A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures

Optimizing non-opioid pain control after implant-based breast reconstruction: a review of the literature and proposed pain control algorithm

Despite the intense focus on the opioid epidemic and its known association with surgical procedures, there is a paucity of evidence-based literature on pain management in implant-based breast reconstruction (IBR). Herein, we present an updated review of the literature aimed at identifying pain treatment protocols to minimize narcotic use and its associated potential addiction in IBR. A comprehensive review of the published English literature was conducted using Ovid Medline/PubMed Database without timeframe limitations. The inclusion criteria of selected articles presented in this review included studies reporting objective outcomes of pain modulation (preoperatively, intraoperatively and postoperatively) in IBR. Articles for inclusion were stratified based on intervention. A total of 219 articles were identified in the initial search query, with 23 studies meeting the inclusion criteria. Pain optimization interventions in IBR are herein summarized and analyzed based on the reported outcomes of each respective study. There is a substantial need for evidence-based guidelines in the plastic surgery literature for pain optimization without the use of opioids. While this review of studies to date investigates potential solutions, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized post-operative care for patients following IBR.

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices.

OBJECTIVE

The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes.

METHODS

A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria.

RESULTS

Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes.

CONCLUSIONS

ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure.

CLINICAL RELEVANCE

This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Fibrin sealants in lumbar annuloplasty after endoscopic discectomy as a method to prevent recurrent lumbar disc herniation

Fibrin sealant as a promising agent for providing scaffold and efficient hemostasis is widely accepted in several specialties. However, the outcome of Fibrin sealants in lumbar annuloplasty after endoscopic discectomy has not been evaluated in patients with disc herniation. The goal of this study was to evaluate the efficacy, response, and probability of future recurrence rates in herniated nucleus pulposus (HNP) with the use of fibrin sealant in conjunction with endoscopic disc surgery. A total of 35 patients (28 men, 7women) were evaluated, including 18 patients who underwent endoscopic discectomy alone and 17 patients that received fibrin sealant at the site of annulus tear and endoscopic discectomy. All patients were followed through both clinical and imaging methods for an average of 10.5 months. Primary outcome measure was defined as lumbar decompression approved by imaging and symptom alleviation after endoscopic spinal discectomy with Visual Analogue Scale (VAS) score ≤ 4 (cut-off point). Median size of annular tearing was significantly lower in the endoscopic discectomy group (median, 3) (minimum, 2; maximum, 5); however, the corresponding factor in the endoscopic discectomy plus fibrin sealant group was significantly larger (median, 6) (minimum, 5; maximum, 10), with P <0.001. Only one patient in the endoscopic discectomy group had an HNP recurrence during follow-up compared to two patients in the endoscopic discectomy plus fibrin sealant group. Due to the temporary effects of fibrin sealant in preventing disc herniation and the observed recurrence rate in both the case and control groups, the results of this study suggest a role of fibrin sealants combined with endoscopic discectomy to prevent early HNP recurrence rate.

Prehabilitative Exercise for the Enhancement of Physical, Psychosocial, and Biological Outcomes Among Patients Diagnosed with Cancer

PURPOSE OF REVIEW

This review summarizes the effects of prehabilitative exercise interventions on the physical, psychosocial, and biological outcomes among patients with cancer. Current gaps and future directions in prehabilitative exercise research will be addressed.

RECENT FINDINGS

Prehabilitative exercise mitigates the detrimental impact of cancer surgery on physical fitness, noted by increases in maximal oxygen consumption and 6-min walk distance. Beneficial effects on psychosocial and biological outcomes remain inconclusive. Aerobic exercise interventions were often prescribed and included low-, moderate-, or high-intensity exercise. Resistance exercise interventions were often performed in conjunction with aerobic exercise. Prehabilitative exercise elicits robust improvements in physical fitness; however, effect on psychosocial and biological outcomes remains inconclusive. Exercise prescription parameters varied greatly by frequency, intensity, time, and type across multiple cancer diagnoses. Future investigations are needed to systematically dose exercise for a wider variety of outcome measures, with an overall goal to set forth pre-operative exercise guidelines.

Enhanced Recovery after Lumbar Spine Fusion

Background

Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion.

Methods

A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein).

Results

The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (−3 h; 95% CI, −6, −0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (−11 h; 95% CI, −19, −6; P &lt; 0.001) were shorter; opioid consumption was lower at day 1 (−57 mg; 95% CI, −130, −5; P = 0.030) without adversely affecting pain scores (−2; 95% CI, −3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037).

Conclusions

Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Enhanced recovery after spine surgery: a systematic review

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, reduced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS principles have been applied to spine surgery only in recent years. The authors examine studies investigating the application of ERAS programs to patients undergoing spine surgery.METHODSThe authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20, 2018.RESULTSTwenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of readmissions or complications after introduction of an ERAS pathway.CONCLUSIONSThese introductory studies demonstrate the potential of ERAS protocols, when applied to spine procedures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.

