Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: A systematic review of the literature

Super-elderly, spinal surgery, evaluating the risks and benefits: a retrospective single-centre cohort study

INTRODUCTION

An increasingly ageing population presents emerging healthcare challenges. Adequate clinical evaluation and understanding of outcome-predicting factors are integral to delivering safe spinal surgery to super-elderly patients.

AIM

To evaluate spine surgery outcomes in patients aged 80 or above.

METHODS

We retrospectively evaluated patients 80 years and above who underwent elective or emergency spinal surgery between 2017 and 2022. The Eurospine Surgery Classification (ESC) was used to classify operations into Large, Medium, and Small. We calculated and compared Clinical Frailty Scores (CFS) pre- and post-operatively.

RESULTS

Two hundred forty-five patients met the inclusion criteria. Most were male (n = 145). The age range was 80 to 99 (mean 83.3). Most operations were elective (n = 151, 62%). In our cohort, 211, 22, 10,2 and 1 patients had degenerative, trauma, tumour, infective and vascular pathologies, respectively. According to the Eurospine classification, 201 (82.0%) had Minor spine surgery (63 emergently and 138 electively), 38 had Medium surgery (15.5% - 30 emergently and 8 electively), and 6 had Large surgery (2.4% - 1 emergently and 5 electively). 163 (66.5%) were discharged or under follow-up. There were 11 in-patient mortalities (4.5%). Outpatient mortality was 51 (20.8%), with the median time from surgery to death being 504.5 days, all the outpatient mortalities were neither non-spinal pathology nor spinal surgical related. CFS improved across the cohort, from 5 pre-operatively to 4 post-operatively (p < 0.001).

CONCLUSION

Spine surgery in those over the 80s can be performed safely and improve their quality of life, as demonstrated by improvements in the CFS. Good patient selection and adequate pre-operative workup is essential, although it may not be possible in emergencies.

Satisfaction following correction of spinal deformity: Cultural and regional effects on outcome

Corrective spine surgery for spinal deformities, such as adolescent idiopathic scoliosis (AIS) and adult spinal deformity (ASD), aims to enhance the quality of life by addressing physical impairments. However, the extent of patient satisfaction after surgery, which includes pain management, functional recovery, and psychological contentment, exhibits considerable variation across different cultural and geographical landscapes. This review describes the influence of cultural and regional disparities on postoperative satisfaction in AIS and ASD surgery with a particular emphasis on the disparities between the US and Japan. This review underscores the intricate relationship between surgical outcomes and patient-reported satisfaction metrics. The investigation reveals significant contrasts in patient satisfaction and clinical results between these 2 countries, attributed to divergent cultural expectations, lifestyle adaptations, and perceptions of bodily image. These distinctions are crucial for healthcare professionals to recognize, as they necessitate a culturally nuanced approach to patient care. This comparative review not only enhances the understanding of patient experiences across cultures but also provides valuable guidance for physicians in customizing their strategies to align with the varied expectations of their patients, thereby improving postoperative satisfaction and overall quality of life. This review emphasizes the necessity of a tailored and culturally sensitive approach to managing spinal deformities, underscoring the need to factor in cultural and regional elements to enhance patient satisfaction and surgical outcomes.

Treatment of Ankylosing Spondylitis Patients with Cervical Spinal Injury with Anterior Single-Stage Fixation with Bone Cement Augmentation

Background/Objectives: Cervical spine fractures in ankylosing spondylitis (AS) are characterized as highly unstable fractures posing an elevated risk of neurological deficit and a significantly elevated mortality rate. This study assesses the efficacy and safety of single-stage plate stabilization with ventral cement augmentation in treating subaxial cervical spine fractures in patients with AS. Methods: Over 86 months, 38 patients diagnosed with AS received ventral plate stabilization with cement augmentation after suffering unstable subaxial cervical fractures. No additional dorsal stabilization was used in any of these surgeries. Results: There were no complications as a result of cement leakage. During the follow-up period, screw loosening and implant displacement were documented in two out of 38 cases. At the time of data analysis, 17 patients who had undergone treatment had died, representing 44.7% of the total cases. Seven patients died within 1 month, two patients died within 6 months, four patients died within 1 year, and four patients died after 1 year. Conclusions: Our study shows that a single-stage anterior screw and plate fixation of the cervical spine with cement augmentation could be a feasible and effective method to treat cervical spine fractures in patients with AS.

