Key Elements to Safely Transition from Inpatient to Outpatient Spine Surgery

17 Key Elements to Safely Transition from Inpatient to Outpatient Spine Surgery

Richard Wohns

Summary

This chapter is a guide to build and transition from the inpatient to the outpatient setting. This is a common practice in some well-developed countries. However, we are certain that using this chapter, the readers not only in the US but around the world would be able to potentially replicate the model suggested by the author.

Keywords: ambulatory surgery ambulatory center outpatient surgery outpatient spine surgery ambulatory spine surgery spine center

17.1 Proper Procedure Choices

The cost-effectiveness of select outpatient spine procedures is well documented.1^,²^,³^,⁴ However, the keys to success lie in patient and case selection. Ambulatory surgery and outpatient surgery can be used as synonyms. However, in this chapter, we will refer to outpatient procedures to those that are done inside a special “outpatient facility” by following specific anesthesia protocols (Table 17.1). On the other hand, “ambulatory” are those procedures performed inside a hospital and where patients may or may not require to stay overnight. In the following paragraphs, we will provide a guide for specific spine procedures that can safely and effectively be transitioned to the outpatient setting.

Table 17.1 Outpatient anesthesia protocol example

1.Specific protocols should be established for pre-, intra-, and postsurgery

2.An overall anesthesia and analgesia plan should be established preoperatively

3.Patient should be allowed to eat solids for up to 6 hours prior to surgery

4.Preoperative analgesia is mandatory to reduce nausea postoperatively

5.Analgesia and anesthesia protocols will be different, depending on the surgery/insult expected (MIS TLIF vs. MIS tubular decompression)

6.Patients should be educated to manage mild or strong analgesics after surgery

7.The panel of anesthesiologist should approve the protocols

8.Patients with any of the following are EXCLUDED from “outpatient” management:

○NYHA 3–4

○Angina

○ASA grade 4

○Excessive anxiety during medical procedures

○Inability to take care of themselves or not having someone at home to take care of them for at least the first 24 hours post procedure

Abbreviations: ASA, American Society of Anesthesiologists; MIS TLIF, minimally invasive transforaminal lumbar interbody fusion; NYHA, New York Heart Association.

17.2 Lumbar Spine

17.2.1 Laminoforaminotomy with or without Microdiscectomy

Zahrawi was the first to report performing an outpatient lumbar microdiscectomy in 1985. He reported on 103 consecutive patients on whom which he performed this procedure via a 1-inch incision and patients were discharged a few hours after the procedure. He reported 88% excellent and good results and concluded that this procedure can be safely performed as an outpatient procedure.¹ This was further corroborated by Asch et al.² However, via bivariate and multivariate analyses, they found workers’ compensation status and older age had a negative effect on outcome. A larger cohort of patients (713) who underwent outpatient microdiscectomy reported that the complication rate following outpatient microdiscectomy is low, consisting mostly of recurrent herniation (6.4%).³ Pugely et al found higher unadjusted and adjusted overall complication rates in patients who underwent microdiscectomy in the inpatient setting versus those who underwent surgery in the outpatient setting.⁴ In fact, inpatient hospital stay was an independent risk factor. Other risk factors included older age, presence of diabetes mellitus, preoperative wound infection, blood transfusion, and operative time.⁴

Because of reported regional ischemia associated with even short duration microdiscectomies in young patient, minimally invasive technical refinements have been advocated toward the transition to outpatient spine surgery, specifically via tube surgery. However, a prospective randomized trial that compared outcomes of tubular microdiscectomies with conventional microdiscectomies found no difference in disability.⁵ Although patients undergoing tube surgery reported higher visual analog scale (VAS) back and leg pain, this difference was not clinically significant. There was no difference in reoperation rates between the two groups.

Bekelis et al assessed the cost of inpatient compared to outpatient microdiscectomy and reported mean total charges of inpatient microdiscectomy to be $29,906, compared to $13,107 for outpatient microdiscectomies.⁶

As demonstrated, microdiscectomy is likely more cost-effective when performed in the outpatient setting compared to the inpatient setting. Actually, performing these procedures in the inpatient setting may be an independent risk factor for postoperative complications. Patient variables that may portend a higher complication rate include older age, history of diabetes mellitus, preoperative wound infection, anemia, and workers’ compensation status. We recommend that patients with these risk factors be operated on in the inpatient setting.

