Investigation Of Project Management Aspects Of Anterior Surgical Approach In Adolescence Idiopathic Scoliosis Treatment

Comparison of 2 Methods

Scoliosis deformity is defined by the Scoliosis Research Society as the lateral curvature of the spine in the coronal plane. This deformity is detected by a radiograph of the spine, taken in standing posture. The degree of the curve is measured as the angle between most inclined end-plates of the vertebral column, at the end of each curve measures the degree of the curve and is referred to as the Cobb angle (Weinstein et al., 2013). Adolescent idiopathic scoliosis (AIS) manifests as a curvature of the lumbar and the thoracic spine. If there is a persistent lateral curvature of more than 10 degrees between the lumbar and thoracic spine, in upright position, the condition is termed AIS. It is a complex 3-dimensional deformity due to spine rotation and various plane curvatures in addition to lateral curvature. Surgery is generally used to treat the scoliotic deformity, which is likely to progress. AIS surgery is recommended for adolescents with a spinal curve with Cobb angle values larger than 45°-50° (Konieczny, Senyurt & Krauspe, 2013). The surgical procedures aim to achieve a solid fusion, correct the deformity and improve cosmetic appearance. Thereby, the curve progression gets arrested.. The main principle underlying this technique is using the spine in the form of a structural scaffold to cement the parts using a bone paste on the scaffold (Donzelli et al., 2014). Metal screws, rods and wires are used to reinforce fusion stability. A posterior or an anterior approach can be used for this fusion surgery.

• Posterior approach-The process involves a straight incision along the midline. It is most commonly used to treat all curvature defects.

ADVANTAGES	DISADVANTAGES
It involves a simple exposure, where it is relatively easy to reach the operative field.	Less disc space is removed. Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper
There are negligible risks associated with neurovascular compromise (Charosky et al., 2012).	There is violation of the posterior musculature.
A good control is provided along the sagittal plane of the vertebral column.	High infections rates are prevalent in this approach due to absence or lack of soft tissue coverages (Yilmaz et al., 2012).
It addresses deformity of the coronal plane thoroughly and the hump is well controlled.	Increases risk of Crankshaft phenomenon (curve gets worsened) among preadolescent children.
The thoracic cage does not get affected and the pulmonary functions are always preserved.	Hypokyphosis (normal outward curvature loss) is not always corrected in the thoracic region of the spine.

• Anterior approach- This process involves making a straightincision in front of the spine. It is generally used in conditions where a single lumbar or thoracic curve deformity needs to be treated.

ADVANTAGES	DISADVANTAGES
Effectively prevents Crankshaft phenomenon.	Screw pullout, rod breakage can occur due to use of single cable or rod (Yagi, Patel & Boachie-Adjei, 2015).
It has the ability to correct thoracic hypokyphosis.	A high risk of non-union or permanent failure to heal the deformed spine exists due to its recent development.
It corrects provides a comprehensive disc space evacuation and increases fusion surface area (Choudhry, Ahmad & Verma, 2016).	Increases risks of lumbar hypolordosis during application of anterior instruments without interbody device in lumbar spinal region.
Allows insertion of larger spinal implants and leads to superior stabilization.	Wide chest incision can impair the chest muscles and lead to poor lung functioning.

The anterior approach is increasingly becoming popular among surgeons to treat curvature deformities in the spine. The process involves a thoracotomy operation through the chest wall (Cho et al., 2014). The anterior spinal instrumentation for lumbar and thoraco-lumbar adolescent idiopathic scoliosis (AIS) gained popularity during the 1970s. This approach is usually preferred by surgeons owing to its ability to prevent the Crankshaft phenomenon. The entire procedure takes several hours for its successful completion (Helenius, 2013). A person undergoing an anterior spinal fusion surgery is first sedated, followed by administration of general anesthesia. The person is rolled to his side, such that the operating side faces up. This is called the lateral decubitus position (Ialenti et al., 2013).

The steps that are carried out during this approach are as follows:

• An incision is initially made on the left or right side, over the abdomen or chest wall, depending upon the region where the curve deformity is located in the spine.
• The lung is then deflated, followed by removal of a rib to reach the exact spine. A detachment of the diaphragm follows in case of curves that are present in the lumbar and thoraco-lumbar spine (Tao et al., 2012).
• There occurs removal of the disc material from the space between the vertebrae where the curve is present. This removal of disc material increases flexibility of the curve. Furthermore, it also provides a greater surface area for the spinal fusion (Sudo et al., 2013).
• The next step involves instrumentation to produce spine correction. The screws are placed at the vertebral levels that are involved in the curve followed by attachment with a single or double rod at each level. The rod is rotated and compressed simultaneously to correct the spinal deformity.
• Bony surface present between the vertebral bodies is roughened. A bone graft or its substitute is put into the space located between the vertebral bodies. This promotes fusion. An allograft bone, removed rib or crest of pelvis may serve as the source for the bone graft.
• The final step involves closure of the incision. Surgeries involving chest cavity include a chest tube insertion through the chest side. This helps to expand the lings after the surgery (Hasler, 2013).