A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Unveiling Timetable for Physical Therapy after Single-Level Lumbar Surgery for Degenerative Disc Disease: Insights from a Systematic Review and Meta-Analysis

Background: Postoperative physical therapy emerges as a pivotal element of the rehabilitation process, aimed at enhancing functional recovery, managing pain, and mitigating the risk of further complications. The debate concerning the optimal timing of physical therapy intervention post-surgery remains unresolved; in particular, whether to initiate physical therapy immediately or to wait weeks is of particular interest. The aim of this study is to review the available literature regarding the optimal timing of physical therapy initiation and the outcomes obtained. Methods: This review was carried out in accordance with the Preferential Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. This search was carried out in February 2024. Only peer-reviewed articles were considered for inclusion. Results: Fourteen studies were included. The primary outcomes assessed in the included studies were the following: 12-week and 12-month low back pain, return to work, function and disability, psychological status, patient satisfaction, and complications associated with early physical therapy. A meta-analysis was performed concerning low back pain after lumbar discectomy at 12 weeks and 12 months and complications after early physical therapy after lumbar discectomy and lumbar interbody fusion. A significant difference was found between early and standard physical therapy in terms of low back pain at 12-18 months (p = 0.0062); no significant differences were found in terms of complications, both for discectomy and arthrodesis. Conclusions: This review indicates that employing early rehabilitation strategies for intervertebral disc disease could enhance results in terms of pain and disability without an enhanced risk of complications.

Promoting postoperative recovery in patients with metastatic epidural spinal cord compression based on the concept of ERAS: a multicenter analysis of 304 patients

BACKGROUND CONTEXT

Enhanced recovery after surgery (ERAS) has proven beneficial for patients undergoing orthopedic surgery. However, the application of ERAS in the context of metastatic epidural spinal cord compression (MESCC) remains undefined.

PURPOSE

This study aims to establish a medical pathway rooted in the ERAS concept, with the ultimate goal of scrutinizing its efficacy in enhancing postoperative outcomes among patients suffering from MESCC.

STUDY DESIGN/SETTING

An observational cohort study.

PATIENT SAMPLE

A total of 304 patients with MESCC who underwent surgery were collected between January 2016 and January 2023 at two large tertiary hospitals.

OUTCOME MEASURES

Surgery-related variables, patient quality of life, and pain outcomes. Surgery-related variables in the study included surgery time, surgery site, intraoperative blood loss, and complication.

METHODS

From January 2020 onwards, ERAS therapies were implemented for MESCC patients in both institutions. Thus, the ERAS cohort included 138 patients with MESCC who underwent surgery from January 2020 to January 2023, whereas the traditional cohort consisted of 166 patients with MESCC who underwent surgery from January 2016 to December 2019. Clinical baseline characteristics, surgery-related features, and surgical outcomes were collected. Patient quality of life was evaluated using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and pain outcomes were assessed using the Visual Analogue Scale (VAS).

RESULTS

Comparison of baseline characteristics revealed that the two cohorts were similar (all p>.050), indicating comparable distribution of clinical characteristics. In terms of surgical outcomes, patients in the ERAS cohort exhibited lower intraoperative blood loss (p<.001), shorter postoperative hospital stays (p<.001), lower perioperative complication rates (p=.020), as well as significantly shorter time to ambulation (P<0.001), resumption of regular diet (p<.001), removal of urinary catheter (p<.001), initiation of radiation therapy (p<.001), and initiation of systemic internal therapy (p<.001) compared with patients in the traditional cohort. Regarding pain outcomes and quality of life, patients undergoing the ERAS program demonstrated significantly lower VAS scores (p<.010) and higher scores for physical (p<.001), social (p<.001), emotional (p<.001), and functional (p<.001) well-being compared with patients in the traditional cohort.

