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Essa A, Shakil H, Malhotra AK, Byrne JP, Badhiwala J, Yuan EY, He Y, Jack AS, Mathieu F, Wilson JR, Witiw CD. Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury. Neurosurgery 2024; 95:408-417. [PMID: 38456683 DOI: 10.1227/neu.0000000000002892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/05/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.
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Affiliation(s)
- Ahmad Essa
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Division of Orthopedics, Department of Surgery, Shamir Medical Center (Assaf Harofeh), Zerifin , Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv , Israel
| | - Husain Shakil
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore , Maryland , USA
| | - Jetan Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Center, Toronto , Ontario , Canada
| | - Eva Y Yuan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
| | - Yingshi He
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
| | - Andrew S Jack
- Division of Neurosurgery, University of Alberta, Edmonton , Alberta , Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, University of Toronto, Toronto , Ontario , Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
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Zhou G, Yao Y, Shen Y, You X, Zhang X, Xu Z. Early ambulation after total knee arthroplasty: a retrospective single-center study. J Orthop Surg Res 2024; 19:446. [PMID: 39075550 PMCID: PMC11285134 DOI: 10.1186/s13018-024-04883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 06/27/2024] [Indexed: 07/31/2024] Open
Abstract
PURPOSE Early ambulation is an important step in accelerating post-joint replacement surgery recovery. However, there is limited research on populations who are unable to walk immediately after the operation. The purpose of this study was to determine the factors influencing postoperative ambulation in total knee arthroplasty (TKA) patients. METHODS Primary TKA patients were included in this retrospective study. All patients were divided into two groups. Patients who began walking within 24 h were categorized as the early ambulation group, while patients who began walking after 24 h were classified as the late ambulation group. Recorded demographic data included age, gender, body mass index (BMI), clinical diagnosis, and comorbidities. Hematological parameters potentially affecting patients' preoperative physical condition were also documented. Additionally, intraoperative metrics such as surgical time, surgical side, tourniquet time, intraoperative blood loss, the placement of drains, and prosthetic model were recorded. RESULTS A total of 453 patients (79.0% female, 21.0% male) were included in this study. The average age of all patients was 68.5±7.9 years, ranging from 36 to 87 years, with an average BMI of 27.2±9.9 kg/ m 2 . The mean postoperative ambulation time was 1.6 days, with a range of 0-4 days. In univariate group comparisons, an increase in postoperative time to ambulation was significantly associated with a history of heart disease ( P < 0.001 ), stroke history ( P = 0.003 ), and prior surgeries ( P = 0.003 ). Patients who delayed ambulation also exhibited significantly higher coagulation-related parameters including PT ( P < 0.001 ), APTT ( P = 0.002 ), TT ( P = 0.039 ) before surgery compared to those who mobilized early. Furthermore, prolonged surgical time ( P = 0.030 ), increased intraoperative blood loss ( P < 0.001 ), and the placement of intraoperative drains ( P < 0.001 ) also significantly extended the time to postoperative ambulation. However, after multivariate logistic regression analysis, only PT (OR 1.86, 95% CI 1.32 - 2.61, P < 0.001 ), TT (OR 1.30, 95% CI 1.09 - 1.55, P = 0.004 ) intraoperative blood loss (OR 1.01, 95% CI 1.00 - 1.01, P = 0.008 ) and the placement of intraoperative drains (OR 11.39, 95% CI 6.59 - 19.69, P < 0.001 ) were identified as predictive factors for late ambulation in patients after TKA. CONCLUSION In this study, preoperative coagulation function, intraoperative blood loss and the placement of intraoperative drains were factors contributing to delay ambulation time. Therefore, it is believed that properly improving preoperative coagulation function, effective intraoperative hemostasis, and reducing the placement of drains have a positive impact on early postoperative ambulation in patients undergoing TKA.
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Affiliation(s)
- Guanjie Zhou
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Yao Yao
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Ying Shen
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Xiaokang You
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Xiaofeng Zhang
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China.
| | - Zhihong Xu
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China.
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Zhang H, Zhao Y, Du Y, Yang Y, Zhang J, Wang S. Early mobilization can reduce the incidence of surgical site infections in patients undergoing spinal fusion surgery: A nested case-control study. Am J Infect Control 2024; 52:644-649. [PMID: 38232902 DOI: 10.1016/j.ajic.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND To examine the influence of early mobilization on the risk of surgical site infections (SSI) in patients undergoing spinal fusion surgery. METHODS The retrospective cohort consisted of all consecutive patients who underwent spinal fusion surgery at our institution. For each case of SSI, 2 control patients without SSI at the corresponding index date were selected. Mobilization was predefined as "delayed" if it occurred more than 36 hours postoperatively. To account for potential confounding variables, we performed further adjustments using conditional logistic regression models. Subgroup analyses were conducted to evaluate the robustness of the statistical associations. RESULTS Following the predefined statistical protocol and matching criteria, we matched 236 control cases to the SSI cases. Upon adjustment for confounding factors, our findings revealed that the risk of SSI was 120% higher in the group beginning mobilization more than 36 hours after surgery compared to the group beginning mobilization within 36 hours postoperatively (odds ratio = 2.206, 95% confidence interval 1.169-4.166, P = .015). In subgroup analyses, this statistical trend remained consistent. CONCLUSIONS Early mobilization within 36 hours following spinal fusion surgery significantly reduces the risk of SSI. This pattern of reduced risk remains consistent among patients with degenerative diseases or spinal deformities.
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Affiliation(s)
- Haoran Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yiwei Zhao
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - You Du
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Shengru Wang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Gray N, Shaikh J, Cowley A, Goosey-Tolfrey V, Logan P, Quraishi N, Booth V. The effect of early mobilisation (< 14 days) on pathophysiological and functional outcomes in animals with induced spinal cord injury: a systematic review with meta-analysis. BMC Neurosci 2024; 25:20. [PMID: 38528450 DOI: 10.1186/s12868-024-00862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION The optimum time to mobilise (standing, walking) following spinal cord injury (SCI) is unknown but may have implications for patient outcomes. There are no high-quality experimental studies that examine this issue, with a paucity of guidance for clinicians. Pre-clinical studies lead research in this field and can contribute to knowledge and support future clinical practice. OBJECTIVE to evaluate the effect of early compared to no mobilisation on pathophysiological and functional outcomes in animals with induced SCI. METHODS A systematic review with meta-analysis was conducted by searching pre-clinical literature in MEDLINE (PubMed), Embase (Ovid), Web of Science, OpenGrey, and EThOS (June 2023). Studies were included of any research method giving numerical results comparing pathophysiological and functional outcomes in rats and mice mobilised within 14-days of induced SCI to those that did not mobilise. Data were synthesised using random-effects meta-analyses. The quality of the evidence was assessed using the CAMARADES checklist. The certainty of findings was reported using the GRADE approach. This study is registered on PROSPERO (CRD42023437494). RESULTS Seventeen studies met the inclusion criteria. Outcomes found that Brain Derived Neurotrophic Factor levels were greater in those that initiated mobilisation within 14-days of SCI compared to the groups that did not. Mobilisation initiated within 14-days of SCI was also associated with statistically significant functional gains: (Basso, Beattie and Bresnahan locomotor rating score (BBB) = 2.13(0-21), CI 1.43, 2.84, Ladder Rung Walking Task = - 12.38(0-100), CI 20.01, - 4.76). Meta-analysis identified the greatest functional gains when mobilisation was initiated within 3 days of SCI (BBB = 3.00, CI 2.31-3.69, p < 0.001), or when delivered at low intensity (BBB = 2.88, CI 2.03-3.70, p < 0.001). Confidence in the findings from this review was low to moderate due to the risk of bias and mixed methodological quality. CONCLUSION Mobilisation instigated within 14-days of injury, may be an effective way of improving functional outcomes in animal models following SCI, with delays potentially detrimental to recovery. Outcomes from this study support further research in this field to guide future clinical practice.
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Affiliation(s)
- Natalie Gray
- School of Medicine, University of Nottingham, Nottingham, UK.
| | - Junaid Shaikh
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Alison Cowley
- School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Vicky Goosey-Tolfrey
- School of Sport, Exercise and Health Sciences, University of Loughborough, Loughborough, UK
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Nasir Quraishi
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Vicky Booth
- School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Pozin M, Najafali D, Naik A, MacInnis B, Subbarao N, Zuckerman SL, Arnold PM. Long-term assessment of the functional independence measure in sports-related spinal cord injury. J Spinal Cord Med 2024; 47:214-228. [PMID: 36977319 PMCID: PMC10885752 DOI: 10.1080/10790268.2023.2167903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
CONTEXT Patients with spinal cord injury (SCI) secondary to traumatic sports-related etiology potentially face loss of independence. The Functional Independence Measure (FIM) assesses the amount of assistance patients require and has shown sensitivity to changes in patient functional status post injury. OBJECTIVES We aimed to (1) examine long-term outcomes following sports-related SCI (SRSCI) using FIM scoring at the time of injury, one year, and five years post-injury, and (2) determine predictors of independence at one and five-year follow-up considering surgical and non-surgical management. Few studies have investigated the cohort analyzed in this study. METHODS The 1973-2016 National Spinal Cord Injury Model Systems (SCIMS) Database was used to develop a SRSCI cohort. The primary outcome of interest captured functional independence using a multivariate logistic regression, defined by FIM individual scores greater than or equal to six, evaluated at one and five years. RESULTS A total of 491 patients were analyzed, 60 (12%) were female, 452 (92%) underwent surgery. The cohort demographics were stratified by patients with and without spine surgery and evaluated for functional independence in FIM subcategories. Increased time spent in inpatient rehabilitation and FIM score at post-operative discharge were associated with greater likelihood of functional ability at both one and five-year follow-up. CONCLUSION Our study demonstrated that SRSCI patients are a unique subset of SCI patients for whom factors repeatedly associated with independence at one year follow-up were dissimilar to those associated with independence at five-year follow-up. Larger prospective studies should be conducted to establish guidelines for this unique subcategory of SCI patients.
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Affiliation(s)
- Michael Pozin
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Daniel Najafali
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Bailey MacInnis
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Natasha Subbarao
- Kansas City University College of Medicine, Joplin, Missouri, USA
| | - Scott L. Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul M. Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois, USA
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Morooka Y, Kunisawa Y, Okubo Y, Araki S, Takakura Y. Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury. J Spinal Cord Med 2024:1-9. [PMID: 38265416 DOI: 10.1080/10790268.2024.2304919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI). DESIGN A retrospective observational study. SETTING Intensive care unit or high care unit of a university hospital emergency center. PARTICIPANTS Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included. INTERVENTIONS Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury. OUTCOME MEASURES The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis. RESULTS Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II. CONCLUSION Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.
