Enhanced recovery after surgery pathway reduces the length of hospital stay without additional complications in lumbar disc herniation treated by percutaneous endoscopic transforaminal discectomy

Abstract

Background Enhanced recovery after surgery (ERAS) pathway in spine surgery is increasingly popular which can reduce the length of hospital stay (LOS). However, there are few studies on the safety and effectiveness of ERAS pathway in the treatment of single-level lumbar disc herniation (LDH) by percutaneous endoscopic transforaminal discectomy (PETD). The aim of this study was to investigate whether ERAS can reduce LOS of patients with single segment LDH treated by PETD. Methods We reviewed the outcomes of all LDH patients (L4/5) who had been treated with PETD at our institution. Quasi-experimental study was adopted between patients treated in an ERAS after PETD with those rehabilitated on a traditional pathway. The two groups were analyzed for LOS, operation time, complications, visual analog scale (VAS), Oswestry Dysfunction Index (ODI), hospitalization expenses (HE), and improved MacNab efficacy assessment criteria (MacNab). Results A total of 120 single segment LDH patients (ERAS pathway 60 cases, traditional care pathway 60 cases) who were selected from January 2019 to January 2021 met the inclusion criteria. There was a significant difference in mean LOS postoperative VAS scores and ODI on the 3rd day after surgery between the two groups (P < 0.05). The incidence of complications and HE were similar in the two groups (P > 0.05). The mean LOS decreased from 3.47 ± 1.14 days to 5.65 ± 1.39 days after application of ERAS pathway (P < 0.05). Conclusions The ERAS pathway reduced LOS without resulting in additional complications after PETD. These findings support the application of the perioperative ERAS pathway in the treatment of single-level LDH with PETD. Level of evidence Level IV, therapeutic

Fast-track protocols for patients undergoing spine surgery: a systematic review

“…In our quality assessment for spine surgery the 44% [ 15 , 23 , 27 , 29 , 32 – 38 , 40 – 42 , 46 – 49 , 51 , 55 , 56 , 61 , 67 , 68 , 70 ] of the studies were rated strong, 25% [ 17 , 18 , 21 , 22 , 25 , 28 , 31 , 39 , 43 , 44 , 60 , 62 , 63 , 65 ] were rated moderate, and 32% [ 16 , 19 , 20 , 24 , 26 , 30 , 45 , 50 , 52 – 54 , 57 – 59 , 64 , 66 , 69 , 71 ] were rated weak. Methodological weaknesses that led to moderate or weak quality scores often included the lack of a sample size justification, power description, or variance and effect estimates, the lack of subjects selected or recruited from the same population, the lack of results evaluation more than once over in time, the lack of blinded assessor and the lack of measurement of potential confounding variables.…”

“…Subsequently, for maintenance of anesthesia, inhalational agents such as sevoflurane, isoflurane and desflurane, or intravenous opioid agents such as sufentanil or remifentanil infusions were used. In 21% of studies, a local anesthesia with anesthetic agents as bupivacaine, lidocaine or ropivacaine was employed [ 18 , 27 , 28 , 33 , 35 , 45 , 48 , 63 , 65 , 66 , 70 , 71 ]. Regarding analgesia management, pain scores were tracked in 30 studies.…”

“…Regarding analgesia management, pain scores were tracked in 30 studies. A significant reduction in pain through visual analog scale (VAS) score, was observed with the fast-track protocols in 40% of studies [ 18 , 21 , 23 , 27 , 31 – 33 , 35 – 39 , 41 , 42 , 45 , 47 , 48 , 55 , 60 – 62 , 65 , 71 ]. The pain reduction during fast-track pathways were associated to pre-emptive and postoperative analgesia use and to intraoperative local analgesics infiltration (LIA).…”