The effects of the addition of motor imagery to home exercises on pain, disability and psychosocial parameters in patients undergoing lumbar spinal surgery: A randomized controlled trial

CONTEXT

Patients who have suffered from persistent symptoms often undergo lumbar spinal surgery (LSS). Motor imagery should be added to postoperative home exercises to reduce patient complaints.

OBJECTIVE

The aim of this study was to compare the effects of home exercise plus motor imagery and only home exercise in patients undergoing LSS.

DESIGN

A randomized controlled study.

SETTINGS

This study was designed by researchers at Dokuz Eylul University.

PARTICIPANTS

Thirty-seven patients undergoing LSS were randomized to motor imagery group (n = 19) and control group (n = 18).

MAIN OUTCOME MEASURES

Pain was measured by Visual Analogue Scale, disability related to low back pain by Oswestry Disability Index, pain-related fear by Tampa Scale of Kinesiophobia, depression by Beck Depression Inventory, quality of life by World Health Organization Quality of Life Scale-Short Form (WHOQOL-BREF). All assessments were repeated in the preoperative period, three weeks after and six weeks after the surgery.

INTERVENTIONS

Motor imagery group underwent home exercise plus motor imagery program applied by voice recording. Control group underwent only home exercise program. Exercise program compliance was monitored by exercise diary and telephone calls once every week.

RESULTS

There was a significant improvement in pain at rest and during activity, disability, kinesiophobia, depression, physical health and psychological sub-parameters of WHOQOL-BREF between preoperative period, and the third week and sixth week in both groups (p < 0.05). When comparing groups for gain scores, there was a more significant improvement in pain during activity in motor imagery group (p < 0.05). Motor imagery should be addressed as an effective treatment after LSS.

Fibrin sealants in lumbar annuloplasty after endoscopic discectomy as a method to prevent recurrent lumbar disc herniation

Fibrin sealant as a promising agent for providing scaffold and efficient hemostasis is widely accepted in several specialties. However, the outcome of Fibrin sealants in lumbar annuloplasty after endoscopic discectomy has not been evaluated in patients with disc herniation. The goal of this study was to evaluate the efficacy, response, and probability of future recurrence rates in herniated nucleus pulposus (HNP) with the use of fibrin sealant in conjunction with endoscopic disc surgery. A total of 35 patients (28 men, 7women) were evaluated, including 18 patients who underwent endoscopic discectomy alone and 17 patients that received fibrin sealant at the site of annulus tear and endoscopic discectomy. All patients were followed through both clinical and imaging methods for an average of 10.5 months. Primary outcome measure was defined as lumbar decompression approved by imaging and symptom alleviation after endoscopic spinal discectomy with Visual Analogue Scale (VAS) score ≤ 4 (cut-off point). Median size of annular tearing was significantly lower in the endoscopic discectomy group (median, 3) (minimum, 2; maximum, 5); however, the corresponding factor in the endoscopic discectomy plus fibrin sealant group was significantly larger (median, 6) (minimum, 5; maximum, 10), with P <0.001. Only one patient in the endoscopic discectomy group had an HNP recurrence during follow-up compared to two patients in the endoscopic discectomy plus fibrin sealant group. Due to the temporary effects of fibrin sealant in preventing disc herniation and the observed recurrence rate in both the case and control groups, the results of this study suggest a role of fibrin sealants combined with endoscopic discectomy to prevent early HNP recurrence rate.

Reducing opioid usage: a pilot study comparing postoperative selective dorsal rhizotomy protocols

OBJECTIVE

Selective dorsal rhizotomy (SDR) is a surgical procedure used to treat spasticity in children with spastic cerebral palsy. Currently, there is a lack of work examining the efficacy of optimizing pain management protocols after single-level laminectomy for SDR. This pilot study aimed to compare the clinical outcomes of SDR completed with a traditional pain management protocol versus one designed for opioid dosage reduction.

METHODS

The Texas Comprehensive Spasticity Center prospective database was queried for all patients who underwent SDR between 2015 and 2018. Demographic, surgical, and postoperative data for all patients who underwent SDR were collected from medical records. The study was designed as a retrospective study between the patient-controlled analgesia (PCA) and dexmedetomidine infusion (INF) groups with 80% power to detect a 50% difference at a significance level of 0.05. Patients in the INF group received perioperative gabapentin, intraoperative dexmedetomidine infusion, and scheduled acetaminophen and NSAIDs postoperatively.

RESULTS

Medication administration records, pain scores, and therapy notes were collected for 30 patients. Patients who underwent SDR between June 2015 and the end of December 2017 received traditional pain management (PCA group, n = 14). Patients who underwent SDR between January 2018 and the end of December 2018 received modified pain management (INF group, n = 16). No patients were lost to follow-up. Differences in age, weight, height, preoperative Gross Motor Function Classification System scores, operative duration, hospital length of stay, and sex distribution were not statistically different between the 2 groups (p > 0.05). Analysis of analgesic medication doses demonstrated that the INF group required fewer doses and lower amounts of opioids overall, and also fewer NSAIDs than the PCA group. When converted to the morphine milligram equivalent, the patients in the INF group used fewer doses and lower amounts of opioids overall than the PCA group. These differences were either statistically significant (p < 0.05) or trending toward significance (p < 0.10). Both groups participated in physical and occupational therapy similarly postoperatively (p > 0.05). Pain scores were comparable between the groups (p > 0.05) despite patients in the INF group requiring fewer opioids.