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Affiliation(s)
- Yusuke Morooka
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
| | - Yosuke Kunisawa
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
| | - Yuya Okubo
- Saitama Medical Center, Department of Rehabilitation, Kawagoe, Japan
| | - Shinta Araki
- Saitama Medical Center, Department of Rehabilitation, Kawagoe, Japan
| | - Yasuyuki Takakura
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
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Robertson SC. Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists. Adv Tech Stand Neurosurg 2024; 49:73-94. [PMID: 38700681 DOI: 10.1007/978-3-031-42398-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.
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Jones RP. Addressing the Knowledge Deficit in Hospital Bed Planning and Defining an Optimum Region for the Number of Different Types of Hospital Beds in an Effective Health Care System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7171. [PMID: 38131722 PMCID: PMC11080941 DOI: 10.3390/ijerph20247171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
Based upon 30-years of research by the author, a new approach to hospital bed planning and international benchmarking is proposed. The number of hospital beds per 1000 people is commonly used to compare international bed numbers. This method is flawed because it does not consider population age structure or the effect of nearness-to-death on hospital utilization. Deaths are also serving as a proxy for wider bed demand arising from undetected outbreaks of 3000 species of human pathogens. To remedy this problem, a new approach to bed modeling has been developed that plots beds per 1000 deaths against deaths per 1000 population. Lines of equivalence can be drawn on the plot to delineate countries with a higher or lower bed supply. This method is extended to attempt to define the optimum region for bed supply in an effective health care system. England is used as an example of a health system descending into operational chaos due to too few beds and manpower. The former Soviet bloc countries represent a health system overly dependent on hospital beds. Several countries also show evidence of overutilization of hospital beds. The new method is used to define a potential range for bed supply and manpower where the most effective health systems currently reside. The method is applied to total curative beds, medical beds, psychiatric beds, critical care, geriatric care, etc., and can also be used to compare different types of healthcare staff, i.e., nurses, physicians, and surgeons. Issues surrounding the optimum hospital size and the optimum average occupancy will also be discussed. The role of poor policy in the English NHS is used to show how the NHS has been led into a bed crisis. The method is also extended beyond international benchmarking to illustrate how it can be applied at a local or regional level in the process of long-term bed planning. Issues regarding the volatility in hospital admissions are also addressed to explain the need for surge capacity and why an adequate average bed occupancy margin is required for an optimally functioning hospital.
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Vinar AL, Cipher DJ, Ormand M, Carlisle B, Behan D. Multidisciplinary Teamwork Perceptions When Mobilizing Ventilated Neurosurgery Patients. J Neurosci Nurs 2023; 55:199-204. [PMID: 37612259 DOI: 10.1097/jnn.0000000000000726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
ABSTRACT BACKGROUND: Multidisciplinary teamwork is essential in delivering holistic care to critically ill populations, including ventilated neurosurgery patients. Although it is considered a safe and feasible aspect of patient care, mobilization is often missed in this population because of negative healthcare provider perceptions regarding barriers and patient safety. Nurse-led teamwork has been suggested to overcome these barriers and to achieve earlier mobilization for patients, as well as positive provider perceptions, which may affect the culture and frequency of mobilization on neurointensive care units. Quantitative studies analyzing multidisciplinary teamwork perceptions to mobilize ventilated neurosurgery patients with or without a nurse-led protocol have not been previously conducted. Analyzing such perceptions may provide insight to team-related barriers related to missed mobility. This pilot quasi-experimental study aimed to determine whether the use of a nurse-led mobility protocol affects teamwork perceptions when mobilizing ventilated neurosurgery patients. METHODS: A sample of multidisciplinary teams, composed of nurses, patient care technicians, and respiratory therapists, mobilized ventilated neurosurgery patients according to either standard of care (for the control group) or a nurse-led mobility protocol (for the interventional group). Teamwork perceptions were measured via the reliable and valid Nursing Teamwork Survey tool. RESULTS: Linear mixed model analyses revealed that multidisciplinary teams in the nurse-led mobility protocol group had significantly higher levels of overall perceived teamwork than those in the control group, t3 = -3.296, P = .038. Such differences were also noted for teamwork variables of team leadership and mutual trust. CONCLUSION: Nurse-led mobility protocols should be considered to increase teamwork when performing multidisciplinary teamwork-based mobility for ventilated neurosurgery patients. Future studies should continue to evaluate teamwork perceptions after nurse-led mobility.
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Meyrat R, Vivian E, Sridhar A, Gulden RH, Bruce S, Martinez A, Montgomery L, Reed DN, Rappa PJ, Makanbhai H, Raney K, Belisle J, Castellanos S, Cwikla J, Elzey K, Wilck K, Nicolosi F, Sabat ME, Shoup C, Graham RB, Katzen S, Mitchell B, Oh MC, Patel N. Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review. Medicine (Baltimore) 2023; 102:e36142. [PMID: 38013300 PMCID: PMC10681460 DOI: 10.1097/md.0000000000036142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023] Open
Abstract
The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.
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Affiliation(s)
- Richard Meyrat
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Elaina Vivian
- Performance Improvement, Methodist Dallas Medical Center, Dallas, TX
| | - Archana Sridhar
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - R. Heath Gulden
- Anesthesia Consultants of Dallas Division, US Anesthesia Partners, Dallas, TX
| | - Sue Bruce
- Clinical Outcomes Management, Methodist Dallas Medical Center, Dallas, TX
| | - Amber Martinez
- Pre-Surgery Assessment, Methodist Dallas Medical Center, Dallas, TX
| | - Lisa Montgomery
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Donald N. Reed
- Neurosurgery Division, Methodist Health System, Dallas, TX
| | | | | | | | | | - Stacey Castellanos
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Judy Cwikla
- Neurocritical Care Unit, Methodist Dallas Medical Center, Dallas, TX
| | - Kristin Elzey
- Pharmacy, Methodist Dallas Medical Center, Dallas, TX
| | - Kristen Wilck
- Clinical Nutrition, Methodist Dallas Medical Center, Dallas, TX
| | - Fallon Nicolosi
- Methodist Community Pharmacy – Dallas, Methodist Dallas Medical Center, Dallas, TX
| | - Michael E. Sabat
- Surgery and Recovery, Methodist Dallas Medical Center, Dallas, TX
| | - Chris Shoup
- Executive Office, Methodist Health System, Dallas, TX
| | - Randall B. Graham
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Stephen Katzen
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Bartley Mitchell
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Michael C. Oh
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
| | - Nimesh Patel
- Methodist Moody Brain and Spine Institute, Methodist Health System, Dallas, TX
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11
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Jain SN, Lamture Y, Krishna M. Enhanced Recovery After Surgery: Exploring the Advances and Strategies. Cureus 2023; 15:e47237. [PMID: 38022245 PMCID: PMC10654132 DOI: 10.7759/cureus.47237] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.
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Affiliation(s)
- Shubhi N Jain
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Malay Krishna
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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12
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Yasin P, Cai X, Mardan M, Xu T, Abulizi Y, Aimaiti A, Yang H, Sheng W, Mamat M. Development and validation of a novel nomogram to predict the risk of the prolonged postoperative length of stay for lumbar spinal stenosis patients. BMC Musculoskelet Disord 2023; 24:703. [PMID: 37660009 PMCID: PMC10474765 DOI: 10.1186/s12891-023-06822-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Lumber spinal stenosis (LSS) is the increasingly reason for spine surgery for elder patients since China is facing the fastest-growing aging population. The aim of this research was to create a model to predict the probabilities of requiring a prolonged postoperative length of stay (PLOS) for lumbar spinal stenosis patients, minimizing the healthcare burden. METHODS A total of 540 LSS patients were enrolled in this project. The outcome was a prolonged PLOS after spine surgery, defined as hospitalizations ≥ 75th percentile for PLOS, including the day of discharge. The least absolute shrinkage and selection operator (LASSO) was used to identify independent risk variables related to prolonged PLOS. Multivariable logistic regression analysis was utilized to generate a prediction model utilizing the variables employed in the LASSO approach. The receiver operating characteristic (ROC) curve's area under the curve (AUC) and the calibration curve's respective curves were used to further validate the model's calibration with predictability and discriminative capabilities. By using decision curve analysis, the resulting model's clinical effectiveness was assessed. RESULTS Among 540 individuals, 344 had PLOS that was within the usual range of P75 (8 days), according to the interquartile range of PLOS, and 196 had PLOS that was above the normal range of P75 (prolonged PLOS). Four variables were incorporated into the predictive model, named: transfusion, operation duration, blood loss and involved spine segments. A great difference in clinical scores can be found between the two groups (P < 0.001). In the development set, the model's AUC for predicting prolonged PLOS was 0.812 (95% CI: 0.768-0.859), while in the validation set, it was 0.830 (95% CI: 0.753-0.881). The calibration plots for the probability showed coherence between the expected probability and the actual probability both in the development set and validation set respectively. When intervention was chosen at the potential threshold of 2%, analysis of the decision curve revealed that the model was more clinically effective. CONCLUSIONS The individualized prediction nomogram incorporating five common clinical features for LSS patients undergoing surgery can be suitably used to smooth early identification and improve screening of patients at higher risk of prolonged PLOS and minimize health care.
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Affiliation(s)
- Parhat Yasin
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xiaoyu Cai
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Muradil Mardan
- Department of Spine center, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Tao Xu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Yakefu Abulizi
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Abasi Aimaiti
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Huan Yang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Weibin Sheng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Mardan Mamat
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China.
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13
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Wu EB, Li YY, Hung KC, Illias AM, Tsai YF, Yang YL, Chin JC, Wu SC. The Impact of Rocuronium and Sugammadex on Length of Stay in Patients Undergoing Open Spine Surgery: A Propensity Score-Matched Analysis. Bioengineering (Basel) 2023; 10:959. [PMID: 37627844 PMCID: PMC10451676 DOI: 10.3390/bioengineering10080959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Enhanced Recovery After Surgery (ERAS), an all-encompassing perioperative care approach, has been demonstrated to enhance surgical results, mitigate postoperative issues, and decrease the length of hospital stay (LOS) in diverse surgical specialties. In this retrospective study, our objective was to examine the influence of muscle relaxant selection on LOS and perioperative results in adult patients undergoing open spine surgery. Specifically, we compared 201 patients who received cisatracurium and neostigmine with 201 patients who received rocuronium and sugammadex, after 1:1 propensity score matching. The utilization of the rocuronium and sugammadex combination in anesthesia for open spinal surgery did not lead to a reduction in the LOS but was associated with a decreased incidence of postoperative chest radiographic abnormalities, including infiltration, consolidation, atelectasis, or pneumonia (p = 0.027). In our secondary analysis, multivariate analysis revealed multiple determinants influencing the prolonged LOS (>7 days) during open spine surgery. Bispectral index-guided anesthesia emerged as a protective factor, while variables such as excessive intraoperative blood loss and fluid administration as well as postoperative chest radiographic abnormalities independently contributed to prolonged LOS.