CONCLUSIONS

The ERAS program, renowned for its ability to expedite postoperative recuperation, emerges as a promising approach to ameliorate the recovery process in MESCC patients. Not only does it exhibit potential in enhancing pain management outcomes, but it also holds the promise of elevating the overall quality of life for these individuals. Future investigations should delve deeper into the intricate components of the ERAS program, aiming to unravel the precise mechanisms that underlie its remarkable impact on patient outcomes.

Mu-Opioid Receptor 1 and C-Reactive Protein Single Nucleotide Polymorphisms as Biomarkers of Pain Intensity and Opioid Consumption

Children constitute a special group in pain therapy. Single nucleotide polymorphisms that are associated with differences in postoperative, inflammatory pain perception and opioid requirement are the A118G SNP in the mu-opioid receptor 1 (OPRM1) gene and the rs1205 CRP. This study aimed to determine connection between OPRM1 and rs1205 CRP SNPs in pediatric patients postoperatively and pain intensity, the opioid dose needed to control pain after scoliosis correction, and other clinical aspects. Genotypes of rs1205 CRP and OPRM1 polymorphisms in a sample of 31 patients were specified, and statistical analysis was performed in terms of age, genotype frequency, pain assessment, sufentanil flow, post-anesthesia care unit stay, and the use of coanalgesics. The frequency of A/A and A/G genotypes in the OPRM1 gene was in line with 1000Genomes data for the European population. Patients from the AG group of OPRM1 SNP more frequently required coanalgesics for adequate pain control; however, it was of weak statistical significance. Other parameters measured in the study were not statistically significant in relation to OPRM1 and CRP polymorphisms. The effect of SNPs on postoperative pain management and opioid therapy in children was not confirmed by this study. An expansion of the study sample and other opioid-related SNPs is required.

Associated Risk Factors for Extended Length of Stay Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database

OBJECTIVES

The aim of this study was to identify the factors associated with extended length of stay (LOS) for pediatric patients with craniosynostosis undergoing cranial vault remodeling (CVR).

METHODS

A retrospective cohort study was performed using the 2012 to 2021 American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients below 2 years old with craniosynostosis who underwent CVR were identified using Current Procedural Terminology and International Classification of Diseases-9/10 codes. Patients were dichotomized according to whether they encountered an extended postoperative hospital LOS, which was defined as LOS greater than the 75th percentile for the entire cohort (4 days). Patient demographics, comorbidities, intraoperative variables, postoperative adverse events, and health care resource utilization were assessed. Multivariate logistic regression analysis was utilized to identify predictors of prolonged LOS.

RESULTS

In our cohort of 9784 patients, 1312 (13.4%) experienced an extended LOS. The extended LOS cohort was significantly older than the normal LOS cohort (normal LOS: 225.1±141.8 d vs. extended LOS: 314.4±151.7 d, P<0.001) and had a smaller proportion of non-Hispanic white patients (normal LOS: 70.0% vs. extended LOS: 61.2%, P<0.001). Overall, comorbidities and adverse events were significantly higher in the extended LOS cohort than the normal LOS cohort. On multivariate logistic regression, independent associations of extended LOS included age, race and ethnicity, weight, American Society of Anesthesiologists classification, impaired cognitive status, structural pulmonary abnormalities, asthma, and neuromuscular disorders.

CONCLUSIONS

This study demonstrates that age, race, comorbidities, and perioperative complications contribute to extended LOS after CVR for craniosynostosis. Further investigations to further elucidate the risk factors of extended LOS is warranted to optimize patient outcomes.