CONCLUSIONS

Infusion with dexmedetomidine during SDR surgery combined with perioperative gabapentin and scheduled acetaminophen and NSAIDs postoperatively resulted in similar pain scores to traditional pain management with opioids. In addition, this pilot study demonstrated that patients who received the INF pain management protocol required reduced opioid dosages and were able to participate in therapy similarly to the control PCA group.

Postoperative quality and safety using Efficacy Safety Score (ESS) and a wireless patient monitoring system at the ward: A randomised controlled study

BACKGROUND

Postoperative pain, side-effects and time to mobilisation are indicators for the quality of postoperative recovery. The aim of this randomised controlled study was to investigate if efficacy safety score (ESS) combined with a wireless patient monitoring system would improve these clinical outcomes for patients at a general surgical ward.

METHODS

The trial included 195 patients randomised to a standard care group (SC-Group) or intervention group (INT-Group) receiving continuous wireless monitoring of vital signs combined with ESS during the first 24 postoperative hours. The primary outcome was time to mobilisation. Secondary outcomes were average pain, doses of postoperative opioids, unscheduled interventions, side-effects, patient satisfaction and length of hospital stay (LOS).

RESULTS

Mean time to postoperative mobilisation was 10.1 hours for patients in the INT-Group compared to 14.2 hours in the SC-Group; this corresponds to an adjusted hazard ratio of 1.54 (95% confidence interval 1.04-2.28). INT-Group patients received a higher dose of oral morphine equivalents; 26 mg vs 15 mg, P < .001; reported lower intensity of pain on a 0-10 scale; 2.1 vs 3.3, P < .001; and had higher patient satisfaction on a 5-point scale; 4.9 vs 4.3, P < .001. The LOS was similar between the groups; 71 hours in INT-Group vs 77 hours in SC-Group, P = .58. No serious side-effects were registered in INT-Group, whereas two were registered in SC-Group.

CONCLUSIONS

Introducing ESS as a decision tool combined with a wireless monitoring system resulted in less pain, increased satisfaction and more rapid mobilisation for patients in this study.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03438578.

Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study

OBJECTIVES

Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium.

DESIGN

Prospective observational study.

SETTING

Single-centre at a European academic hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD.

RESULTS

A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD.

CONCLUSIONS

We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.

Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients

BACKGROUND CONTEXT

Effective postoperative pain management in patients undergoing elective spinal fusion surgery has been associated with shorter hospital stays, reduced rates of hospital readmissions due to pain, and decreased cost of care. Furthermore, preoperative multimodal analgesia regimens have been shown to decrease postoperative subjective pain measurements and narcotic consumption in patients undergoing spinal fusion and total arthroplasty surgeries.

PURPOSE

Compare the difference in effects on 24-hour postoperative narcotic consumption, reported pain, and early mobility with administration of preoperative celecoxib plus gabapentin, gabapentin alone, and a nonstandardized analgesia regimen in patients undergoing elective spinal fusion surgery involving ≤5 levels.

STUDY DESIGN

Retrospective review, Level of Evidence III.

PATIENT SAMPLE

A total of 185 adult patients undergoing elective spinal fusion surgery involving ≤5 levels from 2013 to 2017 at one academic institution. Patients were excluded if the surgery was nonelective, for oncological purposes, or the patient was younger than 17 years old.

OUTCOME MEASURES

Twenty-four-hour postoperative morphine equivalent consumption, 24-hour postoperative visual analogue scale (VAS) pain scores, postoperative day to ambulate, and postoperative day to clear physical therapy.

METHODS

A single-institution retrospective chart review was conducted. Patients meeting inclusion criteria were grouped by whether they had received preoperative celecoxib plus gabapentin, gabapentin alone, or neither of these medications. Opioid medication intake for the first 24 hours after the surgery end time was tabulated and converted to morphine equivalents. Visual analogue scale (VAS) pain scores were also averaged over the first 24 hours. Finally, physical therapy notes were reviewed to determine the time taken for the patient to first ambulate and to clear physical therapy. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.

RESULTS

Twenty-four-hour postoperative morphine equivalent consumption was significantly lower in the celecoxib plus gabapentin group compared with control (p=.004). Patients in the celecoxib plus gabapentin group had significantly lower mean VAS scores (p=.002) and had earlier mobility postoperatively (p=.012) than those in the control group. Early mobility and time to physical therapy clearance did differ between the celecoxib + gabapentin group compared with the gabapentin alone group. The gabapentin group had a significantly higher 24-hour morphine dose equivalent (p=.013) and a significantly higher VAS average (p=.009) compared with the celecoxib + gabapentin group. Gabapentin given alone compared with control did not show statistically significant improved outcomes in postoperative morphine equivalent consumption, pain scores or physical therapy goals.

