Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective
Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration.
We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques. Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups. Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group. We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope.
The purpose of this study is to determine whether the mode of anaesthesia chosen for patients undergoing lumbar microdiscectomy surgery has any significant influence on the immediate outcome in terms of safety, efficacy or patient satisfaction. This prospective randomised study compared safety, efficacy and satisfaction levels in patients having spinal versus general anaesthesia for single level lumbar microdiscectomy. Fifty consecutive healthy and cooperative patients were recruited and prospectively randomised into two equal groups; half the patients received a spinal anaesthetic (SA), the remainder a general anaesthetic (GA). Each specific mode of anaesthesia was standardised. Comprehensive post-operative evaluation concentrated on documenting any complications specific to the particular mode of anaesthesia, recording the pace at which the various milestones of physiological and functional recovery were reached, and the level of patient satisfaction with the type of anaesthesia used. The results showed no serious complication specific to their particular mode of anaesthesia in either group. Thirteen out of 25 SA patients required temporary urinary catheterisation (9 males, 4 females) while among the GA group 4 patients required urinary catheterisation (4 males and 1 female). Post-operative pain perception was significantly lower in the SA group. The SA patients achieved the milestones of physiological and functional recovery more rapidly. While both groups were satisfied with their procedure, the level of satisfaction was significantly higher in the SA group. In conclusion, lumbar spinal microdiscectomy can be carried out with equal safety, employing either spinal or general anaesthesia. While they require more temporary urinary catheterisation associated with the previous use of intrathecal morphine, patients undergoing SA suffer less pain in association with their procedure and recover more rapidly. Blinded to an extent by not having experienced the alternative, both groups appeared satisfied with their anaesthetic. However, the level of satisfaction was significantly higher in the SA group.
Background. Surgical site infection following spine surgery is associated with increased morbidity, mortality and increased cost for the health care system. The reported pooled incidence is 3%. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and often involve the lumbar spine. Accordingly, the objective was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column of the same lumbar vertebra using microdialysis in an experimental porcine model. Method. The lumbar vertebral column was exposed in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously over 10 min. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. Microdialysis is a catheter-based pharmacokinetic tool, that allows dynamic sampling of unbound and pharmacologic active fraction of drugs e.g., cefuroxime. The primary endpoint was the time with cefuroxime above the clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL as this has been suggested as the best predictor of efficacy for cefuroxime. The secondary endpoint was tissue penetration (AUC. tissue. /AUC. plasma. ). Results. Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48). Conclusions. Open
Although patient-reported outcomes (PROs) have become increasingly important in the evaluation of spine surgery patients, interpretability may be limited by a patient's ability to recall pre-intervention impairment. The accuracy of patient recall of preoperative back pain, leg pain, and disability after spine surgery remains unknown. We sought to characterise the accuracy of patient recall of preoperative symptoms in a cohort of
Introduction. This study investigates the effect of somatisation on results of lumbar surgery. Methods. Pre- and post-operative data of all primary discectomies and posterior lumbar decompressions were prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year. Results. There were a total of 320 patients (average age 49.7 years). Pre-operatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up. All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively). At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers. The post-operative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0). The post-operative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5). In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7). These differences are statistically significant. Discussion. Patients with features of somatisation are severely functionally impaired pre-operatively. One year following
