Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

Nicholas D. Fletcher, MD; Michael P. Glotzbecker, MD; Michelle Marks, PT, MA; Peter O. Newton, MD

Disclosures

Spine. 2017;42(9):E547-E554. 

In This Article

Abstract and Introduction

Abstract

Study Design. Delphi process with multiple iterative rounds using a nominal group technique.

Objective. The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

Summary of Background Data. Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.

Methods. An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

Results. Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.

Conclusion. We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

Level of Evidence: 5

Introduction

Posterior spinal fusion (PSF) has become the standard of care for nearly all patients with severe adolescent idiopathic scoliosis (AIS) over the past two decades. AIS patients are uniquely homogeneous within pediatric orthopedics, as most patients are of a similar age and have few comorbidities. Techniques for preoperative planning,[1–4] patient preparation,[5,6] infection prevention,[7–9] blood loss management,[10–15] and surgical correction have become increasingly standardized.[16,17] Length of surgery and estimated blood loss, metrics that may be used for the reproducibility of a surgery, have also become less variable.

Despite significant advances in the care of these patients, length of postoperative stay has remained relatively long,[18–24] especially when compared with similarly standardized techniques in populations who often carry many more comorbidities such as total joint replacement[25,26] or spinal surgery for degenerative spinal conditions.[27–36] Recent studies have suggested that standardization of postoperative processes can reduce length of stay by nearly 50% when compared with more traditional pathways after surgery for AIS.[16,17] Although these novel pathways have begun to see implementation, there are no consensus-based data on postoperative management of patients with AIS after PSF that is widely applicable to the majority of centers. We hypothesized that the use of the Delphi method based on expert opinion would result in consensus surrounding various aspects of postoperative care following PSF for AIS.

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