Role of Enhanced Recovery after Surgery (ERAS) Protocol in the Management of Elderly Patients with Glioblastoma

OBJECTIVE

Among the already difficult management of neuro-oncological patients, the elderly population remains vulnerable. Because of the pathology and the comorbidities, they present a significantly higher rate of medical issues related to surgical management. Despite this, the surgical option, if feasible, remains the gold standard in these patients, and an Enhanced Recovery After Surgery (ERAS) protocol could improve the postoperative safety of the patients. With this purpose, we prepared this study with the aim of defining the postoperative hospital length of stay (LOS), but also of evaluating the postoperative morbidity, perioperative complications, and postoperative pain scores.

METHODS

This was a retrospective, single-cohort study performed at an academic hospital (Department of Neurosurgery, Neurocenter of South Switzerland, Switzerland) on elderly patients who underwent craniotomy for glioblastoma. Patients were enrolled in a novel ERAS protocol from January 2022 to December 2022. Since this is a feasibility study and a direct comparison was not possible, we used a historical cohort of elderly patients who had undergone elective craniotomy surgery for glioblastoma as a control group.

RESULTS

A total of 19 patients treated in our center for glioblastoma multiforme (GBM) who were aged over 75 years were included in this study. Among those, seven were newly recruited patients included in the ERAS protocol, while the remaining twelve were part of a historical cohort of previously treated patients. From a statistical point of view, the two cohorts were comparable in terms of baseline demographics. In the follow-up, it was shown that in the ERAS group, there was a reduction in the use of opioids after the surgical procedures that could be seen at 30 days (36.2% vs. 71.7%, p < 0.001), but also at 3 months, after surgery (33.0% vs. 80.0%, p < 0.001). A significant difference has also been documented in terms of mobilization and ambulation: compared to the historical cohort, in the ERAS group, there was a higher rate of mobilization (60.0% vs. 10.0%, p < 0.001), but also of ambulation (36.1% vs. 10.0%, p < 0.001).

CONCLUSIONS

The ERAS protocol for the management of glioblastoma in elderly patients seems to be an effective option for reducing LOS in the hospital, as well as for reducing the number of days spent in the ICU, improving the general recovery of the patient, and reducing the costs associated with hospitalization.

Cervical muscle morphometry and composition demonstrate prognostic value in degenerative cervical myelopathy outcomes

Objectives

This study aimed to examine whether preoperative cervical muscle size, composition, and asymmetry from magnetic resonance imaging (MRI) can predict post-operative outcomes in patients with degenerative cervical myelopathy (DCM).

Methods

A total of 171 patients with DCM were included. Relative total cross-sectional area (RCSA), functional CSA (fat-free area, FCSA), ratio of FCSA/CSA (fatty infiltration) and asymmetry of the multifidus (MF) and semispinalis cervicis (SCer) together (MF + SCer), and cervical muscle as a group (MF, SCer, semispinalis capitis, and splenius capitis) were obtained from T2-weighted axial MR images at the mid-disk, at the level of maximum cord compression and the level below. Univariate and multivariate linear regression analyses were used to assess the relationship between baseline cervical muscle measurements of interest with the modified Japanese Orthopedic Association (mJOA), Nurick Classification, Neck Disability Index (NDI), and SF-36 health survey at 6-month and 12-month post-surgery.

Results

Lower RCSA of MF + SCer, less CSA MF + SCer asymmetry and greater FCSA/CSA for the cervical muscle group (e.g., less fatty infiltration), and younger age were significant predictors of higher mJOA scores (e.g., less disability) at 6-month and 12-month post-surgery (all p < 0.05). Greater CSA asymmetry in MF + SCer and lower FCSA/CSA (e.g., more fatty infiltration) for the cervical muscle group were significant predictors of higher Nurick scores (e.g., more disability) at 6-month and 12-month post-surgery (all p < 0.05). Lower FCSA MF + Scer asymmetry, lower FCSA/CSA asymmetry of the muscle group, and greater RCSA MF + SCer were significant predictors of higher NDI scores at 6-month and 12-month post-surgery. Finally, greater FCSA/CSA asymmetry of the MF + SCer, greater FCSA asymmetry of the muscle group, greater RCSA of the muscle group, and greater CSA asymmetry of MF + SCer were significant predictors of lower post-operative SF-36 scores at 6- and 12-month post-surgery.