“…=satisfaction, complications (overall, major, minor), 30 days readmission, 30- to 90 days readmission, 90 days reoperation DeVries et al 2020 [ 26 ] Retrospective 244 patients: -Fast-track group ( n = 131, mean age 15.3 ± 1.9, 78.6% females); −Non-fast-track group ( n = 113, mean age 15.2 ± 2.0, 77.0% females) Yes PIF for AIS NR NR NR 3.4 days 50% (2/4) wound complications (surgical site drainage), 50% (2/4) wound dehiscence 66.6% (2/3) screw misplacement and/or removal, 33.3% (1/3) deep wound infection requiring irrigation and debridement, 40.0% (4/10) constipation, 20.0% (2/10) syncope, 10.0% (1/10) pain, 30.0% (3/10) other 30 days ↓LOS (3.4 vs. 5.2 days), patient-controlled analgesia discontinuation (51.7 vs. 62.0 h), catheter discontinuation (1.9 ± 0.3 vs. 2.4 ± 0.6 days), standing initiated (1.0 ± 0.09 vs. 1.9 ± 0.6 days), walking initiated (1.9 ± 0.3 vs. 3.0 ± 0.9 days), and ↑curve magnitude (67.5 ± 13.3° vs. 62.3 ± 10.8°), curve correction (45.8 ± 13.8° vs. 38.2 ± 12.1°) in fast-track group vs. non-fast-track group. =complications, 30 days readmission, 30 days reoperation, 30 days visit, EBL Duojun et al 2021 [ 27 ] Retrospective 120 patients: -Fast-track group (n = 60, mean age 47.92 ± 5.89, 28 females); −Non-fast-track group ( n = 60, mean age 48.60 ± 5.80, 31 females) Yes PETD for adult single-level LDH L4/5 Obesity or intervertebral foraminal stenosis NR 3.47 ± 1.14 days 1 nerve damage, 1 incision infection, 2 lumbar and leg pain, 1 respiratory infection, 1 gastrointestinal reactions NR NR ↓LOS (3.47 ± 1.14 vs. 5.65 ± 1.39 days), VAS pain score (2.25 ± 0.82 vs. 3.33 ± 0.60 at day 1, 1.87 ± 0.50 vs. 3.07 ± 0.66 at day 2, 1.47 ± 0.54 vs. 2.25 ± 0.47 at day 3) in fast-track group vs. non-fast-track group. =complications, ODI, operative time, costs Feng et al 2019 [ 28 ] Retrospective 74 patients: -Fast-track group ( n = 44, mean age 61 ± 10, 63.6% females); −Non-fast-track group (n = 30, mean age 59 ± 9, 70% females) Yes MIS-TLIF (ipsilateral side facetectomy, and interbody fusion with unilateral access, bilateral MIS decompression with unilateral approach, pedicle screws percutaneous via bilateral approaches) for adult lumbar spinal stenosis, spondylolisthesis, degenerative lumbosacral spine diseases, radiculopathy, or neurogenic claudication L3–4, L4–5, L5-S1 Diabetes mellitus, chronic cardiovascular disease NR 5 days 4.5% (1 cage migration without symptoms, 1 epidural hematoma with radiculopathy) 0 30 days readmission, 1...…”

“…Multidisciplinary consultation NR Modern fasting (until 6 h prior to surgery, clear liquids up to 2 h before, carbohydrate supplementation) Limited premedication Hospitalization, anti-infection prophylaxis Short-acting anesthetics, pre-emptive analgesia Use of drains limited NR Debono et al 2021 [ 25 ] General informations. Multidisciplinary consultation NR Modern fasting Taken limited medication Hospitalization, anti-infection prophylaxis (disinfection protocol) Pre-emptive analgesia No drain NR DeVries et al 2020 [ 26 ] General informations NR NR NR NR Intrathecal morphine NR NR Duojun et al 2021 [ 27 ] Oral and written education. Psychological consultation NR Diet (no water deprivation), prevention of gastrointestinal reactions (serotonin receptor antagonists) NR Skin preparation, 0.07–0.08 mg/kg midazolam (1 h before, 0.05–0.06 mg/kg in patients > 60 yr), oral 400 mg celecoxib (200 mg in patients > 70 yr or with BMI < 25 kg/m2) Local anesthesia (1% lidocaine with maximum amount of 300 mg, 4 mg IV ondansetron hydrochloride), analgesia (40 mg IV parecoxib sodium, local subcutaneous injection of ropivacaine) Normothermia (36 °C, insulation blanket, heating fan), vascular condition control 4 mg IV ondansetron hydrochloride Feng et al 2019 [ 28 ] General informations (handout) NR Fasting carbohydrate loading (6 h for liquids, 8 h for solid food and short-chain polypeptides drinks, 2 h for clear liquids) NR Pre-emptive analgesia (oral celecoxib 200 mg and pregabalin 150 mg 1 h before), antimicrobial prophylaxis (1.5 g cefuroxime 1 h before) LIA (ropivacaine), catheters TXA, normovolemia (goal-directed fluid administration), normothermia (> 36 °C, convective warming device) NR Flanders et al 2020 [ 29 ] Written general information.…”