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Affiliation(s)
- En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Yan-Yi Li
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan;
| | - Amina M. Illias
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (A.M.I.); (Y.-F.T.)
| | - Yung-Fong Tsai
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (A.M.I.); (Y.-F.T.)
| | - Ya-Ling Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
| | - Jo-Chi Chin
- Department of Anesthesiology, Park One International Hospital, Kaohsiung 813, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan; (E.-B.W.); (Y.-Y.L.); (Y.-L.Y.)
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung 804, Taiwan;
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Mendez K, Whyte W, Freedman BR, Fan Y, Varela CE, Singh M, Cintron-Cruz JC, Rothenbücher SE, Li J, Mooney DJ, Roche ET. Mechanoresponsive Drug Release from a Flexible, Tissue-Adherent, Hybrid Hydrogel Actuator. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023:e2303301. [PMID: 37310046 DOI: 10.1002/adma.202303301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/22/2023] [Indexed: 06/14/2023]
Abstract
Soft robotic technologies for therapeutic biomedical applications require conformal and atraumatic tissue coupling that is amenable to dynamic loading for effective drug delivery or tissue stimulation. This intimate and sustained contact offers vast therapeutic opportunities for localized drug release. Herein, a new class of hybrid hydrogel actuator (HHA) that facilitates enhanced drug delivery is introduced. The multi-material soft actuator can elicit a tunable mechanoresponsive release of charged drug from its alginate/acrylamide hydrogel layer with temporal control. Dosing control parameters include actuation magnitude, frequency, and duration. The actuator can safely adhere to tissue via a flexible, drug-permeable adhesive bond that can withstand dynamic device actuation. Conformal adhesion of the hybrid hydrogel actuator to tissue leads to improved mechanoresponsive spatial delivery of the drug. Future integration of this hybrid hydrogel actuator with other soft robotic assistive technologies can enable a synergistic, multi-pronged treatment approach for the treatment of disease.
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Affiliation(s)
- Keegan Mendez
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
- Harvard-MIT Program in Health Sciences and Technology, Cambridge, MA, 02139, USA
| | - William Whyte
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
| | - Benjamin R Freedman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 01238, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, 02138, USA
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Yiling Fan
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Claudia E Varela
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
| | - Manisha Singh
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
| | - Juan C Cintron-Cruz
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 01238, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, 02138, USA
| | - Sandra E Rothenbücher
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
| | - Jianyu Li
- Department of Mechanical Engineering, McGill University, Montreal, QC, H3A 0C3, Canada
| | - David J Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 01238, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, 02138, USA
| | - Ellen T Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 01239, USA
- Harvard-MIT Program in Health Sciences and Technology, Cambridge, MA, 02139, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
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Liao J, Qi Z, Chen B, Lei P. Association between early ambulation exercise and short-term postoperative recovery after open transforaminal lumbar interbody fusion: a single center retrospective analysis. BMC Musculoskelet Disord 2023; 24:345. [PMID: 37143006 PMCID: PMC10158157 DOI: 10.1186/s12891-023-06395-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Early ambulation in patients undergoing transforaminal lumbar interbody fusion (TLIF) surgery is recommended, however, the precise time interval after open surgery has never been specified. Current retrospective analysis was conducted aiming to clarify an accurate time interval. METHODS A retrospective analysis of eligible patients was conducted using the databases of the Bone Surgery Department, Third Affiliated Hospital of Sun Yat-sen University from 2016 to 2021. Data pertaining to postoperative hospital stay length, expenses, incidence of complications were extracted and compared using Pearson's χ2 or Student's t-tests. A multivariate linear regression model was conducted to identify the relationship between length of hospital stay (LOS) and other outcomes of interest. A propensity analysis was conducted to minimize bias and to evaluate the reliability of results. RESULTS A total of 303 patients met the criteria and were included for the data analysis. Multivariate linear regression results demonstrated that a high ASA grade (p = 0.016), increased blood loss (p = 0.003), cardiac disease (p < 0.001), occurrence of postoperative complications(p < 0.001) and longer ambulatory interval (p < 0.001) was significantly associated with an increased LOS. The cut-off analysis manifested that patients should start mobilization within 3 days after open TLIF surgery (B = 2.843, [1.395-4.292], p = 0.0001). Further comparative analysis indicated that patients who start ambulatory exercise within 3 days have shorter LOS (8.52 ± 3.28d vs 12.24 ± 5.88d, p < 0.001), total expenses ( 9398.12 ± 2790.82vs 10701.03 ± 2994.03 [USD], p = 0.002). Propensity analysis revealed such superiority was stable along with lower incidence of postoperative complications (2/61 vs 8/61, p = 0.0048). CONCLUSIONS The current analysis suggested that ambulatory exercise within 3 days for patients who underwent open TLIF surgery was significantly associated with reduced LOS, total hospital expenses, and postoperative complications. Further causal relationship would be confirmed by future randomized controlled trials.
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Affiliation(s)
- Jingwen Liao
- Department of Bone Surgery, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhou Qi
- Department of Bone Surgery, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Biying Chen
- Department of Bone Surgery, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Purun Lei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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16
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Gobezie NZ, Endalew NS, Tawuye HY, Aytolign HA. Prevalence and associated factors of postoperative orthostatic intolerance at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022: cross sectional study. BMC Surg 2023; 23:108. [PMID: 37127603 PMCID: PMC10150513 DOI: 10.1186/s12893-023-02015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/24/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Postoperative orthostatic intolerance is an inability to maintain an upright position because of symptoms of cerebral hypoperfusion. It is a common problem in the early postoperative period and hinders early mobilization, however, there is limited information about factors associated with it. Thus, the main aim of this study was to determine the prevalence and identify factors associated with postoperative orthostatic intolerance. METHOD Hospital based cross-sectional study was conducted from April 08 to July 20, 2022, at University of Gondar comprehensive Specialized Hospital. A semi-structured questionnaire containing sociodemographic variables and perioperative factors related to anesthesia and surgery was used for data collection. The presence of postoperative orthostatic intolerance during the first ambulation was evaluated with a standardized symptom checklist which contains symptoms of orthostatic intolerance. Binary logistic regression analysis was performed to assess factors associated with postoperative orthostatic intolerance. In multivariable regression, variables with P-value < 0.05 were considered statistically significant. RESULT A total of 420 patients were included in this study with a response rate of 99.06%. Postoperative orthostatic intolerance was experienced in 254 (60.5%) participants. Being female (AOR = 2.27; 95% CI = 1.06-4.86), low BMI (AOR = 0.79; 95% CI = 0.71-0.95), ASA II and above (AOR = 3.34; 95% CI = 1.34-8.28), low diastolic blood pressure (AOR = 0.82; 95% CI = 0.88-0.99), general anesthesia (AOR = 3.26, 95% CI = 1.31-8.12), high intraoperative blood lose (AOR = 0.93, 95% CI = 0.88-0.99), high postoperative fluid intake (AOR = 2.09, 95% CI = 1.23-3.55), pain before ambulation (AOR = 1.99, 95% CI = 1.28-3.11) and pain during ambulation (AOR = 1.82, 95% CI = 1.23-2.69) were the significant factors associated with orthostatic intolerance. CONCLUSION Our study revealed that postoperative orthostatic intolerance was experienced in nearly two-thirds of participants. During the time of ambulation, assessing patients for the presence of orthostatic intolerance is necessary to reduce the adverse effects of postoperative OI. In addition, maintaining preoperative normotension, reducing intraoperative blood loss and optimizing postoperative pain control is recommended to reduce the risk of postoperative orthostatic intolerance.
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Affiliation(s)
- Negesse Zurbachew Gobezie
- Department of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Nigussie Simeneh Endalew
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Hailu Yimer Tawuye
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Habtu Adane Aytolign
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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17
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Perioperative NSAID use in single level microdiscectomy and hemilaminectomy. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Álvarez-Galovich L, Ley Urzaiz L, Martín-Benlloch JA, Calatayud Pérez J. Recommendations for enhanced post-surgical recovery in the spine (REPOC). Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:83-93. [PMID: 36240991 DOI: 10.1016/j.recot.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programs to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.
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Affiliation(s)
- L Álvarez-Galovich
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| | - L Ley Urzaiz
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J A Martín-Benlloch
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna. Hospital Universitario Dr. Peset de Valencia, Valencia, España
| | - J Calatayud Pérez
- Servicio de Neurocirugía, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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19
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Alvarez-Galovich L, Ley Urzaiz L, Martín-Benlloch JA, Calatayud Pérez J. [Translated article] Recommendations for enhanced post-surgical recovery in the spine (REPOC). Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T83-T93. [PMID: 36535345 DOI: 10.1016/j.recot.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/01/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Enhanced recovery after surgery (ERAS) constitutes a multimodal approach, based on available scientific evidence, that achieves better patient's functionality, reduces pain, and even lowers financial costs. The present consensus statement proposes the standards for the implementation of ERAS programmes to lumbar fusion surgery, a meant benchmark we call REPOC. METHODOLOGY A multidisciplinary group of experts was set up ad hoc to review consensus recommendations for lumbar arthrodesis, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS As a result, 23 recommendations were selected throughout the preoperative, intraoperative, and postoperative phases of the surgical procedure. A 29-item checklist was also drawn up to implement REPOC protocols in spinal surgeries. CONCLUSIONS This list of recommendations will facilitate the implementation of this multimodal approach as a safe and effective tool for reducing adverse events in our environment.
