Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

Reducing costs and improving patient recovery through a nurse-driven centralized spinal orthoses program on a post-surgical unit: A quality improvement initiative

Background

An external vendor providing off-the-shelf spinal orthoses to inpatients created significant costs and barriers to quality care for spinal surgery patients. A nursing leadership team initiated a quality improvement project to reduce the cost of providing off-the-shelf spinal orthoses and improve the care provided to spinal patients.

Objective

To develop and evaluate a nursing-led process for providing off-the-shelf orthoses to spinal surgery patients and eliminate high costs.

Design

Quality improvement project evaluated as a retrospective interrupted time-series.

Setting

Post Surgery Inpatient Unit Level II Trauma Center in a United States hospital located in Florida.

Participants

Vendor Program: 134 patients; Centralized Program: 155 patients.

Methods

The nursing leadership team developed a centralized spinal orthoses program where the bedside nurse fitted the patient with a spinal orthosis, eliminating the need for an external orthotist. The study quantifies changes in study metrics by comparing patients identified through chart review who received care in the vendor program to those who received care in the centralized program utilizing nonparametric statistical techniques.

Results

The centralized nursing-led spinal orthosis program allowed the unit to mobilize patients more quickly than patients managed under the vendor program (3.85 hr. [95 % CI: 1.27 to 7.26 hrs] reduction; p = 0.004). The overall length of stay was reduced by 0.78 days ([1.34 - 0.02 days]; p = 0.063) or 18.72 h. While the statistical test did not indicate significance, the 18.72-hour reduction in length of stay represents a potential clinically relevant finding. Evaluating patients that suffered a primary spinal injury and no complications (vendor program: 54 patients; centralized program: 86 patients) showed a similar reduction in time to mobilization (4.5 hr reduction [0.53 to 12.93 hrs]; p = 0.025), but the length of stay reduction increased to 1.02 days [0.12 to 1.97 days], a difference determined to be statistically significant (p = 0.014). Centralizing the process for providing off-the-shelf spinal orthoses reduced the cost of a thoracic-lumbar sacral orthosis by $1,483 and the price of a lumbar-sacral orthosis by $1,327. Throughout the study, the new program reduced the cost of providing spinal orthoses by $175,319.

Conclusions

The results demonstrate that the nursing-led centralized spinal orthosis program positively impacted the quality of care provided to our patients while also reducing the cost of delivering the orthoses.

Tweetable abstract

A nursing-led centralized spinal orthosis program reduces the cost of care while reducing time to mobilization and length of stay.

Efficacy and Safety of Enhanced Recovery After Surgery (ERAS) Protocols for Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar degenerative disease (LDD).

METHODS

Electronic databases including PubMed, Embase, the Cochrane Library, Web of Science, Clinical Trials.gov, etc. were searched from inception to October 2023. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing ERAS program with traditional protocol of MIS-TLIF for LDD were included.

RESULTS

A total of 11 studies were included for final analysis. The pooled results of RCTs showed that compared with MIS-TLIF, the ERAS program used in MIS-TLIF could reduce the length of hospital stay, operation time, intraoperative blood loss and incidence of postoperative complications, decrease visual analog scale and Oswestry Disability Index (ODI) score, and improve patient satisfaction (P < 0.05). However, the pooled results of CSs revealed no statistical difference in the ODI score, fusion rate, operation time, and incidence of complications between the two groups (P > 0.05).

CONCLUSIONS

Compared with MIS-TLIF, the ERAS program used in MIS-TLIF could effectively shorten the length of hospital stay, operation time, decrease intraoperative blood loss, and incidence of postoperative complications, promote postoperative pain relief, functional recovery, and patient satisfaction. This study confirmed the value of ERAS in MIS-TLIF surgery and provided evidence for the standardization of ERAS in the future. Considering that the pooled results of RCTs and CSs are not completely consistent, more high-quality studies are needed to confirm these conclusions.

