When Spine Surgery Requires Outside-the-Box Thinking 

Neurosurgeon Patrick Hsieh, MD, of Keck Medicine of USC, explains how outside-the-box thinking can keep spine surgeries safe and effective, especially when unexpected challenges arise.  

As an experienced spine surgeon, how often do you feel like you’re in a position to think outside the box over the course of an average month? 

Because I specialize in treating spine tumors, spinal deformities and other unusual spine pathologies, I often have to think outside the box. Many of my patients come in having had challenges in getting a diagnosis and treatment from other providers they previously saw, so I know when I meet them that their symptoms may not match the textbook description of their condition. That alone requires a doctor to think beyond common knowledge to find the answers needed. 

There are also intraoperative findings or challenges that we face that can’t be predicted by an MRI or the patient’s history. In most cases, there are still common processes that we go through to be able to mitigate or address these challenges. In other situations, however, where perhaps the surgeon or their team hasn’t often dealt with the given complication or problem, we have to be able to use other modes of management to figure out how to address the challenge, take care of the patient and see them out of the OR safely.  

When you realize during surgery that adjustments will need to be made, what goes through your mind?  

It’s important to understand that even when I’m thinking outside of the box, I’m not doing anything that I haven’t trained for. So if I encounter any kind of problem or condition that requires thinking on my feet, the first thing I do is fall back on my training and experience.

In some cases, I’ve been trained to use a particular skill set for a given situation, but I’ll later encounter a different problem that behaves very similarly and can therefore be addressed in a similar way.  

For example, in tumor surgeries, we deal with the anatomical constraints and challenges of cancers — how they affect the spine and how to work around vital structures to remove them. This actually helps with spinal deformity surgeries when there are challenges with getting around the spinal cord safely.  

On the other hand, spinal deformity surgeries are all about reconstruction — how we get things put back together as we realign the spine. These methods can be applied in tumor cases once the tumors are removed and everything around the spine needs to be repositioned.  

Being flexible in how certain skills can be applied is a great help when unexpected challenges arise at the start of or during a procedure. 

Once you’ve figured out how to approach the situation, how do you communicate with your team? 

There’s no better preparation for moments like these than a shared history of numerous and varied surgical experiences. This history builds familiarity and strengthens both verbal and nonverbal communication among diverse individuals in a team, especially when the team is faced with time-sensitive situations. 

It’s also worth noting that when you work with the same team for any length of time, routine cases and routine days serve as the building blocks for that strong communicative framework. They’re how you learn to work together effectively, efficiently and safely when things don’t go as planned. 

Is there anything else that you find helpful in those moments? 

I’m a strong believer in technological advances and other innovations that improve safety and minimize risk. At Keck Medicine, we were using robotic arms and navigation well before many other institutions because of the role they play in patient safety. This continues to be one of our top priorities at the USC Spine Center.  

Finally, are there other ways you find yourself pushing the envelope or employing creative problem-solving outside of surgery? 

I make a point to keep up in terms of research. If we’re trying to improve upon what people are doing on a day-to-day basis, it necessitates that we go out of our comfort zones. It’s in challenging the current norms and identifying new opportunities that we’re able to build upon the knowledge that allows us to provide our patients with the safest, most effective care possible. 

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