they need more surgery, and then it opens up Pandora's box.

I think another pitfall in surgery for us, and this comes down to us technically, is making sure we get the correction right the first time. Meaning that whatever alignment goals we have during surgery, we got to make sure that we get them because if we don't accomplish those goals, that sets people up sometimes for a risk of failures.

Glen Stevens, DO, PhD: Do you ever do staged procedures?

Jason Savage, MD: Yeah, we do. Sometimes we will. Most of the time, not honestly. Sometimes we're doing anterior and posterior surgeries, anterior meaning we're coming from the belly first. Sometimes we'll do procedures from the side to access the disc and then do posterior procedures. I would say most of the time, particularly in the thoracolumbar spine, we're doing those kind of on a one stage way. Some of our complex neck surgeries, our complex cervical deformities, we will stage, we'll do either the back part first, then the front part or vice versa.

Glen Stevens, DO, PhD: So when you go anterior in the thoracic area, who's helping you?

Jason Savage, MD: Yeah, good question. It's rare that we go anterior in the thoracic area. Our thoracic surgery colleagues will help us if we really need to do complex stuff in the chest because that's our area of expertise. But most of the time if we're doing something anterior, it's actually in the low lumbar spine. And then either some of our surgeons do their own anterior exposures. A lot of us rely on either our general surgeons, our urologists, or our vasco surgeons to kind of get us to where we need to be.

Glen Stevens, DO, PhD: So you mentioned the pseudoarthrosis. So postoperatively, how do you decrease the risk of this pseudoarthrosis, or can you not know other than we did a bone scan and it looked okay, and I'm putting the screw in. I don't know. Can you feel how the screw is going? And you can kind of go, "I'm just not sure if this is going to..."

Jason Savage, MD: I mean, you get pretty good tactile feedback in the operating room to get a sense of how good the fixation is. If the fixation is really poor, you could augment the fixation with cement. It's really rare that we do that for deformities because we're trying to get their bone improved even before we get into the operating room. After surgery, it's interesting. I mean, there's different biologics that we can use in the OR which help our fusion rates. But I think after surgery, it's interesting. There's really not much we can do outside of really counseling patients. Like, "Look, these are going to be your limitations for the first 6 to 12 weeks. We don't want you doing a lot of bending, a lot of twisting."

We tell people, "Look, we want you in a walker. Nobody wants to use a walker," and it's kind of a pride thing, but we actually want people on a walker for at least six to 12 weeks after deformity surgery. It allows them to take stress and strain off the screw and rod construct that we just put in. But those are the big. We typically don't use braces. I think braces are kind of a thing of the past, particularly for the thoracolumbar deformities.

There are some bone stimulators out there that some data supports may help fusion rates. A lot of us aren't really using those. I think it's really preoperative planning, good execution in the OR, and then little bit of prayer and luck.

Glen Stevens, DO, PhD: There you go. So metrics, how are we measuring how we did and what tools are you using?

Jason Savage, MD: Yeah, so we use a lot of patient reported outcome metrics here at the Clinic, which is nice. So when you come see us, you're going to get a baseline evaluation of what your pain is, what your functional status is, what your mental health status is, and that plays a really big role in terms of patient outcomes. So we have a pain psychology department here, which is just absolutely spectacular and probably one of the only programs in the country that has that.

So a lot of our patients will actually go through our pain psychology pre-operative optimization program prior to surgery, and that's really helped. And then we follow them post-operatively, obviously. So how's your pain? How's your back pain? How's your leg pain? How's your physical function compared to before surgery?

And the good news about deformity patients is that they tend to have improvements for up to one, two, and even five years after surgery. If you continue to follow these people, which we do, they'll be doing better at a year than they were at six months and hopefully be even better at two years than they are at a year.

Glen Stevens, DO, PhD: Oldest patient, you've done deformity surgery on?

Jason Savage, MD: Definitely in their 80s. Definitely in their 80s, but it's amazing.

Glen Stevens, DO, PhD: Make you a little nervous?

Jason Savage, MD: It makes me very nervous, but it's amazing because some 80-year-olds look like 50-year-olds and the vice versa.

Glen Stevens, DO, PhD: Well, as one of the surgeons always told me, no matter how good a patient looks, they reach their chronological age when the scalpel touches the skin.

Jason Savage, MD: Yeah.

Glen Stevens, DO, PhD: Very quickly.

Jason Savage, MD: That's funny. I've never heard that. That's true.