CONCLUSIONS

This study demonstrates that administering a selective COX-2 inhibitor and GABA-analogue preoperatively can significantly decrease 24-hour postoperative opioid consumption, VAS pain scores, and elapsed time to postoperative mobility in patients undergoing elective spine fusion surgery of ≤5 levels. Optimal standardized dosing and drug combination for preoperative multimodal analgesia remains to be elucidated.

Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review

OBJECTIVES

For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR.

METHODS

We conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searched The Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.

INTERVENTIONS

Perioperative non-surgical interventions; control receiving no intervention or alternative treatment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Pain or score with pain component assessed at 6 months or longer postoperative.

RESULTS

44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.

CONCLUSIONS

To prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review

Early mobilisation is a cornerstone of Enhanced Recovery after Surgery (ERAS) and is encouraged following spinal procedures. However, evidence of its implementation is limited and there are no formal guidelines on optimal prescription. This narrative review aimed to evaluate the evidence for the effect of early mobilisation following elective spinal surgery on length of stay, postoperative complications, performance-based function and patient-reported outcomes. Four trials (five articles) that compared a specific protocol of early in-hospital mobilisation to no structured mobilisation or bed rest were selected for inclusion. Nine studies that investigated the implementation of a multimodal intervention that was inclusive of an early mobilisation protocol were also included. Results suggest that goal-directed early mobilisation, delivered using an evidence-based algorithm with a clear, procedure-specific inclusion and exclusion criteria, may reduce length of stay and complication rate. In addition, there is evidence to suggest improved performance-based and patient-reported outcomes when compared to bed rest following elective spinal surgery. Whilst this review reveals a lack of evidence to determine the exact details of which early mobilisation protocols are most effective, mobilisation on the day of surgery and ambulation from the first postoperative day is possible and should be the goal. Future work should aim to establish consensus-based, best practice guidelines on the optimal type and timing of mobilisation, and how this should be modified for different spinal procedures.

Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery: Initial Experience

STUDY DESIGN

A retrospective cohort study of prospectively collected data.

OBJECTIVE

The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression.

SUMMARY OF BACKGROUND DATA

ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery.

METHODS

An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented.

RESULTS

The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195-398 minutes] overall, 298 minutes (IQR 192-811) for lumbar decompression and 285 minutes (IQR 200-372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours).

CONCLUSION

This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery.

LEVEL OF EVIDENCE

3.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

The Benefits of Implementing an Early Mobility Protocol in Postoperative Neurosurgical Spine Patients

: Background: Despite the known benefits of early postsurgical mobility, there are no clear recommendations on early mobility among uncomplicated postoperative neurosurgical spine patients.

PURPOSE

The purpose of this quality improvement initiative was to establish an NP-led early mobility protocol to reduce uncomplicated postsurgical spine patients' length of stay (LOS) in the hospital and eliminate the variability of postsurgical care. A secondary objective was to educate and empower nursing staff to initiate the early mobility protocol independently and incorporate it in their practice to improve patient care.

METHODS

Two neurosurgery NPs led an interprofessional team to develop the early mobility protocol. Team members provided preadmission preoperative education to communicate the necessity for early mobility and provide information about the protocol. New nursing guidelines called for patient mobility on the day of surgery, within six hours of arrival on the medical-surgical unit. Nurses were empowered to get patients out of bed independently, without a physical therapy consultation; they also removed urinary catheters and discontinued IV opioids when patients' status permitted.

RESULTS

Over a one-year period, implementation of the protocol resulted in a nine-hour reduction in LOS per hospitalization in neurosurgical spine patients who underwent lumbar laminectomies. The protocol also allowed nurses more autonomy in patient care and was a catalyst for patient involvement in their postoperative mobility. Given the success of the protocol, it is being replicated by other surgical services throughout the organization.

CONCLUSIONS

This low-cost, high-reward initiative aligns with the strategic plan of the organization and ensures that high-quality, patient-centered care remains the priority. NPs in other institutions can modify this protocol to promote postoperative mobility in their organizations.

Incidence and Predictors of Hardware Failure After Instrumentation for Spine Metastasis: A Single-Institutional Series

OBJECTIVE

We report a retrospective analysis of hardware failure in patients requiring instrumentation for spinal metastasis.

METHODS

In a retrospective study at a single institution, we identified 58 patients who underwent spinal instrumentation for metastasis from 2012 to 2018. Hardware failure was defined as screw pullout/loosening, cage migration, progressive kyphosis, or an otherwise-noticeable instrumentation deficit detectable on imaging. Risk factors for hardware failure with a P < 0.05 in in univariate were included in multivariate logistic regression models controlled for age, sex, and previously identified risk factors for hardware failure.