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Affiliation(s)
- L Alvarez-Galovich
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain.
| | - L Ley Urzaiz
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Martín-Benlloch
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Columna. Hospital Universitario Dr. Peset de Valencia, Valencia, Spain
| | - J Calatayud Pérez
- Servicio de Neurocirugía, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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20
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de Campos TF, Vertzyas N, Wolden M, Hewawasam D, Douglas B, McIllhatton C, Hili J, Molnar C, Solomon MI, Gass GC, Mungovan SF. Orthostatic Intolerance-Type Events Following Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2023; 105:239-249. [PMID: 36723468 DOI: 10.2106/jbjs.22.00600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Orthostatic intolerance (OI)-type events following hip and knee arthroplasty increase the risk of falls, hospital length of stay, and health-care costs. There is a limited understanding of the incidence of and risk factors for OI-type events in patients during the acute hospital stay. Our aim was to systematically review the incidence of and risk factors for OI-type events during the acute hospital stay following hip and knee arthroplasty. METHODS A systematic review and meta-analysis of studies that investigated the incidence of and risk factors for OI-type events was undertaken. A comprehensive search was performed in MEDLINE, Embase, and CINAHL from their inception to October 2021. The methodological quality of identified studies was assessed using the modified version of the Quality in Prognosis Studies (QUIPS) tool. RESULTS Twenty-one studies (14,055 patients) were included. The incidence was 2% to 52% for an OI event, 1% to 46% for orthostatic hypotension, and 0% to 18% for syncope/vasovagal events. Two studies reported female sex, high peak pain levels (>5 out of 10) during mobilization, postoperative use of gabapentin, and the absence of postoperative intravenous dexamethasone as risk factors. There was no consensus on the definition and assessment of an OI-type event. CONCLUSIONS OI-type events are common during the acute hospital stay following hip and knee arthroplasty, and 4 risk factors have been reported for OI-type events. High-quality prospective cohort studies are required to systematically and reliably determine the incidence of and risk factors for OI-type events. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tarcisio F de Campos
- St Vincent's Private Hospital, Sydney, New South Wales, Australia.,St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia.,Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Nick Vertzyas
- Department of Orthopaedic Surgery, St Vincent's Private Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Mitch Wolden
- Physical Therapy Program, University of Jamestown, Fargo, North Dakota.,The Clinical Research Institute, Sydney, New South Wales, Australia
| | - Deshitha Hewawasam
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Ben Douglas
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Christopher McIllhatton
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Jessica Hili
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Chloe Molnar
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Michael I Solomon
- Department of Orthopaedic Surgery, St Vincent's Private Hospital, Sydney, New South Wales, Australia.,Sydney Orthopaedic Specialists, Sydney, New South Wales, Australia
| | - Gregory C Gass
- The Clinical Research Institute, Sydney, New South Wales, Australia
| | - Sean F Mungovan
- St Vincent's Private Allied Health Services, St Vincent's Private Hospital, Sydney, New South Wales, Australia.,Sydney Orthopaedic Specialists, Sydney, New South Wales, Australia.,Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, Australia
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Early Surgical Treatment of Thoracolumbar Fractures With Thoracolumbar Injury Classification and Severity Scores Less Than 4. J Am Acad Orthop Surg 2023; 31:e481-e488. [PMID: 36727915 DOI: 10.5435/jaaos-d-22-00694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/21/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Thoracolumbar fractures (TLFs) are the most common spinal fractures seen in patients with trauma. The Thoracolumbar Injury Classification and Severity (TLICS) classification system is commonly used to help clinicians make more consistent and objective decisions in assessing the indications for surgical intervention in patients with thoracolumbar fractures. Patients with TLICS scores <4 are treated conservatively, but a percentage of them will have failed conservative treatment and require surgery at a later date. METHODS All patients who received an orthopaedic consult between January 2016 and December 2020 were screened for inclusion and exclusion criteria. For patients meeting the study requirements, deidentified data were collected including demographics, diagnostics workup, and hospital course. Data analysis was conducted comparing length of stay, time between first consult and surgery, and time between surgery and discharge among each group. RESULTS 1.4% of patients with a TLICS score <4 not treated surgically at initial hospital stay required surgery at a later date. Patients with a TLICS score <4 treated conservatively had a statistically significant shorter hospital stay compared with those treated surgically. However, when time between initial consult and surgery was factored into the total duration of hospital stay for those treated surgically, the duration was statistically equivalent to those treated nonsurgically. CONCLUSION For patients with a TLICS score <4 with delayed mobilization after 3 days in the hospital or polytraumatic injuries, surgical stabilization at initial presentation can decrease the percentage of patients who fail conservative care and require delayed surgery. Patients treated surgically have a longer length of stay than those treated conservatively, but there is no difference in stay when time between consult and surgery was accounted for. In addition, initial surgery in patients with delayed mobilization can prevent long waits to surgery, while conservative measures are exhausted. LEVEL III EVIDENCE Retrospective cohort study.
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Shah J, Wang F, Ricci JA. Concomitant Cervical Spine Injuries in Pediatric Maxillofacial Trauma: An 11 Year Review of the National Trauma Data Bank. J Oral Maxillofac Surg 2023; 81:413-423. [PMID: 36620992 DOI: 10.1016/j.joms.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Craniofacial trauma with concomitant cervical fractures (CCFs) is responsible for significant morbidity and mortality in the pediatric population. We aim to characterize its incidence, injury patterns, outcomes, and risk factors, along with identifying any association between mandible fractures and cervical injuries via the National Trauma Databank. METHODS A retrospective cohort study was performed using National Trauma Databank records between 2007 and 2017 to identify patients equal or under the age of 18 years hospitalized for maxillofacial trauma and with recorded cervical injury. Variables of interest include age, gender, race/ethnicity, trauma type (blunt vs penetrating), Injury Severity Score, area involved, mechanism of injury, comorbid conditions, inpatient complications, and discharge disposition. Retrospective cohorts were separated by CCF status. Univariate, bivariate, and multivariable regression analysis was utilized, with P-value <.05 considered statistically significant. RESULTS A total of 32,952 patients were included in the study, with the majority being White (60.8%), male (68.2%), and between the ages of 13 and 18 years (65%). Of these, 8.2% experienced CCF. Most common mechanisms of injury were motor vehicle trauma (32.6%), interpersonal violence (18.8%), and falls (13.5%). Univariate analysis revealed patients with CCF were significantly older (15.2 vs 12.9; P < .001), more likely to be motor vehicle occupants (46.6 vs 31.9%; P < .001), and suffer polyfacial fractures (62.6 vs 60.7%; P < .001). Longer length of stay (9.4 vs 3.6 days; P < .001) and significantly higher inpatient complications such as deep vein thrombosis, pulmonary embolism, unplanned intubation, severe sepsis, pressure ulcer, ventilator-associated pneumonia, and unplanned return to operating room were observed in the CCF cohort. Female gender (1.5 [1.37 to 1.64; 95% confidence interval {CI}] P < .001) and higher Injury Severity Score (1.12 [1.11 to 1.11; 95% CI] P < .001) were associated with significantly higher odds on multivariable analysis. The presence of a mandible fracture was not associated with increased CCF on multivariate analysis (1.06 [0.92 to 1.22; 95% CI] P = .36). CONCLUSIONS There are statistically significant differences in demographics, outcomes, and injury patterns in maxillofacial patients with CCF that may help guide treatment. No association between mandible fractures and cervical trauma was identified.
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Affiliation(s)
- Jinesh Shah
- Resident, Division of Plastic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Fei Wang
- Research Assistant, Division of Plastic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Joseph A Ricci
- Assistant Professor, Division of Plastic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY.
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Porche K, Yan S, Mohamed B, Garvan C, Samra R, Melnick K, Vaziri S, Seubert C, Decker M, Polifka A, Hoh DJ. Enhanced recovery after surgery (ERAS) improves return of physiological function in frail patients undergoing one- to two-level TLIFs: an observational retrospective cohort study. Spine J 2022; 22:1513-1522. [PMID: 35447326 PMCID: PMC9534035 DOI: 10.1016/j.spinee.2022.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/14/2022] [Accepted: 04/09/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The enhanced recovery after surgery (ERAS) protocol is a multimodal approach which has been shown to facilitate recovery of physiological function, and reduce early post-operative pain, complications, and length of stay (LOS) in open one- to two-level TLIF. The benefit of ERAS in specifically frail patients undergoing TLIF has not been demonstrated. Frailty is clinically defined as a syndrome of physiological decline that can predispose patients undergoing surgery to poor outcomes. PURPOSE This study primarily evaluated the benefit of an ERAS protocol in frail patients undergoing one- or two-level open TLIF compared to frail patients without ERAS. Secondarily, we assessed whether outcomes in frail patients with ERAS approximated those seen in nonfrail patients with ERAS. STUDY DESIGN Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE Consecutive patients that underwent one- or two-level open TLIF for degenerative disease from August, 2015 to July, 2021 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES Primary outcome measure was return of postoperative physiological function defined as the summation of first day to ambulate, first day to bowel movement, and first day to void. Additional outcome measures included LOS, daily average pain scores, opioid use, discharge disposition, 30-day readmission rate, and reoperation. METHODS A retrospective analysis of frail patients > 65 years of age undergoing one- to two-level open TLIF post-ERAS were compared to propensity matched frail pre-ERAS patients. Frailty was assessed using the Fried phenotype classification (score >1). Patient demographics, LOS, first-day-to-ambulate (A1), first-day-to-bowel movement (B1), first-day-to-void (V1) were collected. Return of physiological function was defined as A1+B1+V1. Primary analysis was a comparison of frail patients pre-ERAS versus post-ERAS to determine effect of ERAS on return of physiologic function with frailty. Secondary analysis was a comparison of post-ERAS frail versus post-ERAS nonfrail patients to determine if return of physiologic function in frail patients with ERAS approximates that of nonfrail patients. RESULTS In the primary analysis, 32 frail patients were included with mean age ± standard deviation of 72.8±4.4 years, mean BMI 28.8±5.5, 65.6% were male, 15 pre-ERAS and 17 post-ERAS. Patient characteristics were similar between groups. After ERAS implementation, return of physiological function improved by a mean 3.2 days overall (post-ERAS 3.4 vs. pre-ERAS 6.7 days) (p<.0001), indicating a positive effect of ERAS in frail patients. Additionally, length of stay improved by 1 day (4.8±1.6 vs. 3.8±1.9 days, p<.0001). Total daily intravenous morphine milligram equivalent (MME) as well as average daily pain scores were similar between groups. Secondarily, 26 nonfrail patients post ERAS were used as a comparison group with the 17 post-ERAS frail cohort. Mean age of this cohort was 73.4±4.6 years, mean BMI 27.4±4.9, and 61.9% were male. Return of physiologic function was similar between cohorts (post-ERAS nonfrail 3.5 vs. post-ERAS frail 3.4 days) (p=.938), indicating the benefit with ERAS in frail patients approximates that of nonfrail patients. CONCLUSIONS ERAS significantly improves return of physiologic function and length of stay in patients with frailty after one- to two-level TLIF, and approximates improved outcomes seen in non-frail patients.
