Letter to the editor regarding, “Outcomes in surgical treatment for tandem spinal stenosis: systematic literature review” by Ahorukomeye et al

I read with interest the systemic review by Ahorukomeye et al [ ] on outcomes in surgical treatment for tandem spinal stenosis. The authors’ primary outcomes included the perioperative parameters of overall operative time and estimated blood loss (EBL) when comparing staged versus simultaneous surgery for tandem spinal stenosis. I would like to point out that it is not fair to compare these outcomes as they have limited clinical utility. In the case of overall operative time, the authors simply added up the individual times of each staged surgery to compare it to the single operative time of a simultaneous surgery. I was not surprised that two surgeries are going to take longer to do than one. In their discussion they mentioned that increased operative times and blood loss have been associated with higher rates of complications. What they fail to mention however is that the whole point of staging spinal surgeries is that it allows for recovery between each surgery in order to mitigate its traumatic effects which we measure only secondarily by operative time and estimated blood loss. Another way to see this is by reasoning backwards: because the review showed no statistically significant difference in major complications between the simultaneous versus staged group despite the staged group having longer operative times, does that imply that longer operative time does not lead to greater complications? A better clinical variable of interest which the authors did not bring up is the time gap between staged surgeries. It could range from 24 hours to months and there is wide variation in practice. Another, related variable would be the overall time to recovery from the initial surgery which is relevant in comparison because there is a question of whether simultaneous or staged surgeries have longer recovery periods.