It is argued by the proponents of anterior approach that it leads to better correction levels for lumbar and thoracolumbar curves, offers a fast recovery time, requires fusion of fewer number of lumbar vertebras and creates less pain among the patients. Moreover, the anterior approach is preferred in surgeries that are limited to the lumbar area owing to the fact that saving a single level of vertebra creates a substantial effect on the spinal flexibility of the patient. Furthermore, historically, the anterior approach has reported producing better rib hump and curve corrections. It produces better radiographic and pulmonary function outcomes. Thus, the above mentioned advantages make the anterior approach a better surgical procedure for treating adolescent idiopathic scoliosis compared to the posterior approach. 

Anterior Scoliosis Surgery

Surgeries are generally applied in cases of severe scoliosis. The cost of scoliosis treatment or surgery varies across regions but can be quite high. The general costs do not include the additional costs for recovery time, revision surgeries or treatment of unforeseen complications. Healthcare challenges will create the need for new managerial approaches (Yoder-Wise, 2014). A large number of organizational theories can be used in this context of healthcare that will help in improving the health outcome of patients who are undergoing the anterior surgical approach. The first approach to be used is the Bureaucratic Theory. This is one of the oldest theories of management that is still in practice. It is used by institutions or organizations of all sizes. This management involves presence of few people at the higher levels of hierarchy, who are entitled to make decisions (Tummers & Bekkers, 2014). A chain of middle and lower managers are responsible for efficiently executing the tasks. These people have limited authority. The orders are sent from the highest levels in a manner that mimics the military. The lines of authority and responsibility are clearly established and there is formal distribution of the duties (Figure 2). The theory works by allocating individuals in positions that best fit their technical competence.  Procedure adherence is of utmost priority in this model.

This theory has proved effective in generating as sense of predictability and stability by careful management approaches and consistent decision making, as evident from several studies. Results from other studies confirm that professionals control the administrative framework of the concerned organization by utilizing this theory. The dominance of professional bureaucratic management among healthcare organizations has been proved by the prevalence of parallel administrative and professional hierarchies, which play a role in clarifying responsibilities and operating procedures (Gittell, Godfrey & Thistlethwaite, 2013). However, the inherent internal focus and closed system perspective of this theory makes it problematic. The assumption of static external environment and external influences lead to several problems while validating this theory across healthcare system.

The human resource/relation theory is of prime importance. Showing consistency with the aforementioned theory, a closed system perspective is adopted here as well. Studies suggest that this theory highlights contribution of creative potential towards betterment of organization in presence of adequate supportive management resources. The theory recognizes individual involvement and motivation as essential features (Jiang et al., 2012). It has proved effective in supporting and encouraging harmonious social relations and fostering development of organizations (Figure 3). This theory involves development of interpersonal collaboration and communication skills in maximizing individual contribution and motivation (Kramar, 2014). Its pervasive impact on the specialized and professional healthcare workforce has been proved (S. Y. D & Weiner, 2012). It promotes high entry-level education and continuous professional development among all groups that finally create positive patient outcomes (Alfes et al., 2013). However, this model also predicts a stable environment. Therefore, application of the framework alone is not sufficient in complex healthcare situations.

Patient centered management is another model. A change in attitude towards patient care and healthcare business environment has resulted in many organizations adopting a patient-centered management approach to management. Top managers often consider some systems to be more effective and easy (Figure 4). However, proper organization according to the demands of the patient-specific health condition helps in delivering best patient care (Cipolle, Strand & Morley, 2012). This theory promotes best financial results through excellence in medical services. Studies have shown that the framework is adopted by top managers to promote collaboration between interdisciplinary approaches and departments in medicine, by ways that are not described in the traditional style of bureaucratic management (Hudon et al., 2012).

Management Theory

The Institutional theory explains the way by which organizations prosper on obtaining a good fit with the external environment. The theory states that key stakeholders help an organization to gain legitimacy by adoption of norms and values that are reflective of the beliefs of stakeholders (Thornton, Ocasio & Lounsbury, 2015). Results suggest that expectations and socialization pressures from expert referents like management consultants or professional bodies have governed the functioning of healthcare systems since many decades (Hörisch et al., 2014). Thus it can be stated that all the above mentioned theories have a role in improving the healthcare industry.

