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

Discussion

Development of perioperative guidelines for patients undergoing PSF for AIS has, until recently, fallen on individual hospitals with little support from the orthopedic literature. Surgeons have typically carried on the dogma from which they were trained. Decisions such as when to transition patients to oral narcotics, when to initiate oral feeds, or when to remove a drain are often rationalized by personal experience or hospital culture rather than evidence-based guidelines. A general lack of literature concerning these "softer" components of the postoperative period have been overshadowed by numerous studies on how to maximize deformity correction or which perioperative antibiotics to give. We hypothesized that the use of a nominal group technique to take advantage of the significant experience of 21 high-volume spinal deformity surgeons would result in the creation of a series of consensus-based guidelines representing the current best practice in care of AIS patients while providing some direction for future studies. This process has been described in multiple other situations and has recently been the foundation for a consensus statement of infection prevention in AIS,[7,8] surgical care for AIS,[38] and indications for surgical management in degenerative lumbar scoliosis.[39] Reducing the variability in care using protocols and pathways has resulted in improvements in quality throughout medicine by standardization of care.[40–45]

As has been previously described, the Delphi process permits discussion and participants may change their opinion based on the review of pertinent literature and face-to-face interaction.[37] Only 6 of original 25 questions resulted in consensus defined as >80% agreement. These included allowing the patient to sit on the side of the bed beginning on POD#1 (100% agree), ambulate on POD#1 (86%), work with physical therapy every day (86%) with 90% recommending that this occur twice each day, initiating a postoperative bowel regimen (90%), and routinely prescribing an antiemetic in the hospital (86%). After two group meetings, this increased to 19 with several statements being modified on the basis of the group discussion (Table 1).

Consensus was met on the decision to transfer routine scoliosis surgeries to the surgical floor rather than the intensive care unit (ICU) despite only a few studies supporting this practice.[16,17,46] Shan et al.[24] compared 66 patients cared for in the ICU with 58 treated on the general floor and found that the latter group required less postoperative analgesia and anxiolytics, received fewer laboratory tests and physical therapy sessions, and a shorter hospital stay that resulted in a lower hospital charge. No patient required transfer from the floor to the PICU.[24]

A significant amount of time was spent discussing perioperative pain control. Forty-four percent of the group felt that consulting a formal pain management team was not necessary after surgery. Consensus was met on the use of a PCA pump rather than a surgically placed epidural catheter despite a modest amount of literature supporting the latter's efficacy. A number of studies have suggested superior pain control with the use of single epidural,[47,48] double epidural,[49] and epidural combined with intrathecal analgesia (i.e., morphine)[50,51] when compared with PCA; however, complications such as pruritis and respiratory depression are challenging and the impact on postoperative mobility was cited by the group as a reason for not adopting this technique regularly. The experience of the group and the ability to discuss in a face-to-face manner, a central tenant of the Delphi process, resulted in the group rejecting the use of an epidural due to a sentiment that pain control was not enough to justify the delay in mobilization and possible side effects of postoperative epidural anesthesia.

Multimodal pain management was favored by the group with the use of postoperative antispasmodics (i.e., diazepam) and anti-inflammatories (i.e., ketorolac), as well as perioperative neuroleptics (gabapentin) all reaching consensus. Although Mayell et al. failed to find any improvement in pain management with a single preoperative dose of gabapentin,[52] Rusy et al. showed a significant benefit in the early postoperative period (before day 2) with the addition of a postoperative regiment of 5 mg/kg prescribed (3x/day) after an initial preoperative loading dose of 15 mg/kg.[53] Although many adult spine surgeons have strayed away from ketorolac due to concerns regarding pseudoarthrosis or bleeding, this has not been noted in studies of patients with adolescent scoliosis.[54,55] In a small randomized trial of 36 hours of postoperative ketorolac, Munro et al. documented a significantly lower pain score and earlier mobilization in patients with no bleeding or pseudoarthrosis in the ketorolac group.[56] The use of antispasmodics, although not studied to our knowledge in the scoliosis literature, was supported by the group. Also included in the consensus statement was the concept that oral analgesics should be initiated on a specific clinical day (i.e., POD#1) rather than based on a certain clinical criteria (i.e., bowel sounds) as long as the patient is tolerating some liquids by mouth. The group was able to reach consensus regarding removal of the PCA before POD#3; however, we were unable to reach agreement on a particular day with 71% favoring POD#1 and 29% favoring POD#2 and thus the specific time for transition was not included in the final consensus statement. The idea of early initiation of oral analgesics has not been formally addressed in the scoliosis literature; however, it is an integral part of the Children's Healthcare of Atlanta accelerated discharge pathway[16,17] as well as the Children's Healthcare of Philadelphia rapid recovery pathway.[57,58]

The reinstitution of an oral diet was a point of significant discussion at our initial meeting. After multiple iterations, the group settled on the statement that clear liquids may started immediately postoperatively (100% consensus) and that a regular diet may be started as soon as the patient is tolerating liquids, regardless of the presence of bowel sounds or other clinical criteria (95% consensus). No studies have evaluated this practice within the scoliosis literature; however, early feeding has been widely supported in many areas that would theoretically be higher risk than PSF with regard to ileus and bowel motility. Both the general surgical literature, including patients with abdominal trauma and colonic resection,[59,60] and major gynecologic surgery literature[61–65] has shown significant benefits of early enteral feeding after major surgery with benefits, including earlier return of bowel sounds, passage of flatus and first bowel movement with no increase in abdominal distension, diarrhea, mild ileus, or vomiting.