Glen Stevens, DO, PhD: There's a lot of interest in outcome measures, reoperation rates, infection, and a lot of hospital ratings based on these things. Reimbursement could get affected by this. So do you follow re-op rates? Do we follow infection rates, radiographic parameters, or imaging isn't that helpful or?

Jason Savage, MD: Yeah. No, I think it's all important. I think the biggest thing is obviously driving down infection rates is incredibly important. I think that's where a lot of the perioperative optimization stuff comes into play. We do everything humanly possible, obviously to drive down infection rates. Our infection rates are fortunately very low here at the Clinic for our deformity program. Obviously, re-operation rates.

Re-operation rates interestingly, for deformity, about 10 to 15% of patients who are having a deformity operation will have something that's called proximal junctional kyphosis or proximal junctional failure, meaning like you were saying before, yeah, we stiffen up one aspect of the spine and then what happens above that? That tends to happen if it happens in the first three to six months. So we really pay attention to radiographic measurements, findings in that first six to 12 month period.

Re-admission rates, obviously, I think re-admission rates are all based on obviously driving that infection rates, working on good pain control, having good access to your patients in the post-operative period with your team answering questions, preventing bounce backs from the ER and that sort of thing. But I think that's all really, really important to get these patients through these surgeries as best we can.

Glen Stevens, DO, PhD: So, the question that's always asked is the AI, how's AI going to help you?

Jason Savage, MD: Yeah, I think AI is going to help us risk stratify. I really do. I also think it's going to help us figure out what the appropriate alignment or correction is in a specific patient. So I think for a bit, we were over-correcting people in their 70s and maybe even 80s. We were using these alignment objectives, radiographic objectives, and trying to correct them like we would a 50-year-old. And we all know that 80-year-olds stand like 50-year-olds, right? And so we're learning a lot about that.

But I think what AI is going to really do is say, okay, we have this patient, and if you can look at a thousand other patients that are very similar to them worldwide using AI and using big data sets, this is their potential risk of surgery. This is what their alignment should be after surgery to minimize risks, and this is the chance that they're going to get better. I think it's going to help us counsel patients a lot better than we can right now.

Glen Stevens, DO, PhD: And what's a smart implant?

Jason Savage, MD: Yeah, smart implant basically is a patient-specific kind of implant. And so there are some of those right now. There's a cost obviously associated to patient-specific implants. It's basically taking a patient and saying, okay, this is what your pre-operative deformity is. This is what we think your appropriate post-operative alignment should be. We're going to build a rod, build an implant to match that, and then we're going to put that in.

There's some centers that are doing it. The data's really still coming out. We're not sure if it's really going to drive outcomes to be in a better direction or not, but I think we'll know that in a few years.

Glen Stevens, DO, PhD: Final takeaways or something that we haven't discussed you think's important?

Jason Savage, MD: Yeah, I think the final takeaways are we try to avoid doing these big surgeries in people for obvious reasons, but I think there's a lot of people are truly debilitated as a result of their deformity, whether or not it be what I call de novo deformity, meaning no previous surgery, and they just develop a deformity from a degenerative process, or potentially people who've had a bunch of surgeries for whatever reason, and then they develop a bigger complex problem.

I do think we have answers for those people. I think those solutions are sometimes complex. We have to do a lot of things to make sure we try to get them through those big procedures as good as we can. But I think that's what kind of coming to a place like this really is a beneficial, because we have all the pieces to the puzzle, so to speak, that allows us to do that.

Glen Stevens, DO, PhD: And I think the takeaway that I'm getting from you as well is the importance of the anesthesiology folks.

Jason Savage, MD: Incredibly important. The anesthesia folk, our pain doctors are potentially ICU doctors because a lot of these patients will spend a little bit of time in the ICU to recover after these big operations. It's a true team effort. Oftentimes, it's a bad joke, but I say, look, my part's the easy part. This is all I do every day. It's the recovery and predicting your recovery and getting you through this surgery. That's the hard part. It's family support, mental health, all this stuff that we try to do to get them through the surgery.

Glen Stevens, DO, PhD: Well, listen, we appreciate your being here today and sharing your knowledge with us and look forward to great things to come. And no offense, I hope I never have to see you in the OR.

Jason Savage, MD: That's my pleasure. Thanks, Glen. Appreciate it.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And for further learning, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, that's consultqd.clevelandclinic.org/neuro, or follow the Cleveland Clinic Neurological Institute on LinkedIn. And thank you for listening.