First, the clinician should confirm that the patient has an appropriate clinical indication to benefit from a percutaneous fusion procedure. For example, if the patient is offered a percutaneous facet joint fusion procedure, the patient should have one of the following diagnoses: facet joint dysfunction and pain, spinal instability from prior spine surgeries, microinstability of certain spinal segments, or requirement for adjunctive therapy or bridging therapy to an interbody fusion surgery. Clinical indications for other percutaneous fusion procedures are presented elsewhere within this atlas. A thorough assessment of contraindications that would preclude the proceduralist from offering this therapy to the patient should be reviewed, including coagulopathy, current infection, malignancy, and other contraindications.

The biopsychosocial approach to chronic pain management involves a complex interaction between biological, psychological, social, and medicolegal factors. It is well-known that chronic pain and mood disorders often cooccur, as highlighted by studies citing that up to 85% of chronic pain patients are impacted by severe depression.^1,2 Furthermore, chronic pain patients who suffer from uncontrolled mood disorder exhibit a poorer prognosis than patients who have chronic pain only.³ Thus it is not uncommon for the proceduralist to obtain a presurgical psychological assessment of patients before offering them advanced interventional options. Presurgical psychosocial health is a major predictor of pain relief, quality of life, and satisfaction after spinal cord stimulator placement.^4,5 Thus although a patient may appear to be an ideal candidate for a surgery based on their clinical indication, poorly controlled psychological comorbidities may make them suboptimal candidates. Furthermore, even other psychosocial factors, such as history of drug abuse, alcoholism, personality issues, marital discord, job dissatisfaction, pending litigation, and prior abuse or abandonment, may play a role in a patient’s postsurgical efficacy. Thus a preoperative general psychosocial assessment should include a survey of pain symptoms, demographic data, prior surgeries, employment status, level of education, history of workers’ compensation or other injury litigation, disability payment status, and personality traits.

Preoperative advanced imaging of the surgical area of interest, utilizing either computed tomography (CT) or magnetic resonance imaging (MRI), is recommended for presurgical planning, to rule out any contraindications or anatomic abnormalities that would preclude the proceduralist from offering percutaneous fusion, and to minimize risk of complications. This imaging should be recent to within 1 to 2 years of the planned procedure. Spine surgeons typically utilize preoperative multiplanar advanced imaging to inform medical decisions and surgical plans before spine fusion surgery that involves pedicle screw instrumentation.⁶ Similarly, in the neuromodulation space, obtaining preoperative thoracic MRI for thoracic lead placement is the standard of care and has been recommended by consensus committees.⁷ Thus the authors recommend obtaining either an MRI or CT scan before performing percutaneous fusion procedures.

In addition, osteoporosis has often been considered as a contraindication to spine surgeries that involve instrumentation.⁸ Studies have demonstrated that patients with substantially lower bone mineral density are at high risk for developing graft subsidence, failure of spinal fusion and implant fixation, and vertebral compression fractures surrounding fusion sites.^9,10 Presurgical optimization with bisphosphonates may lead to improved outcomes including increased solid intervertebral fusion, decreased vertebral compression fractures, decreased pedicle screw loosening, and decreased case subsidence.¹⁰ Obtaining a presurgical bone density scan, such as a dual-energy x-ray absorptiometry (DEXA) scan, may help inform this decision.

Many percutaneous fusion procedures are in proximity to the neuraxial space and are thus considered as high-to-intermediate risk procedures. Anticoagulation should be held with approval of the prescribing physician for an adequate length of time specific for the anticoagulant medication, before the procedure. Commonly, proceduralists follow anticoagulation practice guidelines as stated by the American Society of Regional Anesthesia and Pain Medicine Consensus committee.^11,12 Proceduralists may also choose to follow consensus guidelines that are in place for spinal cord stimulator placement.¹³ Generally, nonsteroidal antiinflammatory drugs, other antiplatelet agents, and anticoagulants should be discontinued for at least five half-lives. Furthermore, depending on the patient’s bleeding risk, medical comorbidities (e.g., renal or hepatic dysfunction), and the type of anticoagulant, proceduralists may also consider obtaining diagnostic workup that includes hemoglobin, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time.

In settings where a patient is at high risk for a thromboembolic event, a shared assessment and risk stratification approach between the proceduralist and the provider who prescribes anticoagulation is warranted. High-risk patients who require bridging of anticoagulation therapy may be bridged with low-molecular-weight heparin or heparin. Proceduralists may consider consulting with a vascular medicine service if a thrombophilia specialty service is available to assist in anticoagulation management perioperatively.

Optimal glucose control is recommended, and most guidelines advise a hemoglobin A1c level below 8% to 9%.¹⁴ Tobacco cessation is also recommended, as continued use may impair surgical healing. Patients who are carriers of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) should receive mupirocin nasal ointment and chlorhexidine baths for decolonization.¹⁵

Strict sterile precautions are recommended intraoperatively. This entails performing a surgical scrub for 2 to 5 minutes with an antiseptic, wearing a surgical mask, wearing a sterile gown and double gloves, using chlorhexidine gluconate for preoperative skin preparation, placing an iodophor-impregnated drape, removing hair near surgical site with electric clippers, and using laminar flow and high-efficiency particulate air (HEPA) filters in the operating room.¹⁵ Administration of prophylactic antibiotics within 1 hour of surgical incision is recommended. Finally, application of a bioocclusive dressing after the surgery that remains in place for 24 to 48 hours is recommended.

When resuming antiplatelet and anticoagulation agents after percutaneous fusion, proceduralists should adhere to practice guidelines from the American Society of Regional Anesthesia and Pain Medicine Consensus committee.^11,12 Aspirin may be resumed after 24 hours, and clopidogrel may be resumed after 12 to 24 hours. Warfarin may be restarted 6 hours postoperatively. All novel oral anticoagulants (NOACs) should be restarted 24 hours postoperatively. Exceptions to standard care should be individualized and should be made through expert consultation with the vascular medicine service.

Follow-up visits are crucial to address any adverse effects and to monitor treatment efficacy from the surgical intervention. Traditionally, patients would follow up with the proceduralist at postoperative weeks 10 to 14 for inspection of incisions and removal of any superficial closure materials (e.g., staples). Thereafter routine follow-up is at the discretion of the proceduralist, but may occur at 3 months, 6 months, and 1 year postsurgery to monitor for efficacy of treatment.