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Affiliation(s)
- Ken Porche
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608; 1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA.
| | - Sandra Yan
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Basma Mohamed
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1600 SW Archer Road, Department of Anesthesiology, University of Florida, Gainesville, FL, USA 32608
| | - Cynthia Garvan
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1600 SW Archer Road, Department of Anesthesiology, University of Florida, Gainesville, FL, USA 32608
| | - Ronny Samra
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608
| | - Kaitlyn Melnick
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Sasha Vaziri
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Christoph Seubert
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1600 SW Archer Road, Department of Anesthesiology, University of Florida, Gainesville, FL, USA 32608
| | - Matthew Decker
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Adam Polifka
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Daniel J. Hoh
- 1600 SW Archer Rd, College of Medicine, University of Florida, Gainesville, FL, USA 32608,1505 SW Archer Rd, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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DiMaria S, Wilent WB, Nicholson KJ, Tesdahl EA, Valiuskyte K, Mao J, Seger P, Singh A, Sestokas AK, Vaccaro AR. Patient Factors Impacting Baseline Motor Evoked Potentials (MEPs) in Patients Undergoing Cervical Spine Surgery for Myelopathy or Radiculopathy. Clin Spine Surg 2022; 35:E527-E533. [PMID: 35221326 DOI: 10.1097/bsd.0000000000001299] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/17/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of 2532 adults who underwent elective surgery for cervical radiculopathy or myelopathy with intraoperative neuromonitoring (IONM) with motor evoked potentials (MEPs) between 2017 and 2019. OBJECTIVE Evaluate attainability of monitorable MEPs across demographic, health history, and patient-reported outcomes measure (PROM) factors. SUMMARY OF BACKGROUND DATA When baseline IONM responses cannot be obtained, the value of IONM on mitigating the risk of postoperative deficits is marginalized and a clinical decision to proceed must be made based, in part, on the differential diagnosis of the unmonitorable MEPs. Despite known associations with baseline MEPs and anesthetic regimen or preoperative motor strength, little is known regarding associations with other patient factors. METHODS Demographics, health history, and PROM data were collected preoperatively. MEP baseline responses were reported as monitorable or unmonitorable at incision. Multivariable logistic regression estimated the odds of having at least one unmonitorable MEP from demographic and health history factors. RESULTS Age [odds ratio (OR)=1.031, P <0.001], sex (male OR=1.572, P =0.007), a primary diagnosis of myelopathy (OR=1.493, P =0.021), peripheral vascular disease (OR=2.830, P =0.009), type II diabetes (OR=1.658, P =0.005), and hypertension (OR=1.406, P =0.040) were each associated with increased odds of unmonitorable MEPs from one or more muscles; a history of thyroid disorder was inversely related (OR=0.583, P =0.027). P atients with unmonitorable MEPs reported less neck-associated disability and pain ( P <0.036), but worse SF-12 physical health and lower extremity (LE) and upper extremity function ( P <0.016). Compared with radiculopathy, unmonitorable MEPs in myelopathy patients more often involved LE muscles. Cord function was monitorable in 99.1% of myelopathic patients with no reported LE dysfunction and no history of hypertension or diabetes. CONCLUSION Myelopathy, hypertension, peripheral vascular disease, diabetes, and/or symptomatic LE dysfunction increased the odds of having unmonitorable baseline MEPs. Unmonitorable baseline MEPs was uncommon in patients without significant LE weakness, even in the presence of myelopathy.
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Affiliation(s)
- Stephen DiMaria
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Kristen J Nicholson
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | - Jennifer Mao
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Philip Seger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Akash Singh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Alex R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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Neurosurgeons Relate Heterogeneous Practices Regarding Activity and Return to Work After Spine Surgery. World Neurosurg 2022; 162:e309-e318. [PMID: 35259506 DOI: 10.1016/j.wneu.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Given the paucity of relevant data, the Council of State Neurosurgical Societies Workforce Committee launched a survey of neurosurgeons to assess patterns in activity restriction recommendations following spine surgery; the ultimate goal was to optimize and potentially standardize these recommendations. The aim of this initial study was to determine current practices in activity restrictions and return to work guidelines following common spinal procedures. METHODS The survey included questions regarding general demographics and practice data, postoperative bracing/orthosis utilization, and guidelines for postoperative return to different levels of activity/types of work following specific spine surgery interventions. A spectrum of typical spine surgeries was assessed, including microdiscectomy, anterior cervical discectomy and fusion (ACDF), and lumbar fusion, both open and minimal invasive surgery (MIS) approaches. RESULTS There was significant interprocedure and intraprocedure variation in the neurosurgeons' recommendations for postoperative activity and return to work recommendations after various spinal surgery procedures. Comparisons of the different surgical procedures evaluated revealed significant differences in cervical collar use (more often used following ≥2-level ACDF than single-level ACDF; P < 0.001), return to both sedentary and light physical work (greater restriction with ≥2-level ACDF than with single-level ACDF; P < 0.001), and return to a light exercise regimen (sooner following MIS versus open lumbar fusion; P < 0.001). CONCLUSIONS This survey demonstrated little consistency regarding return to work recommendations, general activity restrictions, and orthosis utilization following common spinal surgical procedures. Addressing this issue also has significant implications for the societal and personal costs of spine surgery.
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Porche K, Samra R, Melnick K, Brennan M, Vaziri S, Seubert C, Polifka A, Hoh DJ, Mohamed B. Enhanced recovery after surgery (ERAS) for open transforaminal lumbar interbody fusion: a retrospective propensity-matched cohort study. Spine J 2022; 22:399-410. [PMID: 34687905 PMCID: PMC9595392 DOI: 10.1016/j.spinee.2021.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/10/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population. PURPOSE This study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF. STUDY DESIGN/SETTING Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE Consecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 - 02/2021 and controls from 12/2011-12/2017 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES Primary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations. METHODS Demographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use. RESULTS There were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p <.0001) as did length of stay (4.6±1.7 vs. 3.6±1.6 days, p<.0001). First day of ambulation, bowel movement, and bladder voiding improved by 0.8 (p<.0001), 0.7 (p=.008), and 0.8 (p<.0001) days, respectively, in the ERAS cohort. Total daily intravenous morphine milligram equivalent (MME) (8±9 vs. 36±38, p<0.0001) and total 72-hour MME consumption (53±33 vs. 68±48, p<.0001) was significantly lower in the ERAS cohort; however, 72-hour MME consumption was not found to be significantly different in a sensitivity analysis controlling for preoperative MME. Average daily pain scores were similar between groups. CONCLUSIONS Consistent with other studies demonstrating benefit of an ERAS protocol for minimally invasive spine procedures, ERAS was associated with decreased operative time, reduced length of stay, decrease in IV opioid consumption, and improved physiological outcomes for open 1- and 2-level TLIF. ERAS can be a potentially effective strategy for improving patient outcome and efficiency of healthcare resources for common conventional spinal surgeries such as open TLIF.
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Affiliation(s)
- Ken Porche
- College of Medicine, University of Florida, Gainesville, FL, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
| | - Ronny Samra
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kaitlyn Melnick
- College of Medicine, University of Florida, Gainesville, FL, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Meghan Brennan
- College of Medicine, University of Florida, Gainesville, FL, USA; Department of Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Sasha Vaziri
- College of Medicine, University of Florida, Gainesville, FL, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Christoph Seubert
- College of Medicine, University of Florida, Gainesville, FL, USA; Department of Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Adam Polifka
- College of Medicine, University of Florida, Gainesville, FL, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Daniel J Hoh
- College of Medicine, University of Florida, Gainesville, FL, USA; Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Basma Mohamed
- College of Medicine, University of Florida, Gainesville, FL, USA; Department of Anesthesiology, University of Florida, Gainesville, FL, USA
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Taylor SM, Slowinske L, Dennison M, Manusky C, Tan S, Patel K, Brewington D. Inpatient rehabilitation wheelchair management quality improvement project: Implications for patients with spinal cord injury. J Spinal Cord Med 2022; 46:414-423. [PMID: 35108164 PMCID: PMC10114970 DOI: 10.1080/10790268.2021.2019656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
CONTEXT/OBJECTIVE Evaluate hospital fleet wheelchair (WC) requests submitted by physical therapists (PT) for patients with spinal cord injury (SCI) to trial and use during inpatient rehabilitation. DESIGN Quality improvement project secondary analysis of delivery process and WC trials. SETTING Urban inpatient rehabilitation hospital. PARTICIPANTS Internal review of 4,371 WC requests narrowed to 750 patients with SCI. INTERVENTIONS PTs submitted WC requests between March 25, 2017, and September 30, 2019. OUTCOME MEASURES WC delivery timeframe, level of SCI, type of WC. RESULTS PTs requested power (28%), and manual WC bases: standard (19.1%), tilt (18.9%), ultralight rigid (18.9%), ultralight folding (13.5%), and recliner (1.6%) respectively. Patients received fleet WCs 49.9% of the time within specified urgency timeframes. A Chi-Square test showed a significant association between WC request urgency and fulfillment within established timeframes (χ2 = 19.68, P < 0.001, n = 750). Broken down by urgency level: 60.0% low (n = 12), 56.2% medium (n = 244), and 39.9% high (n = 118) received their WC within established timeframes. Patients with cervical level SCI (n = 162) had the highest mean wait time of 8.28 days for power WCs. The second highest wait time was 6.29 days (SD 6.6) for manual ultralight rigid WCs (n = 34). CONCLUSION Inpatient fleet WC delivery is critical to patients with SCI. Variation occurs by WC type requested and by the level of injury. Gaps exist in providing appropriate WCs in facility timeframe guidelines by the level of urgency that is within 24 h for high, 3-5 days for medium, and 5-7 days for low.
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Affiliation(s)
- Sally M Taylor
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.,Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Laura Slowinske
- Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department at Northwestern Medicine, Northwestern Medical Group Women's Health Physical Therapy, Chicago, Illinois, USA
| | - Michael Dennison
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Colton Manusky
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shawn Tan
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kinjal Patel
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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Lall A, Behan D. Mobilizing Ventilated Neurosurgery Patients: An Integrative Literature Review. J Neurosci Nurs 2022; 54:13-18. [PMID: 34864793 DOI: 10.1097/jnn.0000000000000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT BACKGROUND: Lack of mobilization in ventilated neurosurgery patients is problematic due to significant consequences. Although early mobility addresses these complications, few studies have been conducted in this population, resulting in infrequent mobilization efforts. Nurses prioritize and implement patient care interventions, including mobilization, with multidisciplinary teams. This integrative literature review examines what is known regarding nursing perceptions on mobilization and their role within a multidisciplinary team for mobilization in ventilated neurosurgery patients. METHODS: A comprehensive literature search was conducted using online databases to identify research articles on early mobility studies in ventilated critically ill and neurosurgical patients from 2010 to 2020. RESULTS: Twenty studies were identified and indicated a paucity of research specific to mobilizing ventilated neurosurgery patients. Nurses understand the purpose and benefits of early mobility in critically ill and mechanically ventilated patients. Mixed perceptions exist regarding the responsibility for prioritizing and initiating mobilization. Main barriers include patient safety concerns, untimeliness due to limited resources, unit culture, lack of nursing knowledge, and need for improved teamwork. Associations between teamwork-based interventions and decreased length of stay, increased rates of mobility, and faster time to early mobilization exist. Nurse-led interventions showed additional benefits including positive perceptions such as empowerment, confidence, increased knowledge, and a progressive shift in unit culture. CONCLUSION: This review demonstrates a continued need for understanding nursing perceptions and role in teamwork to mobilize ventilated neurosurgery patients. Future research should focus on testing nurse-led mobility interventions so higher rates of mobilization and provision of holistic patient care can be achieved.
