The Spine Journal Outstanding Paper Award Winner Q&A
Andrew Schoenfeld, MD, MSc
Mass General Brigham, Harvard Medical School
Boston, MA
Each year, The Spine Journal honors excellence in original spine-related research through its Outstanding Paper Award, presented in up to four categories. In 2025, the distinction was given to a single study: “Clinical outcomes following elective lumbar spine surgery in patients living with dementia,” authored by Patawut Bovonratwet, MD; Kaitlyn E. Holly, BS; Lingwei Xiang, MPH; Rachel R. Adler, ScD, RD; Clancy J. Clark, MD; Karen Sepucha, PhD; Samir K. Shah, MD; Dae Hyun Kim, MD, ScD; John Hsu, MD; Joel S. Weissman, PhD; and Andrew J. Schoenfeld, MD, MSc. For this issue of SpineLine, Dr. Schoenfeld reflects on the team’s award-winning work in a 10-question Q&A.
1. In one or two sentences, what’s the key takeaway clinicians should carry into preop conversations with patients living with dementia who are considering elective lumbar surgery?
There is a higher risk of adverse events which can fundamentally alter life-trajectory in these patients. There should be frank conversation about this prior to the intervention. Surgeries should be the least intensive (eg, smallest possible incisions, fewest levels possible, limiting instrumentation, ensuring operative time is efficient, etc) interventions possible.
2. Your analysis shows higher hazards for adverse events, mortality, and intensive interventions in the dementia cohort. Mortality is obviously the most serious, but which outcome to you think offers the clearest opportunity to improve care, and why?
It would be the intensity of the intervention, because this is the area under which the surgeon has the greatest control. Some of the simplest options include the extent of the instrumentation used, the number of levels selected for surgery, and operative time, which are, of course, interrelated to a certain degree.
3. You group procedures by decompression and fusion. Did risk differ meaningfully by procedure type or intensity (eg, operative time, instrumentation use), and how should that inform case selection?
The primary focus of this study was the impact of dementia across the spectrum of potential surgical interventions. Clearly, however, anesthesia time, blood loss, and extent of surgical exposure impact adverse events in the setting of dementia and these tie in directly to operative time and instrumentation use. These realities are also not isolated to lumbar spine surgery alone; similar results occurred in a cohort of patients living with dementia undergoing total knee arthroplasty.
4. Many patients pursue surgery to preserve mobility and independence, which may also influence the course of their memory and thinking. How do you balance those potential benefits against the elevated postoperative risks you observed?
This is absolutely the most critical question and frankly needs to be handled on a case-by-case basis with patients, surgeons, and families having a transparent discussion on goals, anticipated outcomes and inherent risks. We noted that, “Therefore, patients and their support network must adequately understand the potential for heightened adverse-event rates, additional postsurgical intensive interventions and discharge to SNF or NH before agreeing to proceed with elective surgical interventions for lumbar disorders or similar conditions. Surgeons who feel that patients with dementia are reasonable candidates for lumbar spine procedures should look to fully optimize these individuals to the extent possible, limiting procedural intensity, anesthesia time and postoperative pain medication requirements to reduce the risk of delirium and further cognitive impairment while maximizing the prospects for functional recovery.”
We are also in the process of trying to develop more specific evidence in this context through prospective studies that are currently in the planning stage.
5. Given the increased hazard for stroke, sepsis, and cardiac events, what preparation or preventive measures should be standard before surgery in this population?
The single best intervention is to ensure physiologic and cognitive optimization prior to surgery. This involves a multidisciplinary team including the patient’s primary care clinicians, geriatricians, and neuro-cognitive consultants.
6. Were there certain patient characteristics or system-level issues that had the biggest impact on risk and that clinicians should be most alert to?
Given the nature of this study and our data (Medicare claims), we are unable to speak to this issue at present. Hopefully, we will have more information based on the results of the prospective study referenced above.
7. How should spine surgeons frame shared decision-making conversations with families or caregivers? Are there particular ways of explaining risks, goals, and alternatives that you’ve seen work well?
The best approach is to have conversations with all parties about the goals for surgery from the perspective of both the practitioner as well as the patient and family, and aligning those goals.
8. Based on your findings, in which scenarios would you still consider fusion for a patient living with dementia, and when would you steer toward decompression only or nonoperative care?
Accepted, evidence-based indications for fusion are just that, regardless of the presence or absence of dementia, eg, instability or extensive decompression, which would destabilize the spine. Certainly, the impact may be minimized by the use of minimally invasive surgery. As noted above, in patients living with dementia, the surgical intervention should represent the least invasive rendition possible that will still result in satisfactory outcome.
9. You note that claims data can only tell us so much. If you could design the ideal future study, which patient-centered outcomes, such as quality of life, cognition, or caregiver burden, would you want to measure, and when?
Our prospective study that is in its early stages includes pre- and postoperative measures of patient outcomes and caregiver burden. This includes patient-reported outcome assessments and neurocognitive assessments at 1-month, 3-months, 6-months and 1-year after surgery. Ideally, comprehensive assessment would continue out to 2-years after the surgical intervention.
10. You note that the results might apply to other elective, high-intensity procedures. Which procedures do you think this research speaks to most directly, and where would you be cautious about drawing parallels?
In the spine space, there is probably some correlation with cervical spine surgery, particular posterior procedures including laminoplasty. At this point, it would not appear this would be directly applicable to deformity procedures which have a different level of surgical intensity. In addition, our findings would not be considered applicable to surgery for trauma, infection, or spine tumors.