RESULTS

In total, 58 patients required instrumentation for metastatic spine disease. Median age was 60.2 years (interquartile range 49.0-66.3), 38 patients (65.5%) were male, and median follow-up was 8.1 months (interquartile range 3.1-20.7). Eight patients (13.8%) developed signs of hardware failure during follow-up, of whom 2 patients (3.4%) underwent operative revision. In univariate analysis, Eastern Cooperative Oncology Group performance status >2 (P = 0.049) and multiple myeloma lesions (P = 0.010) were significant predictors of failure. Both factors maintained significance in a multivariate logistic regression model controlled for age, sex, history of spine radiation, and number of fused levels with P = 0.047; odds ratio 12.7 (95% confidence interval 1.03-156.4) for Eastern Cooperative Oncology Group performance status over 2 and P = 0.012; odds ratio 31.5 (95% confidence interval 2.2-460.0) for multiple myeloma lesions.

CONCLUSIONS

The rate of hardware failure in this cohort was 13.8%, although operative revision rate was 3.4%. Spinal instrumentation in patients with poor preoperative functional status or multiple myeloma may be more likely to develop instrumentation failure.

Enhanced recovery care versus traditional care following laminoplasty: A retrospective case-cohort study

Enhanced recovery after surgery (ERAS) has been shown to shorten length of hospital stay and reduce perioperative complications in many types of surgeries. However, there has been a paucity of research examining the application of ERAS to major spinal surgery. The current study was performed to compare complications and hospital stay after laminoplasty between an ERAS group and a traditional care group.The ERAS group included 114 patients who underwent laminoplasty managed with an ERAS protocol between January 2016 and June 2017. The traditional care group included 110 patients, who received traditional perioperative care between November 2014 and December 2015. Postoperative hospital stay (POPH), physiological function, postoperative visual analogue scale (VAS) pain score, and postoperative complications were compared between the 2 groups.The mean POPH was significantly shorter in the ERAS group than traditional care group (5.75 ± 2.46 vs. 7.67 ± 3.45 d, P < .001). ERAS protocol significantly promoted postoperative early food-taking (8.45 ± 2.94 h vs 21.64 ± 2.66 h, P < .001), reduced the first time of assisted walking (30.79 ± 14.45 vs. 65.24 ± 25.34 h, P < .001), postoperative time of indwelling urinary catheters (24.76 ± 12.34 vs. 53.61 ± 18.16 h, P < .001), and wound drainage catheters (43.92 ± 7.14 vs. 48.85 ± 10.10 h, P < .001), as compared with the traditional care group. Pain control was better in the ERAS group than traditional care group in terms of mean VAS score (2.72 ± 0.46 vs. 3.35 ± 0.46, P < .001) and mean maximum VAS score (3.76 ± 1.12 vs. 4.35 ± 1.15, P < .001) in 3 days after surgery. The morbidity rate was 21.05% (24 of 114 patients) in the ERAS group and 20.90% (23 of 110 patients) in the control group (P = .75).The ERAS protocol is both safe and feasible for patients undergoing laminoplasty, and can decrease the length of postoperative hospitalization without increasing the risk of complications.

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

Background

Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis.

Methods

Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay.

Results

LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline.

Conclusions

In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations.

Level of Evidence

2.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Energy efficiency of ambulation-A comparison of various orthopaedic possibilities

BACKGROUND

In most developing countries, accessibility for people using walking aids is limited due to architectural and environmental barriers. As observed from anecdotal accounts, even a minor orthopaedic injury/disorder may restrict a person's ambulation due to fatigue associated with using walking aids. Hence this study was undertaken with the following objective.

OBJECTIVE

to estimate the magnitude of energy consumption using energy expenditure index (EEI) during gait under different conditions.

DESIGN

Repeated measures design (within subjects study).

SETTING

School.

PARTICIPANTS

Ten healthy, typical young adults between 17 and 25 years of age.

OUTCOME MEASURE

Energy Expenditure Index (EEI) was estimated for each of the conditions of the study using consistent measurement procedures.

RESULTS

Energy consumption with immobilization is greater (ankle-16.2%, knee-36.7% and ankle and knee-49.2%) than typical self-selected ambulation. During on ground ambulation the energy cost was greatest for an axillary crutches than a standard walker with ankle and knee immobilized being the highest in relation to typical ambulation (78.2% greater). Axillary crutches were more efficient than a walker during stair climbing.

CONCLUSION

For young adults a standard walker may be the right option for over-ground ambulation, when a lower limb joint in immobilized; with an axillary crutch used during stair climbing.

Predictors of readmission to acute care during inpatient rehabilitation for non-traumatic spinal cord injury

OBJECTIVES

To investigate the frequency of and reasons for readmissions to acute care (RTAC) during inpatient rehabilitation (IPR) after non-traumatic spinal cord injury (NT-SCI). To develop a predictive model for RTAC using identified risk factors.

DESIGN

Retrospective case-control.

SETTING

Academic IPR hospital.

PARTICIPANTS

Individuals with NT-SCI admitted to an academic SCI rehabilitation unit from January 2014-December 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Readmissions to acute care services from IPR.