Conclusion

Our result suggested that cervical paraspinal muscle morphology, specifically greater asymmetry, and fatty infiltration may be important predictors of functional recovery and post-surgical outcomes in patients with DCM.

The influence of enhanced recovery after surgery protocol adherence in patients undergoing elective neuro-oncological craniotomies

Objectives

Enhanced recovery after surgery (ERAS) protocols have reduced the length of hospital stay (LOS) and healthcare costs without increasing adverse outcomes. We describe the impact of adherence to an ERAS protocol for elective craniotomy among neuro-oncology patients at a single institution.

Methods

This retrospective study enrolled adult patients who underwent elective craniotomy and the ERAS protocol at our institute between January 2020 and April 2021. The patients were divided into high- and low-adherence groups depending on their adherence to ≥9 or <9 of the 16 items, respectively. Inferential statistics were used to compare group outcomes, and multivariable logistic regression analysis was used to examine factors related to delayed discharge (LOS>7 days).

Results

Among the 100 patients assessed, median adherence was 8 items (range, 4-16), and 55 and 45 patients were classified into the high- and low-adherence groups, respectively. Age, sex, comorbidities, brain pathology, and operative profiles were comparable at baseline. The high-adherence group showed significantly better outcomes, including shorter median LOS (8 days vs. 11 days; p ​= ​0.002) and lower median hospital costs (131,657.5 baht vs. 152,974 baht; p ​= ​0.005). The groups showed no differences in 30-day postoperative complications or Karnofsky performance status. In the multivariable analysis, high adherence to the ERAS protocol (>50%) was the only significant factor preventing delayed discharge (OR ​= ​0.28; 95% CI ​= ​0.10 to 0.78; p ​= ​0.04).

Conclusions

High adherence to ERAS protocols showed a strong association with short hospital stays and cost reductions. Our ERAS protocol was feasible and safe for patients undergoing elective craniotomy for brain tumors.

Enhanced recovery of postoperative nursing for single-port thoracoscopic surgery in lung cancer patients

Lung cancer is a common clinical malignant tumor, and the number of new lung cancer patients is increasing year by year. With the advancement of thoracoscopy technology and equipment, the scope of application of minimally invasive surgery has expanded to almost all types of lung cancer resection, making it the mainstream lung cancer resection surgery. Single-port thoracoscopic surgery provides evident advantages in terms of postoperative incision pain since only a single incision is required, and the surgical effect is similar to those of multi-hole thoracoscopic surgery and traditional thoracotomy. Although thoracoscopic surgery can effectively remove tumors, it nevertheless induces variable degrees of stress in lung cancer patients, which eventually limit lung function recovery. Rapid rehabilitation surgery can actively improve the prognosis of patients with different types of cancer and promote early recovery. This article reviews the research progress on rapid rehabilitation nursing in single-port thoracoscopic lung cancer surgery.

Does intraoperative patellar eversion affect clinical and functional outcomes in patients undergoing primary total knee arthroplasty? An evidence-based meta-analysis

PURPOSE

This meta-analysis aims to compare the early postoperative recovery, complications encountered, length of hospital stay, and initial functional scores between patellar eversion and non-eversion manoeuvres in patients undergoing during primary total knee arthroplasty (TKA) based on clinical studies available in the literature.

METHODS

A systematic literature search was conducted using PubMed, Embase, Web of Science, and the Cochrane Library databases between January 1, 2000 and August 12, 2022. Prospective trials comparing clinical, radiological, and functional outcomes in patients undergoing TKA with and without patellar eversion manoeuvre were included. The meta-analysis was performed using Rev-Man version 5.41 (Cochrane Collaboration). Pooled-odds ratios (for categorical data) and mean differences with 95% confidence intervals (for continuous data) were calculated (p < 0.05 was regarded as statistically significant).