Use of management approaches

Several approaches can be taken to reduce hospitalization costs and or stay duration. Offering a consumer-directed health plan that includes health savings account or health reimbursement arrangements focus on making the employees become better healthcare consumers. Management strategies will be used to persuade the employees to carry out healthful choices. Adequate training and tools will be provided to ensure that the healthcare employees are aware of the costs associated with the surgical procedure. Providing them incentives to reduce treatment costs will act as a motivation and bring desired results. Effective communication strategies will enable the participants to engage in healthful behavior (Knapp, Vangelisti & Caughlin, 2014). The other approach involves application of consume directed health designs (Fischer, 2015).

This will promote healthcare consumerism and will help in keeping costs down. Developing a health savings account, linked to high deductible health plans will also prove effective. Pain management is critical to the recovery of a patient. A pain control policy will be initiated (McQuay et al., 2013). Professionals will discuss about pain control with their patients and will provide a chance to the latte to voice their opinion. The hands-on providers will be educated about cohesive-pain management. Lack of timely medication delivery post surgery will be avoided by utilizing efficient human resource coordination.

Keeping a record of the average daily admissions, managing of elective admissions, discharging patients as soon as it is clinically feasible and initiating multidisciplinary rounding will help to reduce hospital stay. 2-4 weeks post surgery; the incision part can come in contact with water. Patients will be taken off opioids and narcotics and a switch to weaker pain medication like acetaminophen will aid in quick healing. X-rays will be taken around 6 weeks after surgery to assess the surgical healing and efficiency of fusion process. Administration of physical therapy in the patients can also improve surgical healing.

Data collection involves administration of the Scoliosis Research Society-30 (SRS-30) outcome questionnaire to all 30 patients during preoperative, postoperative and final follow-up period. This questionnaire measures the health-related quality of life (HRQoL) among patients with adolescent idiopathic scoliosis, who had undergone anterior approach surgery or was not under surgical intervention (Carriço, Meves & Avanzi, 2012). The individual domain and total scores for self-image, pain, mental health, function, and satisfaction will be compared between the control and patient group. The responses will be evaluated and analyzed using the SPSS 21 version.

The questionnaire has been prepared. It has been given to the respondents who are about to undergo anterior scoliosis fusion surgery. They have been made to fill their responsiveness to the surgical treatment prior to the surgery, in the questionnaire. Every possible measure has been taken to protect their privacy. Post-surgical intervention, the questionnaire is again being sent to the respondents currently.

The plan for the next semester includes a follow up where responses will be taken from the participants for a follow-up of 4 months. The data will then be analyzed using the SPSS 21 statistical software. The simulation modeling will improve decision making related to the anterior approach of adolescent idiopathic scoliosis. Thus, the study will help us to compare the fusion rates among patients who reported AIS. The analysis will help in reviewing major neurological or vascular complications that occur post-surgical intervention. Moreover, the data will give an insight into the financial condition, current physical activity level, medication management and patient satisfaction, which will provide a deeper understanding of the management frameworks that need to be put to practice for reducing the duration of hospital stays, lowering healthcare costs, managing pain and increasing overall satisfaction.

Conclusion

Thus, scoliosis is a three-dimensional deformity of the spinal axis. Adolescent idiopathic scoliosis occurs among patients, 10 years or above. It leads to the occurrence of an idiopathic structural lateral curve. The angle of the curvature is at least 10 degrees and is measured using the Cobb technique. A longitudinal radiograph based vertebral rotation of the spine helps in its diagnosis. Surgery is generally regarded as a preferred option for all skeletally immature patients who have a progressing 40 degree scoliosis or for skeletally mature patients who report of progressive or painful spine curvature greater than 45 degrees. An anterior growth among skeletally immature patients after a posterior fusion surgery leads to Crankshaft phenomenon. This generally manifests in the form of an increase in rib hump among post-surgical patients. An anterior fusion surgery is therefore used to prevent this phenomenon. The goals of anterior surgery include pain-free spinal fusion, restoration of truncal balance, improved cosmesis and shoulder, rib hump and hip symmetry.

The progress report utilized several management theories that can be used across healthcare system for efficient care service delivery. The application of these management frameworks will help in improving patient outcome, reducing hospital stay and lowering treatment costs. Moreover, they will also assist in pain management and increasing healing capabilities post the surgery. The data will be collected based on a questionnaire. Thus, it can be concluded that an analysis of the questionnaire responses will act as valuable means of managing patients with adolescent idiopathic scoliosis.

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