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Cha EDK, Lynch CP, Mohan S, Geoghegan CE, Jadczak CN, Singh K. Impact of Obesity Severity on Achieving a Minimum Clinically Important Difference Following Minimally Invasive Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2022; 35:E267-E273. [PMID: 34050042 DOI: 10.1097/bsd.0000000000001205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to determine the impact of obesity on postoperative outcomes and minimum clinically important difference (MCID) achievement following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA Obesity is a proven risk factor for poorer outcomes in MIS TLIF patients. However, few studies have investigated the impact of body mass index (BMI) on achievement of a MCID for Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). METHODS A prospective surgical database was retrospectively reviewed for primary, elective, single level MIS TLIF patients. Patients were categorized into BMI groups: nonobese (<30 kg/m2); obese I (≥30 and <35 kg/m2); severe (≥35 and <40 kg/m2); and morbid (≥40 kg/m2). Demographic, perioperative information, and complication rates were compared between groups. Visual Analog Scale (VAS) back and leg, Oswestry Disability Index (ODI), 12-Item Short Form-12 Physical Composite Score (SF-12 PCS), and PROMIS PF were collected preoperatively and up to 2-year postoperatively. Impact of BMI on outcome measures and MCID achievement at all timepoints was evaluated. RESULTS A total of 162 patients were included with 88 patients categorized as normal weight, 37 obese I, 25 severe, and 12 morbid. SF-12 PCS, and PROMIS PF significantly differed by BMI at all timepoints, but only at 6- and 12-week for VAS back, preoperatively and 12 weeks for VAS leg, and preoperatively to 1-year for ODI. MCID achievement only differed for PROMIS PF and VAS back at 2 years, but did not for overall MCID achievement. CONCLUSIONS BMI is a significant predictor of ODI, SF-12 PCS, and PROMIS PF preoperatively to 1-year postoperatively, but only through 12-week for VAS scores. MCID achievement varied for PROMIS PF and VAS back, suggesting that though BMI may affect postoperative outcome values, obesity may impact a patient's perception of meaningful improvements in pain and physical function.
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Affiliation(s)
- Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Zhang H, Wang Z, Li K. Clinical application of enhanced recovery after surgery in lumbar disk herniation patients undergoing dynamic stabilization and discectomy. J Back Musculoskelet Rehabil 2022; 35:47-53. [PMID: 34180404 DOI: 10.3233/bmr-200238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been demonstrated to improve early postoperative outcomes and is becoming a crucial component of any perioperative management paradigm. OBJECTIVE To investigate the effect of an ERAS protocol on lumbar disk herniation (LDH) patients undergoing dynamic stabilization and discectomy. METHODS A total of 119 lumbar disk herniation (LDH) patients undergoing Dynesys dynamic stabilization and discectomy were divided into the ERAS (n1 = 56) and control group (n2 = 63). ERAS group received an enhanced recovery after surgery (ERAS) protocol, and control group received a traditional care protocol. RESULTS Both the ERAS and control groups had significantly decreased visual analog scale (VAS) score and Oswestry Disability Index (ODI) and increased Japanese Orthopaedic Association (JOA) score at postoperative 1 week, 1 month and 3 months compared with preoperative scores. Moreover, the ERAS group had lower postoperative VAS score and ODI and higher postoperative JOA score and rate of improved JOA score compared with the control group. Intraoperative blood loss, operation time, ambulation time and length of stay were all lower in the ERAS group than in the control group. CONCLUSIONS The ERAS protocol designed was feasible for LDH patients undergoing dynamic stabilization and discectomy with significantly improved perioperative outcomes.
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Zhang Z, Hou QQ, Luo X, Li HM, Hou Y. The role of nursing in enhanced recovery after surgery programs in accordance with spine surgery: A mini review. JOURNAL OF INTEGRATIVE NURSING 2022. [DOI: 10.4103/jin.jin_08_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Joo B, Marquez J, Model G, Fan B, Osmotherly PG. Impact of a new post-operative care model in a rural hospital after total hip replacement and total knee replacement. Aust J Rural Health 2021; 30:115-122. [PMID: 34932241 DOI: 10.1111/ajr.12826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 10/19/2021] [Accepted: 10/29/2021] [Indexed: 11/27/2022] Open
Abstract
PROBLEM The predicted global trend of increasing total hip replacement and total knee replacement numbers leads to a direct and growing impact on health care services. Models of care including 'fast-track' mobilisation after total hip replacement and total knee replacement have been reported to reduce length of stay. This has not been verified in rural settings. SETTING Armidale Rural Referral Hospital. KEY MEASURES FOR IMPROVEMENT The new post-operative care included early discharge planning with or without Day 0 mobilisation with aims to decrease hospital length of stay without affecting complication rates, compared to the conventional model of care. STRATEGIES FOR CHANGE Consistent communication and planning for early discharge occurred before and throughout admission and Day 0 mobilisation. EFFECTS OF CHANGE There was a statistically significantly less median length of stay following implementation of the new post-operative care model (3.24 vs 2.29 days [P < .01]). There was no statistically significant difference in complications or readmissions following the change. Those who were allocated to mobilise on Day 0 had a lesser median length of stay than those who did not (2.40 vs 2.27 days, P = .03). LESSONS LEARNT Our results indicate that the new post-operative care model is safe and feasible for total knee replacement or total hip replacement patients in a rural setting and might reduce length of stay without compromising clinical outcomes.
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Affiliation(s)
- Baeho Joo
- Physiotherapy Department, Armidale Rural Referral Hospital, Armidale, NSW, Australia
| | - Jodie Marquez
- School of Health Sciences, The University of Newcastle, Callaghan, NSW, Australia
| | - Gemma Model
- Physiotherapy Department, Armidale Rural Referral Hospital, Armidale, NSW, Australia
| | - Bo Fan
- School of Health Sciences, The University of Newcastle, Callaghan, NSW, Australia
| | - Peter G Osmotherly
- School of Health Sciences, The University of Newcastle, Callaghan, NSW, Australia
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Factors Affecting Postoperative Length of Stay in Patients Undergoing Anterior Lumbar Interbody Fusion. World Neurosurg 2021; 155:e538-e547. [PMID: 34464773 DOI: 10.1016/j.wneu.2021.08.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND With hospital leaders and policy makers increasingly seeking ways to improve resource use, there has been heightened interest in reducing hospital length of stay (LOS) and performing spine procedures on an outpatient basis. We aimed to determine which risk factors correlated with prolonged LOS after anterior lumbar interbody fusion (ALIF). METHODS Medical records for patients who underwent ALIF were retrospectively reviewed. Patients were divided into those who had extended (≥3 days) versus nonextended (<3 days) LOS, and patient demographics, medical comorbidities, and preoperative medications were analyzed. Univariate and multivariate regression were then used to determine preoperative risk factors for extended LOS. RESULTS A total of 166 patients were included (mean age, 48.7 years). Medical comorbidities included hypertension (31.9%), diabetes (8.4%), and obesity (body mass index >30 kg/m2) (48.8%). LOS was not extended in 121 patients and extended in 45. Mean LOS was 2.2 days (95% confidence interval, 1.9-2.5). On multivariate logistic analysis, age ≥65 years (P = 0.001), preoperative benzodiazepine use (P = 0.014), 12-item Short Form mental component score (P = 0.008), estimated blood loss (P = 0.015), time to mobilization (P < 0.001), and total operative time (P = 0.020) were independent predictors for extended LOS. CONCLUSIONS As attempts are made to perform more spine procedure in ambulatory surgical centers, strict patient selection criteria are all critical in making this possible. Our results suggest that age, preoperative benzodiazepine use, higher intraoperative blood loss, delayed mobilization, and lower 12-item Short Form mental component score were correlated with increased LOS. Therefore, inpatient ALIF may be more suitable for patients with these risk factors.
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Falls from height: Ambulation following spinal cord injury and lower extremity polytrauma. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Thoracolumbar Interfascial Plane Block Results in Opioid-Free Postoperative Recovery After Percutaneous/Endoscopic Transforaminal Lumbar Interbody Fusion Surgery. World Neurosurg 2021; 153:e473-e480. [PMID: 34242827 DOI: 10.1016/j.wneu.2021.06.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate efficacy in reducing postoperative pain and opioid analgesia of a novel interdisciplinary strategy combining preoperative thoracolumbar interfascial plane (TLIP) block and percutaneous/endoscopic transforaminal lumbar interbody fusion surgery and to determine time to first postoperative ambulation and hospital length of stay. METHODS In this retrospective review, 42 patients who underwent elective single-level percutaneous/endoscopic transforaminal lumbar interbody fusion surgery between 2015 and 2021 were divided into 2 groups: TLIP group with 17 patients who underwent TLIP block and non-TLIP group with 25 patients. Both groups received the same postoperative analgesia with morphine as patient-controlled rescue medication. Visual analog scale and Oswestry Disability Index scores were evaluated. Statistical evaluation was performed with Student t test. RESULTS In contrast to the non-TLIP group, in the TLIP group, postoperative mean visual analog scale back score and mean Oswestry Disability Index score significantly decreased from 6.6 to 3.3 (P < 0.01) and 32.8 to 23.6 (P < 0.01), respectively, at hospital discharge. No differences were found between the groups at 1 month. Overall mean follow-up time was 29 ± 18 months (range, 3-78 months). Patients in the non-TLIP group were administered a median postoperative 24-hour morphine dose equivalent of 23 mg (range, 8-31 mg), while patients in the TLIP group did not require opioid analgesia (P < 0.01). Patients in the TLIP group started postoperative ambulation at a median of 4.1 hours (range, 2.5-26 hours) with a median hospital length of stay of 24 hours (range, 20-48 hours) (P = 0.112). CONCLUSIONS TLIP block significantly improves patient outcome at hospital discharge after transforaminal lumbar interbody fusion surgery without postoperative administration of opioids. A prospective study is recommended to confirm our preliminary results.