RESULTS

Ten (out of the 298 publications identified in this subject) were included for the meta-analysis. The patellar eversion group (PEG) had a significantly shorter tourniquet time [mean difference (MD) - 8.91 min; p = 0.002], although the overall intraoperative blood loss was higher (IOBL; MD 93.02 ml; p = 0.0003). The patellar retraction group (PRG), on the other hand, revealed statistically better early clinical outcomes in terms of shorter time necessary to perform active straight leg raising (MD 0.66, p = 0.0001), shorter time to achieve 90° knee-flexion (MD 0.29, p = 0.03), higher degree of knee flexion achieved at 90 days (MD - 1.90, p = 0.03), and reduced length of hospital stay (MD 0.65, p = 0.03). There was no statistically significant difference in the early complication rates, 36-item short-form health survey (1 year), visual analogue scores (1 year), and Insall-Salvati index at follow-up between the groups.

CONCLUSION

The implications from the evaluated studies suggest that in comparison with patellar eversion, patellar retraction manoeuvre during surgery provides significantly faster recovery of quadriceps function, earlier attainment of functional knee range of motion (ROM), and shorter length of hospital stay in patients undergoing TKA.

Association of frailty with healthcare resource utilization after open thoracic/thoracolumbar posterior spinal fusion for adult spinal deformity

PURPOSE

The Hospital Frailty Risk Score (HFRS) is a frailty-identifying metric developed using ICD-10-CM codes. While other studies have examined frailty in adult spinal deformity (ASD), the HFRS has not been assessed in this population. The aim of this study was to utilize the HFRS to investigate the impact of frailty on outcomes in ASD patients undergoing posterior spinal fusion (PSF).

METHODS

A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults with ASD undergoing elective PSF were identified using ICD-10-CM codes. Patients were categorized into HFRS-based frailty cohorts: Low (HFRS < 5) and Intermediate-High (HFRS ≥ 5). Patient demographics, comorbidities, intraoperative variables, and outcomes were assessed. Multivariate regression analyses were used to determine whether HFRS independently predicted extended length of stay (LOS), non-routine discharge, and increased cost.

RESULTS

Of the 7500 patients identified, 4000 (53.3%) were in the Low HFRS cohort and 3500 (46.7%) were in the Intermediate-High HFRS cohort. On average, age increased progressively with increasing HFRS scores (p < 0.001). The frail cohort experienced more postoperative adverse events (p < 0.001), greater LOS (p < 0.001), accrued greater admission costs (p < 0.001), and had a higher rate of non-routine discharge (p < 0.001). On multivariate analysis, Intermediate-High HFRS was independently associated with extended LOS (OR: 2.58, p < 0.001) and non-routine discharge (OR: 1.63, p < 0.001), though not increased admission cost (OR: 1.01, p = 0.929).

CONCLUSION

Our study identified HFRS to be significantly associated with prolonged hospitalizations and non-routine discharge. Other factors that were found to be associated with increased healthcare resource utilization include age, Hispanic race, West hospital region, large hospital size, and increasing number of AEs.

The efficacy of laser interstitial thermal therapy in the management of spinal metastases: a systematic review of the literature

BACKGROUND

In the last years, laser interstitial thermal therapy (LITT) has started to be used also in neurosurgical setting. Its efficacy for intracranial pathologies, namely, tumors and epilepsy, has been widely demonstrated. However, the literature evidences about the use of LITT for spinal lesions are recent, and it is still a topic of discussion regarding its efficacy. Here, the authors sought to present a systematic review of the literature investigating the utility of LITT for spinal lesions.