Postoperative bowel regimens have been advocated in most surgical specialties, but there are very limited data in pediatric spinal surgery. Smith and Smith randomized 60 patients to a preoperative bowel regimen of Nulytely and showed minor improvements in time to first bowel movement and overall distention as measured by weight gain, but the decreased length of stay was "minimal" (0.68 days shorter) and the authors recommended against implementation of a preoperative bowel regimen. Certainly, narcotic-related ileus is common postoperatively, and although rarely associated with significant complications, is a common source of discomfort for the patient. As such, the group recommended for the use of a postoperative bowel regimen to be started as soon as the patient is tolerating clear liquids. Due to the multitude of options, it was beyond the scope of this study to advocate for a specific regimen. There was consensus, based on a recently published randomized control trial by Jennings et al. touting the benefits of chewing gum for postoperative bowel motility. Patients in this study who were randomized to chewing gum had their first bowel movement 30 hours earlier than those who did not chew gum.[66] The literature is more equivocal in general surgery and gynecological surgery, with smaller trials showing benefit while larger meta-analyses have failed to do so.[67,68]

The group advocated for early removal of the Foley catheter, with 24% of surgeons favoring removal on POD#1 and 76% on POD#2. Early removal of the Foley allows the patient to mobilize quicker and may theoretically decrease the risk of postoperative infection.[69–71] In the one small investigation evaluating the link between catheterization and postoperative infection, Normelli et al.[70] randomized adult patients undergoing lumbar spinal fusion to placement of a urinary catheter versus no catheterization and found a higher rate of urinary tract infection in the catheter group.[72] Certainly, the presence of a urinary catheter has been associated with the development of a urinary tract infection in other areas of medicine[73,74] and the concern for subsequent surgical site infection (SSI) has been evaluated in the adult literature. Although consensus could not be reached on whether to remove the Foley on either the first or second postoperative day, no member of the group advocated for removal after the second day. The primary concern of surgeons advocating for later removal of the Foley was related to difficulty with ambulating to the commode on the first postoperative day, while those favoring early removal felt it helped to mobilize patients and promote walking.

The group arrived at the consensus that some form of radiograph is indicated for assessment of postoperative spinal implant positioning. All members utilize intraoperative fluoroscopy during spinal fusion to evaluate screw trajectory and hardware alignment. As such, 100% agreed that intraoperative fluoroscopy should suffice for hardware evaluation and that additional postoperative imaging while in the hospital is likely superfluous and excessive. Although not focusing specifically on perioperative radiographs taken after PSF, both Garcia et al.[75] and Pensak et al.[76] have looked at the utility of postoperative radiographs and failed to show any significant benefit in asymptomatic patients.

The group was unable to reach consensus on changing of a dry (nonsaturated) surgical bandage while the patient was in the hospital with 52% disagreeing with this practice. Although not addressed in the pediatric spinal literature, a recent Cochrane systematic review of available literature failed to show any benefit of early bandage removal at 48 hours. Drain usage is a frequently debated topic among most surgical specialties with little literature definitively supporting its usage. Multiple prospective randomized controlled trials have failed to show an advantage of drains in arthroplasty,[76] trauma,[77] or adult lumbar spine surgery.[78–80] Drain usage in neuromuscular scoliosis may have some benefit;[81] however, the data in AIS surgery are more limited with the largest retrospective series published by Diab et al. of reviewing 500 patients.[82] Approximately two-third of this group was treated without a drain with the remainder being treated with a drain. The authors mentioned that most of these drains were placed deep and approximately 50% were removed on the basis of drain output and 50% based on the duration of drain implantation. No benefit was found in the drainage group, with more patients in the drainage group requiring a transfusion (43% vs. 22%, P < 0.001). Ho et al. reviewed a 3:1 matched cohort of patients following PSF who did not develop an infection to a group of patients who developed an infection and found a three-fold increase in infection rate among patients treated without a drain.[83] Our group was able to reach a consensus that a drain was used with most surgeons advocating for a subcutaneous rather than deep drain location, although this differentiation was not part of the questionnaire. We were not able to comment on the timing of drain removal due to the lack of available literature to help determine this often debated question.

Perhaps one of the most controversial area areas that the group was able to reach consensus on was the ability to discharge patients on postoperative day #2 or #3 (with the day of surgery being POD#0) before the patient's first bowel movement. Despite a paucity of data suggesting that early discharge is related to adverse outcomes, there has been a long history of lengthy hospital stays following PSF for AIS. A recent review by Erickson et al. surveyed 38 children's hospital and found that the average length of stay was 5.2 days.[20–24,84,85] An accelerated discharge pathway, as described by Fletcher et al.,[17] takes this one step further by speeding up the transition to oral pain medication, early mobilization, and allowing discharge before the patient's first bowel movement. This has resulted in safely reducing the length of stay to 2.2 days.[16]

This study has limitations related to the fact that it is based on expert opinion that has been formed around personal experiences due to a lack of abundant data. We attempted to mitigate this through the inclusion of a relatively large number of experts in spinal deformity who practice at unique centers. The authors do represent a spinal deformity study group, however, and thus the opinions of the participants may be impacted by the regular interactions with one another at group meetings.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....