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Engel O, Haikin Herzberger E, Yagur Y, Hershko Klement A, Fishman A, Constantini N, Biron Shental T. Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study. Int J Gynaecol Obstet 2021; 157:391-396. [PMID: 34214190 DOI: 10.1002/ijgo.13815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/29/2021] [Accepted: 07/01/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the correlation between maternal mobility after cesarean delivery and postoperative morbidity. METHODS A prospective study was conducted in a tertiary hospital among patients after cesarean delivery. The women were recruited after surgery and before ambulation. Each participant received an accelerometer and routine instructions for mobilization. The patients were asked to wear the accelerometer constantly. It was collected at discharge. Electronic files were reviewed and patients' outcomes were analyzed. The Mann-Whitney U test was used to compare groups and a receiver operating characteristic curve was calculated for the threshold of number of steps. RESULTS Data were analyzed for 199 patients, among which 107 (54.4%) deliveries were urgent and 90 (45.6%) were elective. The median number of steps was higher for multiparous women compared to nulliparous women (P = 0.035). Patients who developed complications after discharge walked significantly less during their hospitalization compared to those who did not. There was a trend toward increased risk for in-hospitalization complications among patients who walked less while hospitalized. A threshold of more than 9716 steps per hospitalization was found to be associated with fewer post-discharge complications. CONCLUSION There is a significant correlation between the extent of ambulation after cesarean delivery and fewer postoperative complications.
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Affiliation(s)
- Offra Engel
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Haikin Herzberger
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Yagur
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Hershko Klement
- Hadassah Hospital Mt. Scopus, The Hebrew University of Jerusalem and the Hebrew University Medical School, Jerusalem, Israel
| | - Ami Fishman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Constantini
- Heidi Rothberg Sports Medicine Center, Shaare Zedek Medical Center, Jerusalem, Israel.,Israel Ministry of Health, Exercise Medicine Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Biron Shental
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gebauer A, Petersen J, Konertz J, Brickwedel J, Schulte-Uentrop L, Reichenspurner H, Girdauskas E. Enhanced Recovery After Cardiac Surgery: Where Do We Stand? CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00455-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose of Review
Enhanced recovery after surgery (ERAS) protocols are multimodal and multi-professional strategies to enhance postoperative convalescence and thereby reduce the length of hospital stay and hospital-associated complications. This review provides an up-to-date overview about basic principles of enhanced recovery after surgery protocols, their transfer into cardiac surgery, and their current state of evidence. It is supposed to offer clinical implications for further adaptations and implementations of such protocols in cardiac surgery.
Recent Findings
ERAS protocols are a story of success in numerous surgical disciplines and led to a paradigm shift in perioperative care and the establishment of ERAS Cardiac Society, a non-profit organization that provides evidence-based guidelines and recommendations for further development of enhanced recovery protocols, trying to harmonize the many existing efforts of individual approaches for cardiac surgery.
Summary
Promising results from comprehensive ERAS protocols in cardiac surgery emerged. Nevertheless, there is a paucity of high-quality data about holistic approaches in cardiac surgery and further efforts need to be promoted.
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Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study. Spine (Phila Pa 1976) 2021; 46:E679-E687. [PMID: 33315772 DOI: 10.1097/brs.0000000000003869] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, comparative. OBJECTIVE The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care. SUMMARY OF BACKGROUND DATA Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes. METHODS Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals. RESULTS A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months). CONCLUSION Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.
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Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G, de Boer HD. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021; 21:729-752. [PMID: 33444664 DOI: 10.1016/j.spinee.2021.01.001] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/02/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery. PURPOSE This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program. STUDY DESIGN This is a review article. METHODS Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature. RESULTS Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. CONCLUSION Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Thomas W Wainwright
- Research Institute, Bournemouth University, Bournemouth, UK; The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Freyr G Sigmundsson
- Department of Orthopedic Surgery, Örebro University Hospital, Södra Grev Rosengatan, Örebro, Sweden
| | - Michael M H Yang
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Aurélien Bonnal
- Department of Anesthesiology, Clinique St-Jean- Sud de France, Santécité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery - Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, SantéCité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, the Netherlands
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Dass D, Dhawan R, Maybin J, Kiely NT, Davidson NT, Trivedi JM. Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key? J Pediatr Orthop B 2021; 30:218-224. [PMID: 32694433 DOI: 10.1097/bpb.0000000000000764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Current trends in the surgical treatment of patients with adolescent idiopathic scoliosis (AIS) involve the use of high dependency unit (HDU) in the postoperative period. The British Scoliosis Society also recommends the availability of HDU support in the postoperative period for these patients. However, this practice may lead to unexpected theatre cancellations due to lack of availability of HDU bed on the day of surgery. We also hypothesize that this practice may eventually lead to longer inpatient stay for the patients. All AIS patients at our unit are managed on a paediatric ward postoperatively, without HDU support. The primary aim of the study therefore is to evaluate whether operating on AIS patients without HDU support is well tolerated practice. Secondary aims were to evaluate patient related outcomes, including length of stay (LOS), and postoperative analgesia requirements. Adolescents aged 12-17 years with idiopathic scoliosis deformity who were treated with posterior instrumented scoliosis (PIS) correction were included in this prospective cohort study. The study period was between 12 November 2012 and 6 August 2018. Twenty-two patients were included in the HDU group and 33 patients in the non-HDU group. These were two matched cohort groups. Data were collected on complication rates, LOS, analgesic requirements, time to bowel opening, and attainment of physiotherapy goals in the immediate postoperative period. Statistical analysis was performed using statistical software R (3.4.3). There were no complications in the non-HDU group and one pneumothorax in the HDU group. There was a significant reduction in the LOS from 7.4 days (SD ±2.3, CI 0.012) days, to 5.8 (SD ±1.4, CI 0.01) days in the non-HDU group (P = 0.0001). There was no significant difference statistically or clinically in opiate usage between the HDU group, 115 mg (SD ±60.7, CI 0.8) and the non-HDU group 116 mg (SD ±55.8, CI 0.6) (P = 0.609). However, there was an improvement in pain scores in the non-HDU group where oral analgesics only were used (P = 0.002). A cost saving of £2038.80 per AIS case was made in the non-HDU group. AIS surgery can be performed safely without the need for HDU support in healthy adolescents. An oral analgesia-based enhanced recovery regime compares favourably to patient-controlled analgesia (PCA) and indicates these patients can be managed safely with strong multidisciplinary support on a paediatric ward.
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Affiliation(s)
| | | | | | - Nigel T Kiely
- Paediatric Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
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Zaed I, Bossi B, Ganau M, Tinterri B, Giordano M, Chibbaro S. Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: A systematic review of the literature. Neurochirurgie 2021; 68:61-68. [PMID: 33901525 DOI: 10.1016/j.neuchi.2021.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 03/07/2021] [Accepted: 04/11/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Recent years have been characterized by a great technological and clinical development in spine surgery. In particular, enhanced recovery after surgery (ERAS) programs, started to gain interest also in this surgical field. Here we tried to analyse the current state of art of ERAS technique in spine surgery. MATERIAL AND METHOD A systematic review of the literature has been performed in order to find all the possible inclusions. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, Medline databases was conducted to identify all full-text articles in the English-language literature describing the use of ERAS programs or techniques for spine surgery in adult patients. RESULTS Out of the 827 studies found, only 21 met the inclusion criteria has been retained to be included in the present study. The most frequently benefits of ERAS protocols were shorter hospitalisations (n=15), and decreased complication rates (n=8) lower postoperative pain scores (n=4). These benefits were seen in the 3 main categories considered: lumbar spine surgeries, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine. CONCLUSION There are an arising amount of data showing that the use of ERAS programs could be helpful in reducing the days of hospitalizations and the number of complications for certain spinal procedures and in a highly selected group of patients. Despite the large interest on the topic; there is an important lack of high level of scientific evidences. Because of that, there is the need to encourage the design and creation of new randomized clinical trials that will validate the present findings.
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Affiliation(s)
- I Zaed
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy; Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano (MI), Italy.
| | - B Bossi
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy
| | - M Ganau
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - B Tinterri
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele (MI), Italy
| | - M Giordano
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - S Chibbaro
- Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
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Kelly M, Turcotte J, Aja J, MacDonald J, King P. Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia. Arthroplast Today 2021; 8:200-203. [PMID: 33937458 PMCID: PMC8076614 DOI: 10.1016/j.artd.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intrathecal opioids have been used to reduce pain after total joint arthroplasty; however, the utility of these drugs is disputed. We examined the impact of eliminating intrathecal fentanyl on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA). METHODS Retrospective review of 376 THA patients from a single institution was conducted. Univariate analysis was used to compare intraoperative medication usage and postoperative outcomes for THA patients receiving intrathecal fentanyl compared with those who did not receive intrathecal fentanyl. RESULTS Recovery room pain scores were significantly lower for patients who received intrathecal fentanyl (intrathecal fentanyl 1.4 vs no 2.2, P = .001), but no difference in opioid consumption was observed (intrathecal fentanyl 9.3 milligram morphine equivalent vs no 10.5 milligram morphine equivalent, P = .200). Intraoperative use and dose of intravenous morphine, hydromorphone, and dexamethasone did not differ significantly between groups. There were no significant differences in length of stay between the groups (intrathecal fentanyl 1.1 days vs 1.1 days, P = .973), 90-day readmission, or recatherization rates between groups (readmission, intrathecal fentanyl 4.8% vs no 5.8%, P = .709; recatherization, intrathecal fentanyl 0% vs no 0.7%, P = 1.00). CONCLUSION The administration of intrathecal fentanyl does not have a significant effect on early postoperative narcotic consumption, length of stay, 90-day readmissions, or recatheterization after THA with neuraxial anesthesia. Intrathecal fentanyl does not appear to improve outcomes and should not be included as a standard element of THA rapid recovery protocols.