RESULTS

Thirty-seven participants (20%) experienced a RTAC for a total of 39 episodes. Thirty-five experienced 1 RTAC, while two had 2. The most common medical reasons for RTAC were infection (27%), neurological (27%), and noninfectious respiratory (16%). Multivariable logistic regression was used to develop a model to predict RTAC. Paraplegia was associated with 3.2 times increase in the odds of RTAC (P = 0.03). For every unit increase in FIM-Motor, there was a 5% reduction in the odds of RTAC (P = 0.03) Body mass index less than 30 decreased odds of RTAC by 61% (P = 0.004).

CONCLUSION

RTACs were associated with body mass index greater than 30, decreased FIM-Motor subscore on admission, and paraplegia. Physiatrists caring for the non-traumatic SCI patient need be more circumspect of individuals with these parameters to potentially prevent the problems necessitating acute care transfer.

Clinical and radiological outcome of non-surgical management of thoracic and lumbar spinal fracture-dislocations - a historical analysis in the era of modern spinal surgery

Context: It is well established that traumatic spinal dislocations (AO Type C injuries) should be surgically treated. However, no recent comparative study of surgical versus non-surgical management of type C injuries was found attesting the superiority of surgical treatment.Objective: Due to the lack of information about the natural history of non-surgical management of type C injuries, we evaluated the outcome of historical conservative treatment of type C injuries.Methods: An extensive manual search of articles was performed in the Pubmed Database. We included articles that reported the clinical and/ or the radiological outcome of non-surgical management of thoracic and/ or lumbar spinal fracture-dislocations.Results: Three well described retrospective studies where fracture-dislocations of the thoracolumbar spine were managed non-surgically were included. Non-surgical management typically consisted in postural reduction and prolonged bed rest (about 10-13 weeks on average). Residual deformity was common, and some studies reported a high rate of post treatment pain syndromes. Some studies reported surgery for gibbus deformity after conservative treatment or persistent instability requiring further bed rest. Neurological deterioration was rare, and some patients had some improvement, although the vast majority of the patients had persistent, severe neurological deficits.Conclusions: Compared with historical non-surgical care, surgery for type C injuries decreases the chances of post-operative pain, late spinal deformity and also allowed early rehabilitation, once no bed restriction is necessary. Ethical issues based on this historical analysis may preclude performing a comparative study of non-surgical versus surgical management of these injuries in the modern spine era.

First in the Nation: One Unit's Journey to Achieving Fragility Fracture Certification

Osteoporosis is related to more than 2 million fractures and $19 billion in healthcare costs each year (). A fragility fracture (FF) is a low-energy fracture of the distal radius, proximal humerus, ankle, or proximal femur (hip) from minimal trauma such as a fall from a standing height. In addition to cost, FFs often result in the loss of independence and productivity (). In 2015, our orthopaedic unit received the first certification ever awarded for FFs. Fragility fracture certification is a new certification demonstrating that a healthcare facility complies with national patient care standards and uses evidence-based practice guidelines to deliver quality outcomes. Orthopaedic nurses have a critical role in optimizing future bone health and fracture prevention. Our story describes the process and challenges faced becoming the first organization in the nation to be successfully surveyed for The Joint Commission's Fragility Fracture Certification.

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.].

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study

OBJECTIVE

Early mobilisation is recommended following total hip arthroplasty (THA) or total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). We sought to determine the proportions of patients that first mobilised on post-operative day 0 (POD 0) and factors associated with earlier time to mobilisation.

METHODS

A prospective cohort study was conducted involving patients with hip or knee osteoarthritis who had undergone primary unilateral THA (n = 818) and TKA (n = 989) at 19 Australian hospitals. Patient-related (e.g. age, gender, body mass index), treatment-related (e.g. hospital site, presence of indwelling catheter) and mobilisation-related variables were collected on standardised forms. Time was measured by post-operative days, where POD 0 was defined as the day of surgery ending at midnight. Multivariate Poisson regression analysis identified associations between patient- and treatment-related covariates and time to mobilisation.

RESULTS

Inter-hospital variation was evident, but overall, only 9.4% of THA and 5.6% of TKA patients mobilised on POD 0. For THA patients, earlier time to mobilisation was associated with hospital site and absences of an indwelling catheter and acute complications. For TKA patients, earlier time to mobilisation was associated with hospital site and absence of donor blood transfusion.

CONCLUSIONS

Few THA and TKA patients mobilise POD 0, although some hospitals appear more aggressive with their mobilisation attempts than others. Treatment-related factors, not patient-related, are associated with post-operative day of mobilisation, indicating the potentially pivotal role of service providers in promoting early mobilisation to improve health outcomes and reduce rates of VTE.

Urinary tract infection in patients with hip fracture: An underestimated event?

AIM

Urinary tract infections (UTI) represent a common perioperative complication among elderly patients with hip fracture. To determine the impact of UTI on the perioperative course of elderly patients with hip fractures, a prospective study was carried out.