METHODS

Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the use of spinal laser interstitial thermal therapy (sLITT). Included in the search were randomized controlled trials, cohort studies, and clinical series. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

RESULTS

Out of the initial 134 studies, 6 met the inclusion criteria for the systematic review, resulting in a total of 206 patients. All the patients have been treated with sLITT for compressive spinal metastases. Most of the lesions were thoracic (88.8%). All the studies reported an effective local control of the disease with a reduction of epidural compression at 30 days. Complication rate was 12.6%, but most of them were transient conditions, and only 3.4% patients needed a revision surgery.

CONCLUSION

sLITT is safe and provides effective local control for epidural compression from metastases, particularly in the thoracic spine. The authors propose considering sLITT as an alternative to open surgery in selected patients with spinal metastases.

Methodological quality in guidelines for enhanced recovery after surgery was suboptimal

OBJECTIVE

We aimed to appraise the methodological quality of existing guidelines for Enhanced Recovery After Surgery (ERAS) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to identify the concordance of different recommendations.

STUDY DESIGN AND SETTING

PubMed, Embase, Google Scholar, Web of Science, and clinical practice guideline websites were systematically searched. Four reviewers independently assessed the guidelines using the AGREE II instrument. The mean score of each AGREE II item, number of recommendations, strength of recommendation, and level of evidence were calculated. Agreement among reviewers was assessed using the intraclass correlation coefficient.

RESULTS

We identified 23 guidelines from 7,127 records. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.92; 95% confidence interval [CI], 0.86-0.96). The mean scores of the six AGREE domains were scope and purpose, 60.1% (95% CI, 55.9-64.1); stakeholder involvement, 40.7% (95% CI, 35.4-46.0); rigor of development, 44.7% (95% CI, 42.2-47.2); clarity and presentation, 69.8% (95% CI, 65.3-74.3); applicability, 37.2% (95% CI, 31.8-42.6); and editorial independence, 47.8% (95% CI, 39.0-56.7). Only 2/23 ERAS guidelines were considered applicable without modifications.

CONCLUSIONS

The methodological quality of the ERAS management guidelines varied and was generally low. Future guideline development should adhere to the use of the AGREE II instrument and the GRADE system to better guide clinical practice and improve individualized treatment strategies.

Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity

OBJECTIVE

As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity.

METHODS

A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD).

RESULTS

Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077).

CONCLUSION

Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.

Perioperative and Radiographic Outcomes Between Single-Position Surgery (Lateral Decubitus) and Dual-Position Surgery for Lateral Lumbar Interbody Fusion and Percutaneous Pedicle Screw Fixation: Meta-Analysis

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) and percutaneous posterior screw fixation (PPSF) techniques is used to treat degenerative lumbar pathologies. Dual-position (DP) lumbar surgery involves repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. Single-position (SP) lumbar surgery is commonly performed nowadays, a minimally invasive alternative performed entirely from the lateral decubitus position. However, controversy still exists. This meta-analysis aimed to compare perioperative outcomes between SP lumbar surgery and DP lumbar surgery for LLIF and PPSF.

METHODS

We conducted this meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched Medline and Scopus from inception to November 11, 2021, for relevant studies.

RESULTS

Six studies were identified, which contained totals of 502 and 447 patients in the SP and DP groups, respectively. The unstandardized mean difference in operative time, length of hospital stay, intraoperative blood loss, radiation doses, lumbar lordosis, and pelvic incidence-lumbar lordosis mismatch were -86.1 (95% confidence interval [CI] -149.2 to -23.1) minutes, -1.6 (95% CI -2.4 to -0.9) days, -55.6 (95% CI -127.5 to 16.2) mL, -30.3 (95% CI -80.5 to 19.8) mGy, 1.34 (95% CI -1.17 to 3.86) degrees, and -4.06 (95% CI -5.65 to -2.47) lower in SP when compared with DP. The chances of having complications and reoperations in SP were 0.75 (95% CI 0.49-1.14) and 0.77 (95% CI 0.44-1.36) times, respectively, compared with the DP group. No significant differences were found for intraoperative blood loss, radiation dose, lumbar lordosis, complications, and reoperations between the 2 groups.