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Affiliation(s)
| | | | - Jacob Aja
- Anne Arundel Medical Center, Annapolis, MD, USA
| | | | - Paul King
- Anne Arundel Medical Center, Annapolis, MD, USA
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Huq S, Khalafallah AM, Jimenez AE, Gami A, Lam S, Ruiz-Cardozo MA, Oliveira LAP, Mukherjee D. Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index. Neurosurgery 2021; 88:147-154. [PMID: 32803222 DOI: 10.1093/neuros/nyaa335] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/31/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Frailty indices may represent useful decision support tools to optimize modifiable drivers of quality and cost in neurosurgical care. However, classic indices are cumbersome to calculate and frequently require unavailable data. Recently, a more lean 5-factor modified frailty index (mFI-5) was introduced, but it has not yet been rigorously applied to brain tumor patients. OBJECTIVE To investigate the predictive value of the mFI-5 on length of stay (LOS), complications, and charges in surgical brain tumor patients. METHODS We retrospectively reviewed data for brain tumor patients who underwent primary surgery from 2017 to 2018. Bivariate (ANOVA) and multivariate (logistic and linear regression) analyses assessed the predictive power of the mFI-5 on postoperative outcomes. RESULTS Our cohort included 1692 patients with a mean age of 55.5 yr and mFI-5 of 0.80. Mean intensive care unit (ICU) and total LOS were 1.69 and 5.24 d, respectively. Mean pulmonary embolism (PE)/deep vein thrombosis (DVT), physiological/metabolic derangement, respiratory failure, and sepsis rates were 7.2%, 1.1%, 1.6%, and 1.7%, respectively. Mean total charges were $42 331. On multivariate analysis, each additional point on the mFI-5 was associated with a 0.32- and 1.38-d increase in ICU and total LOS, respectively; increased odds of PE/DVT (odds ratio (OR): 1.50), physiological/metabolic derangement (OR: 3.66), respiratory failure (OR: 1.55), and sepsis (OR: 2.12); and an increase in total charges of $5846. CONCLUSION The mFI-5 is a pragmatic and actionable tool which predicts LOS, complications, and charges in brain tumor patients. It may guide future efforts to risk-stratify patients with subsequent impact on postoperative outcomes.
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Affiliation(s)
- Sakibul Huq
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Abhishek Gami
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shravika Lam
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Miguel A Ruiz-Cardozo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leonardo A P Oliveira
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lee KE, Martin TA, Peterson KA, Kittel C, Zehri AH, Wilson JL. Factors associated with length of stay after single-level posterior thoracolumbar instrumented fusion primarily for degenerative spondylolisthesis. Surg Neurol Int 2021; 12:48. [PMID: 33654551 PMCID: PMC7911038 DOI: 10.25259/sni_954_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/11/2021] [Indexed: 01/03/2023] Open
Abstract
Background: The postoperative length of stay (LOS) is an important prognostic indicator for patients undergoing instrumented spinal fusion surgery. Increased LOS can be associated with higher infection rates, higher incidence of venous thromboembolisms, and a greater frequency of hospital-acquired delirium. The day of surgery and early postoperative mobilization following single-level posterior thoracolumbar stabilizations may impact the LOS. In this study, we evaluated the effects of weekday (Monday–Thursday) versus weekend (Friday–Sunday) surgery and postoperative rehabilitation services on LOS following primarily transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis (DS). Methods: In this single-institution retrospective chart review, we identified 198 adults who received a one-level thoracolumbar instrumented fusion through a posterior only approach (2017–2019). The majority of these patients underwent TLIF for DS. A zero truncated negative binomial model was used for predictors of the primary outcome of LOS (weekday of surgery, duration of operation, first or repeat surgery, and physical therapy/ occupational therapy [PT/OT] evaluation). Covariates were sex, age, and body mass index. Results: We found that operative duration, repeat surgery, and in-hospital PT/OT all significantly increased the LOS (P < 0.05). Furthermore, those undergoing weekday surgery (Monday–Thursday) had 1.29 times longer LOS than those on the weekend (Friday–Sunday), but this did not reach statistical significance (P = 0.09). Conclusion: In our patient sample, duration, repeat surgery, and in-hospital PT/OT increased the LOS following primarily TLIF for DS. The increased LOS in these cases is likely due to higher overall disease burden and case complexity. In addition, those patients with a greater likelihood of extended recovery and ongoing neurologic deficits are more likely to have PT/OT evaluations. Notably, LOS was not significantly impacted by the day of surgery at our institution.
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Affiliation(s)
- Katriel E Lee
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Tamriage A Martin
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Keyan A Peterson
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Carol Kittel
- Department of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States
| | - Aqib H Zehri
- Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Jonathan L Wilson
- Department of Neurosurgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
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45
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Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform 2021; 9:893-904. [PMID: 33725329 PMCID: PMC8270839 DOI: 10.1007/s43390-021-00310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/13/2021] [Indexed: 12/28/2022]
Abstract
STUDY DESIGN A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS. OBJECTIVE To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published. METHODS A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model. RESULTS Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy. CONCLUSION This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Akshay D. Gadiya
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Jonathan E. J. Koch
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Mohammed Shakil Patel
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Masood Shafafy
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Michael P. Grevitt
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - Nasir A. Quraishi
- Centre for Spinal Studies and Surgery, D Floor, West Block, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH UK
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46
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Garg B, Mehta N. Brothers-in-arms: Liaison between spine surgeons and plastic surgeons in wound repair after complex spine surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL 2020; 4:100031. [PMID: 35141600 PMCID: PMC8820055 DOI: 10.1016/j.xnsj.2020.100031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 06/14/2023]
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47
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Pederson JL, Padwal RS, Warkentin LM, Holroyd-Leduc JM, Wagg A, Khadaroo RG. The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients. PLoS One 2020; 15:e0241554. [PMID: 33156849 PMCID: PMC7647086 DOI: 10.1371/journal.pone.0241554] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 10/16/2020] [Indexed: 12/30/2022] Open
Abstract
Surgeons are increasingly treating seniors with complex care needs who are at high-risk of readmission and functional decline. Yet, the prognostic importance of post-operative mobilization in older surgical patients is under-investigated and remains unclear. Thus, we evaluated the relationship between post-operative mobilization and events after hospital discharge in older people. Overall, 306 survivors of emergency abdominal surgery aged ≥65y who required help with <3 activities of daily living were prospectively followed at two Canadian tertiary-care hospitals. Time until mobilization after surgery was attained from hospital charts and a priori defined as ‘delayed’ (≥36h) or ‘early’ (<36h). Primary outcomes for 30-day and 6-month all-cause readmission/death after discharge were assessed in multivariable logistic regression. Patients had a mean age of 76 ± 7.7 years, 45% were women, 41% were ‘vulnerable-to-moderately-frail’, according to the Clinical Frailty Scale. Most common reasons for admission were gallstones (23%), intestinal obstructions (21%), and hernia (17%). Median time to post-operative mobilization was 19h (interquartile range 9−35); 74 (24%) patients had delayed mobilization. Delayed mobilization was independently associated with higher risk of 30-day readmission/death (19 [26%] vs. 22 [10%], P<0.001; adjusted odds ratio [aOR] 2.24, 95%CI 0.99–5.06, P = 0.05), but this was not statistically significant at 6-months (38 [51%] vs. 64 [28%], P<0.001; aOR 1.72, 95%CI 0.91−3.25, P = 0.1). One-quarter of older surgical patients stayed in bed for 1.5 days post-operatively. Delayed mobilization was associated with increased risk of short-term readmission/death. As older, more frail patients undergo surgery, mobilization of older surgical patients remains an understudied post-operative factor. Trial registration: clinicaltrials.gov identifier: NCT02233153
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Affiliation(s)
- Jenelle L Pederson
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Raj S Padwal
- Division of General Internal Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.,Alberta Diabetes Institute, Edmonton, Alberta, Canada
| | - Lindsey M Warkentin
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | | | - Adrian Wagg
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Rachel G Khadaroo
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
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48
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Khozenko A, Lamperti M, Velly L, Simeone P, Tufegdzic B. Role of anaesthesia in neurosurgical enhanced recovery programmes. Best Pract Res Clin Anaesthesiol 2020; 35:241-253. [PMID: 34030808 DOI: 10.1016/j.bpa.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.
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Affiliation(s)
- Andrey Khozenko
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates
| | - Massimo Lamperti
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
| | - Lionel Velly
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Pierre Simeone
- Aix Marseille Univ, AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, 264 rue saint Pierre, 13005, CEDEX 5, Marseille, France.
| | - Boris Tufegdzic
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO box 112412, Abu Dhabi, United Arab Emirates.
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49
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van Delft LMM, Bor P, Valkenet K, Slooter AJC, Veenhof C. The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Movement Behavior During Hospitalization. Phys Ther 2020; 100:2090-2098. [PMID: 32915985 PMCID: PMC7720640 DOI: 10.1093/ptj/pzaa160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Hospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior. METHODS This prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data. RESULTS Patient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures. CONCLUSION The implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting. IMPACT Inpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.
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Affiliation(s)
| | - Petra Bor
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Centre Utrecht, Utrecht University; and UMC Utrecht Brain Center, Utrecht University
| | - Karin Valkenet
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Centre Utrecht, Utrecht University
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht University; and UMC Utrecht Brain Center, Utrecht University
| | - Cindy Veenhof
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Centre Utrecht, Utrecht University; and Research Group Innovation of Human Movement Care, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
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50
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Cunningham BP, Ali A, Parikh HR, Heare A, Blaschke B, Zaman S, Montalvo R, Reahl B, Rotuno G, Kark J, Bender M, Miller B, Basmajian H, McLemore R, Shearer DW, Obremskey W, Sagi C, O'Toole RV. Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:235-243. [PMID: 32797351 DOI: 10.1007/s00590-020-02759-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. METHODS This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). RESULTS Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. CONCLUSION An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA. .,TRIA Orthopaedics, Bloomington, MN, USA. .,Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA. .,, Saint Paul, MN, 55101, USA.
| | - Ashley Ali
- Florida Orthopaedic Institute, Tampa, FL, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Austin Heare
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA.,Department of Orthopaedic Surgery, University of Miami Health System, Miami, FL, USA
| | - Breanna Blaschke
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA.,TRIA Orthopaedics, Bloomington, MN, USA
| | - Saif Zaman
- Department of Orthopaedics, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ryan Montalvo
- Department of Orthopaedics, R Adam Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MA, USA
| | - Bradley Reahl
- Department of Orthopaedic Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Giuliana Rotuno
- Department of Orthopaedic Surgery, University of South Florida College of Medicine, Tampa, FL, USA
| | - John Kark
- Department of Orthopaedic Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Mark Bender
- Department of Orthopaedic Surgery, University of South Florida College of Medicine, Tampa, FL, USA
| | - Brian Miller
- Department of Orthopaedic Trauma, Sonoran Orthopaedic Trauma Surgeons, Scottsdale, AZ, USA
| | - Hrayr Basmajian
- Department of Orthopaedics, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ryan McLemore
- Clinical Outcomes and Data Engineering Technology, Phoenix, AZ, USA
| | - David W Shearer
- Department of Orthopaedic Surgery, San Francisco General Hospital, University of CA - San Francisco, San Francisco, CA, USA
| | - William Obremskey
- Department of Orthopaedics, Vanderbilt University, Nashville, TN, USA
| | - Claude Sagi
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA, USA.,Department of Orthopaedic Trauma, University of Cincinnati, Cincinnati, OH, USA
| | - Robert V O'Toole
- Department of Orthopaedics, R Adam Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MA, USA
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