METHODS

A total of 402 surgically-treated geriatric hip fracture patients were consecutively enrolled at a level 1 trauma center. On admission, all patients received an indwelling urinary catheter. Clinically symptomatic patients were screened more closely for UTI. Patients diagnosed with UTI were compared with asymptomatic patients. Outcomes in both patient groups were measured using in-hospital mortality, overall length of hospital stay, wound infection, functional results and mobility at discharge. Multivariate regression analysis was carried out to control for influencing factors.

RESULTS

A total of 97 patients (24%) sustained a UTI during in-hospital treatment. UTI were independently associated with inferior functional outcomes as assessed by the Barthel Index (β = -0.091; P = 0.031), Timed Up and Go test (β = 0.364; P = 0.001) and Tinetti test (β = -0.169; P = 0.001) at discharge. Additionally, length of hospital stay was significantly longer for patients with a UTI diagnosis (β = 0.123; P = 0.029) after controlling for all other variables. No differences were observed in the rate of wound infection (odds ratio 1.185; P = 0.898) or in-hospital mortality (P < 0.997).

CONCLUSIONS

Patients with UTI seem to be at risk of inferior functional outcomes. In addition to an early detection of symptomatic UTI and a targeted antibiotic therapy, perioperative care should focus on preserving functional ability to protect these patients from further loss of independence and prolonged clinical courses. Geriatr Gerontol Int 2017; 17: 2369-2376.

Meta-Analysis of the Ease of Care From a Patients' Perspective Comparing Fentanyl Iontophoretic Transdermal System Versus Morphine Intravenous Patient-Controlled Analgesia in Postoperative Pain Management

PURPOSE

The purpose of this meta-analysis was to evaluate patients' assessment of fentanyl iontophoretic transdermal system (ITS) and morphine intravenous patient-controlled analgesia (IV PCA) ease of care (EOC) using a validated patient EOC questionnaire. Fentanyl ITS is a preprogrammed, needle-free PCA system used for the management of acute pain in postoperative patients.

METHODS

This meta-analysis assessed the patient EOC of fentanyl ITS and morphine IV PCA using data from three randomized, active-comparator trials in adult postoperative patients with moderate-to-severe pain. All three studies utilized a validated patient EOC questionnaire which consists of 23 items grouped into seven subscales (confidence with device, comfort with device, movement, dosing confidence, pain control, knowledge/understanding, and satisfaction). Each item is scored on a six-point Likert scale. The weighted mean difference between treatments was calculated for the overall EOC and for each of the seven subscales.

RESULTS

The EOC analyses were based on responses to questionnaires from 1,943 patients treated with either fentanyl ITS (n = 961) or morphine IV PCA (n = 982). There was a statistically significant advantage in favor of fentanyl ITS over morphine IV PCA in terms of overall EOC (weighted mean difference = 0.28; 95% confidence interval (0.22 to 0.34); P < 0.0001). Five of the seven subscales (confidence with device, comfort with device, movement, dosing confidence, and knowledge/understanding) on the patient EOC questionnaire showed a statistically significant advantage for fentanyl ITS versus morphine IV PCA. The two subscales that did not show any difference were pain control (P = 0.7303) and satisfaction (0.0561).

CONCLUSION

In this meta-analysis, fentanyl ITS is associated with some advantages in terms of an EOC profile from a patients' perspective when compared with morphine IV PCA.

Infectious complications in obese patients after trauma

BACKGROUND

Obesity is a public health concern in the United States due to its increasing prevalence, especially in younger age groups. Trauma is the most common cause of death for people under aged 40 y. The purpose of this study is to determine the association between obesity and specific infectious complications after traumatic injury.

MATERIALS AND METHODS

A retrospective analysis was conducted using data from the 2012 National Trauma Data Bank. The National Trauma Data Bank defined obesity as having a body mass index of 30 or greater. Descriptive statistics were calculated and stratified by obesity status. A hierarchical regression model was used to determine the odds of experiencing an infectious complication in patients with obesity while controlling for age, gender, diabetes, number of comorbidities, injury severity, injury mechanism, head injury, and surgical procedure.

RESULTS

Patients with a body mass index of 30 or greater compared with nonobese patients had increased odds of having an infectious complication (Odds Ratio, 1.59; 1.49-1.69). In addition to obesity, injury severity score greater than 29, age 40 y or older, diabetes, comorbid conditions, and having a surgical procedure were also predictive of an infectious complication.

CONCLUSIONS

Our results indicate that trauma patients with obesity are nearly 60% more likely to develop an infectious complication in the hospital. Infection prevention and control measures should be implemented soon after hospital arrival for patients with obesity, particularly those with operative trauma.

Can Dysphagia Following Anterior Cervical Fusions With rhBMP-2 Be Reduced With Local Depomedrol Application?: A Prospective, Randomized, Placebo-Controlled, Double-Blind Trial

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blind trial.

OBJECTIVE

The aim of this study was to investigate whether the local administration of depomedrol decreases the severity of dysphagia after anterior cervical discectomy and fusion (ACDF) surgery using bone morphogenetic protein (BMP).