CONCLUSIONS

This meta-analysis found that SP have lower operative time and length of hospital stay compared with DP LLIF and PPSF. However, no differences in intraoperative blood loss, radiation dose, radiographic change, complications, and reoperation rates were found.

Comparison of Percutaneous Endoscopic Cervical Keyhole Foraminotomy versus Microscopic Anterior Cervical Discectomy and Fusion for Single Level Unilateral Cervical Radiculopathy

Objective

To compare the clinical and radiological outcomes between microscopic anterior cervical discectomy and fusion (ACDF) and percutaneous endoscopic cervical keyhole foraminotomy (PECF) for single level unilateral cervical radiculopathy.

Methods

A total of 127 patients (59 in PECF VS 68 in ACDF) were enrolled in this study from April 2016 to May 2018 with a minimum follow-up of 2 years. Clinical data including baseline data, Neck Disability Index (NDI), and Visual Analogue Scale for neck and arm (VAS-n, VAS-a) were collected and compared. Radiological evaluation such as disc height, ROM of cervical, Cobb’s angle of cervical and Cobb’s angle of operated segment was measured by two experienced radiologists in twice.

Results

There was no significant difference between the two groups in the baseline data, and hospital stay was significantly decreased in PECF group than ACDF group (P < 0.001). PECF group did not yield superior better outcomes in NDI, VAS-a and VAS-n than ACDF group except at 1-month follow-up. As for radiological outcomes, PECF group has significantly better cervical motion, cervical angle and segmental angle than ADCF group at 12- and 24-month follow-up visit (P < 0.05); however, ACDF had shown better disc height restoration and maintenance than PECF (P < 0.05). More complications including surface hematoma and swallowing difficulty were occurred in ADCF group.

Conclusion

Percutaneous endoscopic cervical keyhole foraminotomy could be the alternative method for anterior cervical discectomy and fusion in selective cases. However, the indication should be fulfilled, more studies need to be conducted to further testify the efficacy of PECF.

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Clinical evaluation of enhanced recovery after surgery protocol for anterior cervical decompression and fusion (ACDF): study protocol for a multicentre randomised controlled trial

INTRODUCTION

To improve the efficacy of anterior cervical decompression and fusion (ACDF) and reduce postoperative complications in degenerative cervical myelopathy, our team established a set of perioperative care of enhanced recovery guidelines of ACDF based on the concept of enhanced recovery after surgery. In addition, a prospective, multicentre, randomised clinical trial was designed.

METHODS AND ANALYSIS

A total of 260 patients aged 18-65 years will be included. Preoperative MRI and CT will be used to confirm the typical manifestations of cervical spondylosis, such as cervical disc herniation and spinal cord compression. The patient presents with neck and shoulder pain, numbness of upper limbs, weakened grip strength and cotton sense of foot tread. Patients received normal conservative treatment for 3 months with no obvious relief or even aggravation of symptoms. Patients will be assigned to the group in strict accordance with the random allocation table. Patients in groups A and B will receive conventional perioperative care and perioperative care for enhanced recovery, respectively. The main outcome indicators are the Karnofsky Performance Scale score and the Japanese Orthopaedic Association scale. Secondary outcome indicators are pain assessment by Numeric Rating Scale, Neck Disability Index, quality of life index (QL-Index) and postoperative complications. Follow-up will be conducted at 3, 6 and 12 months postoperatively.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Ethics Committee of Fujian Medical University Union Hospital, Fuzhou, China (2020YF034-01). Results of the research will be published in an international peer-reviewed scientific journal and disseminated through presentation at scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2000040508.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery

PURPOSE

This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery.

METHODS

The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals.

CONCLUSIONS

Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion?

Purpose

We aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF).

Patients and Methods

We performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost.

Results

Forty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468).

Conclusion

In the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.