Frailty, Myelopathy, and Enhanced Recovery after Surgery in Patients Undergoing Posterior Cervical Fusion

BACKGROUND

The enhanced recovery after surgery (ERAS) protocol is a proven method to improve postsurgical outcomes. While recent studies have shown the benefit of ERAS even in frail patient populations, myelopathy is another factor affecting outcomes in patients undergoing posterior cervical fusion (PCF). This study evaluated the benefit of an ERAS protocol in frail patients undergoing PCF.

METHODS

A retrospective chart review identified consecutive patients undergoing PCF by a single surgeon from August 2015-July 2021, with implementation of ERAS in December 2018. Outcome measures included length of stay (LOS), nonhome discharge disposition, complications, return of physiologic function, and severe pain score. A mFI-5 score of ≥ 2 and a Nurick score of ≥ 3 defined frail and myelopathic patients, respectively. Univariate analysis (P < 0.05) and multivariate analyses using mixed-effect models (P < 0.0125) were performed.

RESULTS

There were a total of 174 patients, 71 frail (41%). Of the frail patients, 61% were also myelopathic, and 56% underwent ERAS. Of the nonfrail patients, 43% were myelopathic, and 57% underwent ERAS. On univariate analyses, frail patients with ERAS had less drains placed (P < 0.0001), decreased urinary retention (P = 0.0002), decreased LOS (P = 0.013), and were less likely to have a nonhome discharge (P = 0.001). On multivariate analysis, LOS (P = 0.0003), time to return of physiologic function (P = 0.004), complications (P = 0.001), and nonhome discharges (P < 0.0001) were decreased with ERAS, irrespective of groups.

CONCLUSIONS

ERAS is an effective protocol in PCF patients that may expedite return of physiologic function, lessen LOS, decrease the number of nonhome discharges, and reduce complications, irrespective of frailty or myelopathy status.

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis

Background

Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.

Methods

A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.

Results

Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).

Conclusions

Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients

BACKGROUND AND OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries.

METHODS

A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression.

CONCLUSION

The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.

Activity and sports resumption after long segment fusions to the pelvis for adult spinal deformity: survey results of AO Spine members

PURPOSE

To assess recommendations for when adult spinal deformity (ASD) patients may return to athletic activities after surgery.

METHODS

A web-based survey was administered to members of AO Spine. The survey consisted of surgeon demographic information and questions asking when a patient undergoing a long thoracolumbar fusion (> 5 levels) with pelvic fixation for ASD would be allowed to resume unrestricted range of motion (ROM), non-contact sports, and contact sports postoperatively. Ordinal logistic regression was used to determine predictors for time to resume each activity.

RESULTS

One hundred twenty four members' responses were included for analysis. The majority of respondents would allow unrestricted ROM within 3 months postop (< 3 months: 81% vs > 3 months: 19%]. For when to return to non-contact sports, the most common responses were "2-3 months" (26.6%), "3-4 months" (26.6%), and "6-12 months" (18.5%). For when to return to contact sports, the majority advised > 4 months postop [> 4 months: "4-6 months" (19.2%), "6-12 months" (28.0%), " > 12 months" (28.8%) versus < 4 months: "1-2 months" (4.0%), "2-3 months" (1.6%), "3-4 months" (8.8%)]. 8.8% responded they would "never" allow resumption of contact sports.

CONCLUSION

There was significant variation between surgeons' recommendations for resumption of unrestricted range of motion and sports following long fusion with pelvic fixation for ASD. An evidence-based approach to activity recommendations will require information on outcomes and complications.

Hospital Frailty Risk Score and Healthcare Resource Utilization After Surgery for Primary Spinal Intradural/Cord Tumors

OBJECTIVE

The Hospital Frailty Risk Score (HFRS) is a metric that measures frailty among patients in large national datasets using ICD-10 codes. While other metrics have been utilized to demonstrate the association between frailty and poor outcomes in spine oncology, none have examined the HFRS. The aim of this study was to investigate the impact of frailty using the HFRS on complications, length of stay, cost of admission, and discharge disposition in patients undergoing surgery for primary tumors of the spinal cord and meninges.