SUMMARY OF BACKGROUND DATA

Although recombinant human BMP-2 is effective in promoting arthrodesis, many physicians avoid using it in anterior cervical spine fusions due to concern for increased incidence of dysphagia, significant pre-vertebral swelling, and airway compromise. Pilot studies have shown that the local application of depomedrol may decrease the incidence of postoperative dysphagia. We performed a prospective, randomized trial to evaluate the efficacy of local depomedrol application in reducing the severity of postoperative dysphagia following anterior cervical fusions using low-dose rhBMP-2. We hypothesized that locally administered depomedrol reduces dysphagia following such surgeries.

METHODS

Fifty patients between 18 and 70 years of age, undergoing 1, 2, and 3-level ACDFs, were randomized to 1 of 2 groups: BMP-2 with depomedrol or BMP-2 with saline. Patients were followed for 4 weeks postoperatively by the study administrator. Dysphagia was measured at 5 time intervals (postoperative days 1, 4, 7, 14, and 28) using a 4-point Modified Dysphagia Scoring System. Additional data regarding overall length of hospital stay and the administration of dysphagia-directed treatments were also recorded.

RESULTS

Twenty-seven patients were randomized to the treatment (depomedrol) group and 23 were randomized to the control (saline) group. The 2 groups were nearly identical in terms of their demographic and operative characteristics. Patients receiving depomedrol experienced decreased dysphagia incidence and magnitude at all time intervals, with differences reaching statistical significance on postoperative days 4, 7, 14, and 28 (P < 0.05).

CONCLUSION

This study provides Level 1 evidence that locally administered depomedrol on a collagen sponge significantly decreases postoperative dysphagia incidence and magnitude following anterior cervical spine fusion using low-dose rhBMP-2.

LEVEL OF EVIDENCE

1.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

Impaired postural stability after laparoscopic surgery

BACKGROUND

Early postoperative mobilisation may reduce patient morbidity and improve hospital efficiency by accelerated discharge. The aim of this study was to measure postural stability early after laparoscopic surgery in order to assess how early it is safe to mobilise and discharge patients.

METHODS

We included 25 women undergoing outpatient gynaecological laparoscopic surgery in the study. Patients received standardised anaesthesia with propofol, remifentanil and rocuronium. Postural stability was assessed preoperatively, at 30 min after tracheal extubation, and at discharge from the post-anaesthesia care unit using a force platform where sway area, mean sway and sway velocity were determined. The assessments were done with eyes closed and with eyes open. The primary outcome was the change in sway area with eyes closed 30 min after extubation. Data are reported as median (25-75% range).

RESULTS

Three patients could not perform all the test's 30 min after extubation. Thirty minutes after extubation, sway area with eyes closed had increased significantly with 84 mm(2) (9-172, P = 0.011) and 108 mm(2) with eyes open (25-295, P = 0.0017). Median mean sway had also increased significantly 30 min postoperatively. No significant changes were found for sway velocity. We found no significant changes in mean sway, sway area or sway velocity at discharge from the post-anaesthesia care unit approximately 2 h after surgery.

CONCLUSION

Postural stability was significantly impaired 30 min after outpatient gynaecological laparoscopic surgery. However, the postural stability was normalised at discharge from the post-anaesthesia care unit 2 h after surgery.

Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data

Current guidelines for the care of patients with acute spinal cord injuries (SCIs) recommend maintaining mean arterial pressure (MAP) values of 85-90 mm Hg for 7 days after an acute SCI however, little evidence supports this recommendation. We sought to better inform the relationship between MAP values and neurological recovery. A computer system automatically collected and stored q1 min physiological data from intensive care unit monitors on patients with SCI over a 6-year period. Data for 100 patients with acute SCI were collected. 74 of these patients had American Spinal Injury Association Impairment Scale (AIS) grades determined by physical examination on admission and at time of hospital discharge. Average MAP values as well as the proportion of MAP values below thresholds were explored for values from 120 mm Hg to 40 mm Hg in 1 mm Hg increments; the relationship between these measures and outcome was explored at various time points up to 30 days from the time of injury. A total of 994,875 q1 min arterial line blood pressure measurements were recorded for the included patients amid 1,688,194 min of recorded intensive care observations. A large proportion of measures were below 85 mm Hg despite generally acceptable average MAP values. Higher average MAP values correlated with improved recovery in the first 2-3 days after SCI while the proportion of MAP values below the accepted threshold of 85 mm Hg seemed a stronger correlate, decreasing in strength over the first 5-7 days after injury. This study provides strong evidence supporting a correlation between MAP values and neurological recovery. It does not, however, provide evidence of a causal relationship. Duration of hypotension may be more important than average MAP. It provides support for the notion of MAP thresholds in SCI recovery, and the highest MAP values correlated with the greatest degree of neurological recovery. The results are concordant with current guidelines in suggesting that MAP thresholds >85 mm Hg may be appropriate after acute SCI.