Outpatient and ambulatory surgeries are becoming increasingly prevalent, as are corresponding surgery centers. The success of this type of surgery as well as the recent interest in the wake of spinal fusion surgery is based on advances made in the perioperative management of pain, as outlined in Michael Wang’s Chapter 16 on ERAS.

17.2.2 Laminectomy (One or Two Level) and Interspinous Process Devices (IPD)

Multiple studies have reported that multilevel laminectomies can be safely performed in the outpatient setting. Yen and Albargi reported on 41 and 82 patients who underwent single or multilevel laminectomies before and after full implementation of their outpatient spine surgery protocol respectively.7 In the postprotocol cohort, patients were assigned to outpatient surgery based on two factors: (1) American Society of Anesthesiologists (ASA) of 3 or less and (2) availability of someone to help perform homemaking activities. None of the patients designated to have outpatient surgery required overnight stay. Also, there were no 30-day readmissions in this cohort.

To further hone in on patient selection, one study assessed a database of 2,358 patients who underwent laminectomy for lumbar spinal stenosis between 2011 and 2012.⁸ They reported independent risk factors for prolonged hospital stay after multivariate analysis were increased age, increased body mass index (BMI), ASA class of 3–4, and preoperative hematocrit of less than 36.0.

From a technical standpoint, the merit of minimally invasive unilateral laminectomy for bilateral decompression toward minimizing soft tissue trauma, and hence improving postoperative outcomes, has been a point of contention. Phan and Mobbs performed a systematic review and meta-analysis comparing this approach with the traditional open laminectomy. They reported a higher satisfaction rate, lower VAS back pain score, less blood loss, and shorter hospital stay in the minimally invasive approach compared to the traditional approach.⁹ Furthermore, Schöller et al reported that minimally invasive decompression in patients with degenerative spondylolisthesis, compared to traditional open laminectomy, is associated with lower reoperation and fusion rates, less slip progression, and greater patient satisfaction.¹⁰

For low-demand elderly patients with good general health and minimal comorbidities who are candidates for decompressive surgery, an IPD may be a viable option. A little over a decade ago, IPDs were introduced as a minimally invasive method for treating lumbar spinal stenosis (LSS) in patients who were poor surgical candidates and whose symptoms abated with forward flexion.¹¹^,¹² The biomechanical rationale behind these devices is fairly intuitive. IPDs were subsequently introduced into the market showing promise with pain and functional outcomes between minimally invasive surgery (MIS) decompression and X-STOP (early generation IPD) being equivalent.¹³ However, over time, X-STOP was found to be associated with unacceptably high revision rates of up to 30%.¹⁴^,¹⁵ Most recently, a systematic review and meta-analysis of randomized controlled trials comparing IPD alone to decompressive surgery for LSS concluded that IPD alone was less cost-effective than traditional decompression alone.¹⁶

Newer generation technologies have been more encouraging; most notably the Coflex Interlaminar Stabilizing System (ILS). A recent meta-analysis showed decompression and Coflex was more effective than decompression and instrumented fusion in terms of Oswestry Disability Index (ODI), length of stay, and blood loss for patients with stenosis due to degenerative spondylolisthesis.¹⁷ However, the role of IPDs is still being defined in the spectrum of surgical treatment options for LSS with or without instability and should be cautiously utilized in the outpatient setting.

In conclusion, we believe most one- and two-level laminectomies and IPD implants can be safely transitioned to the outpatient setting. Utilizing minimally invasive techniques may enhance this transition. We recommend to be cautious when performing these outpatient procedures on patients >60 years of age, with a BMI >35, ASA class 3–4, and with preoperative anemia. Perhaps, these procedures should be performed in the inpatient setting.

17.2.3 MIS TLIF with Percutaneous Pedicle Screw Fixation

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