METHODS

A retrospective cohort study was performed using the Nationwide Inpatient Sample database from 2016 to 2018. Adult patients undergoing surgery for primary tumors of the spinal cord and meninges were identified using ICD-10-CM codes. Patients were categorized into 2 cohorts based on HFRS score: Non-Frail (HFRS<5) and Frail (HFRS≥5). Patient characteristics, treatment, perioperative complications, LOS, discharge disposition, and cost of admission were assessed.

RESULTS

Of the 5955 patients identified, 1260 (21.2%) were Frail. On average, the Frail cohort was nearly 8 years older (P < .001) and experienced more postoperative complications (P = .001). The Frail cohort experienced longer LOS (P < .001), a higher rate of non-routine discharge (P = .001), and a greater mean cost of admission (P < .001). Frailty was found to be an independent predictor of extended LOS (P < .001) and non-routine discharge (P < .001).

CONCLUSION

Our study is the first to use the HFRS to assess the impact of frailty on patients with primary spinal tumors. We found that frailty was associated with prolonged LOS, non-routine discharge, and increased hospital costs.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date.

METHODS

A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried.

RESULTS

A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery.

CONCLUSIONS

MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.

Unilateral biportal endoscopic lumbar interbody fusion enhanced the recovery of patients with the lumbar degenerative disease compared with the conventional posterior procedures: A systematic review and meta-analysis

Background

Minimally invasive endoscopic technique is an important component of Enhanced Recovery After Surgery (ERAS) protocol for neurosurgery. In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been used in the treatment of lumbar degenerative diseases (LDD). This study aims to investigate whether ULIF could enhance the recovery of patients with LDD compared with the conventional minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) or posterior lumbar interbody fusion (PLIF).

Methods

A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, Cochrane Library database, China National Knowledge Internet, and Wanfang database. Surgical data, clinical outcomes, radiographic outcomes, and surgical complications were compared between patients with LDD who underwent ULIF and those who underwent conventional MI-TLIF or PLIF.

Results

Notably, 12 studies, comprising 981 patients with LDD, were included. Of these patients, 449 underwent ULIF and 532 patients (355 MI-TLIF and 177 PLIF) were treated with conventional procedures. There was no significant difference in the fusion rate, cage subsidence rate, and surgical complications between the ULIF group and the MI-TLIF or PLIF group. Compared with MI-TLIF, the ULIF group presented a significantly reduced estimated blood loss (EBL) (WMD, -106.00; 95% CI -140.99 to -71.10, P < 0.001) and shorter length of hospital stay (LOS) (WMD, -1.27; 95% CI -1.88 to -0.66, P < 0.001); better short-term improvement in ODI (WMD, -2.12; 95% CI -3.53 to -0.72, P = 0.003) and VAS score for back pain (VAS-BP) (WMD, -0.86; 95% CI -1.15 to -0.58, P < 0.001) at 1 month post-operatively. Compared with PLIF, the ULIF group presented a significantly reduced EBL (WMD, -149.22; 95% CI -284.98 to -13.47, P = 0.031) and shorter LOS (WMD, -4.40; 95% CI -8.04 to -0.75, P = 0.018); better short-term improvement in VAS-BP (WMD, -1.07; 95% CI -1.77 to -0.38, P = 0.002) and VAS score for leg pain (VAS-LP) (WMD, -0.40; 95% CI -0.72 to -0.08, P = 0.014) at 1-2 week post-operatively; enhanced short- and long-term improvement in ODI at 1 month post-operatively (WMD, -3.12; 95% CI -5.72 to -0.53, P = 0.018) and the final follow-up (WMD, -1.97; 95% CI -3.32 to -0.62, P = 0.004), respectively.

Conclusion

Compared with conventional MI-TLIF and PLIF, ULIF was associated with reduced EBL, shorter LOS, and comparable fusion rate as well as complication management. Compared with MI-TLIF, a better short-term improvement in VAS-BP and ODI was achieved by ULIF; compared with open PLIF, additional enhanced short-term improvement in VAS-LP and long-term improvement in ODI were observed in ULIF. ULIF could enhance the recovery of patients with LDD compared with conventional posterior procedures.

Systematic trial registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=230695, CRD42021230695.

Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review

Degenerative spine disease increases in prevalence and may become debilitating as people age. Complex spine surgery may offer relief but becomes riskier with age. Efforts to lessen the physiological impact of surgery through minimally invasive techniques and enhanced recovery programs mitigate risk only after the decision for surgery. Frailty assessments outperform traditional tools of perioperative risk stratification. The extent of frailty predicts complications after spine surgery such as reoperation for infection and 30-day mortality, as well as elements of social cost such as hospital length of stay and discharge to an advanced care facility. Symptoms of spine disease overlap with phenotypic markers of frailty; therefore, different frailty assessment tools may perform differently in patients with degenerative spine disease. Beyond frailty, however, cognitive decline and psychosocial isolation may interact with frailty and affect achievable surgical outcomes. Prehabilitation, which has reduced perioperative risk in colorectal and cardiac surgery, may benefit potential complex spine surgery patients. Typical prehabilitation includes physical exercise, nutrition supplementation, and behavioral measures that may offer symptomatic relief even in the absence of surgery. Nonetheless, the data on the efficacy of prehabilitation for spine surgery remains sparse and barriers to prehabilitation are poorly defined. This narrative review concludes that a frailty assessment-potentially supplemented by an assessment of cognition and psychosocial resources-should be part of shared decision-making for patients considering complex spine surgery. Such an assessment may suffice to prompt interventions that form a prehabilitation program. Formal prehabilitation programs will require further study to better define their place in complex spine care.

Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors

BACKGROUND

Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center.

METHODS

The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]).

RESULTS

A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001).

CONCLUSIONS

The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.

Adoption of awake spine surgery - trends from a national registry over 14 years

BACKGROUND CONTEXT

Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied.

PURPOSE

To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States.

STUDY DESIGN/SETTING

A retrospective observational study.

PATIENT SAMPLE

Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019.

OUTCOME MEASURES

The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019.

METHODS

Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006.

RESULTS

We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m²; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively).

CONCLUSIONS

Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.

Value-based Care and Quality Improvement in Perioperative Neuroscience

Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.

A novel online calculator to predict nonroutine discharge, length of stay, readmission, and reoperation in patients undergoing surgery for intramedullary spinal cord tumors

BACKGROUND CONTEXT

Intramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity.

PURPOSE

To determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator.

STUDY DESIGN

Retrospective cohort study PATIENT SAMPLE: A total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center.

OUTCOME MEASURES

Nonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODS: Patients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model.

RESULTS

Of 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 10³/μL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day).

CONCLUSIONS

We found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.

Efficacy of perioperative pharmacological and regional pain interventions in adult spine surgery: a network meta-analysis and systematic review of randomised controlled trials

BACKGROUND

Development of a widely accepted standardised analgesic pathway for adult spine surgery has been hampered by the lack of quantitative analysis. We conducted a systematic review and network meta-analysis (NMA) to compare, rank, and grade all pharmacological and regional interventions used in adult spine surgery.

METHODS

A systematic search was performed in January 2021. We performed double study screening, selection, and data extraction. The co-primary outcomes were cumulative morphine consumption (mg) and visual analogue pain score (range 0-10) at postoperative 24 h. An NMA was performed using the Bayesian approach (random effects model). We also ranked and graded all analgesic interventions using the Grading of Recommendations Assessment, Development and Evaluation approach for NMA.

RESULTS

We screened 5908 studies and included 86 randomised controlled studies, which comprised 6284 participants. Of 20 pharmacological and 10 regional interventions, the most effective intervention was triple-drug therapy, consisting of paracetamol, nonsteroidal anti-inflammatory drugs, and adjunct. The pooled mean reduction in morphine consumption and pain score at postoperative 24 h were -26 (95% credible interval [CrI]: -39 to -12) mg and -2.3 (95% CrI: -3.1 to -1.4), respectively. Double-drug therapy was less effective, but showed moderate morphine reduction in a range of -15 to -17 mg and pain score reduction in a range of -1 to -1.6. Single-agent interventions were largely ineffective.

CONCLUSIONS

Triple-drug therapy is the most effective pain intervention in adult spine surgery with moderate-to-high certainty of evidence. We have also identified a graded analgesic effect, in which analgesic efficacy increased with the number of multimodal drugs used.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42020171326).

Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases

PURPOSE

The objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways.

METHODS

Using major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed.

RESULTS

Fourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively.

CONCLUSIONS

Use of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction.

LEVEL OF EVIDENCE III

Meta-analysis of Level 3 studies.

Drivers of Readmission and Reoperation After Surgery for Vertebral Column Metastases

OBJECTIVE

To determine those clinical, demographic, and operative factors that predict 30-day unplanned reoperation and readmission within a population of adults who underwent spinal metastasis surgery at a comprehensive cancer center.

METHODS

Adults who underwent spinal metastasis surgery at a comprehensive cancer center were analyzed. Data included baseline laboratory values, cancer history, demographics, operative characteristics and medical comorbidities. Medical comorbidities were quantified using the modified Charlson Comorbidity Index (CCI). Values associated with the outcomes of interest were then subjected to multivariable logistic regression to identify independent predictors of readmission and reoperation.

RESULTS

A total of 345 cases were identified. Mean age was 59.4 ± 11.7 years, 56% were male, and the racial makeup was 64% white, 29% black, and 7.3% other. Forty-two patients (12.2%) had unplanned readmissions, most commonly for wound infection with dehiscence (14.2%), venous thromboembolism (14.2%), and bowel obstruction/complication (11.9%). Thirteen patients required reoperation (4%), most commonly for wound infection with dehiscence (39%) or local recurrence (23%). Multivariable analysis showed that the modified CCI (odds ratio [OR], 1.25; 95% confidence interval [CI] 1.03-1.52; P = 0.03) was an independent predictor of 30-day readmission. Independent predictors of 30-day unplanned reoperation were: black (vs. white) race (OR, 0.08; 95% CI, 0.01-0.41; P < 0.01), length of stay (OR, 1.05 per day; 95% CI, 1.00-1.09; P = 0.04), and CCI (OR, 1.72 per point; 95% CI, 1.29-2.28; P < 0.01).

CONCLUSIONS

Increasing medical comorbidities is independently predictive of both 30-day unplanned readmission and reoperation after spinal metastasis surgery. Unplanned reoperation is also positively predicted by a longer index admission. Neither tumor pathology nor age predicted outcome, suggesting that poor wound-healing factors and increased surgical morbidity may best predict these adverse outcomes.

Potential for optimizing the perioperative care in robotic prostatectomy patients by adoption of enhanced recovery after surgery principles

Several benefits have been reported after applying the principles of enhanced recovery after surgery (ERAS) into the perioperative care of patients undergoing robot-assisted radical prostatectomy (RARP). Nevertheless, there are still barriers. We aimed to identify the key areas by systematically surveying urology departments in Germany and Austria. A 27-question survey on the adoption of ERAS principles for the perioperative care of RARP patients was designed, in compliance with the guidelines on good practice in conducting and reporting of survey research. After positive testing for face and content validity, the survey was distributed via postal mail to 82 departments performing RARP. In total, 39 departments responded to our survey (response rate 48%). The ERAS adoption rates ranged from 21 to 97%, with nine ERAS principles being widely adopted (72-92% of the departments). The lowest adoption rates and, subsequently, the largest potential for optimization were detected for the preoperative nutrition counselling (21%), preoperative pelvic floor physiotherapy (54%), postoperative early initiation of nutrition (44%) and postoperative patient audit for further quality improvement (36%). High-volume centers performed more frequently a perioperative nutrition counselling (8/27; 30%) than low-volume centers (0/12; 0%; p = 0.036). The implementation of the ERAS principles into the perioperative care algorithm were medium-to-high, yet not optimal. Our real-world data assessment revealed four key areas showing low adoption rates (nutrition counselling, preoperative pelvic floor physiotherapy, early initiation of nutrition and patient audit), implying a great potential for further optimization.

[Enhanced recovery after surgery-Does the ERAS concept keep its promises]

INTRODUCTION

Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment.

METHODS

Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment.

RESULTS

The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions.

CONCLUSION

Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.