Study Design. A retrospective cohort study of prospectively collected data. Objective. The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. Summary of Background Data. ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. Methods. An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. Results. The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195–398 minutes] overall, 298 minutes (IQR 192–811) for lumbar decompression and 285 minutes (IQR 200–372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). Conclusion. This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. Level of Evidence: 3
Newer navigation protocols that rely on intraoperative CT registration have improved the accuracy of imaging models and allowed surgeons to rely less on fluoroscopy. Despite concerns regarding ionizing radiation exposure to the patient, use of CT navigation systems was found to reduce radiation exposure by more than 90% compared to traditional fluoroscopic guided percutaneous surgical techniques (1). Furthermore, the surgeon's exposure to radiation is almost eliminated, as the surgeon does not need to be close to the patient during the CT image registration.The accuracy of navigation has also undergone a huge amount of progress. In addition to higher quality registration, the use of stereotactic 3D cameras allows the system to predict relative position between instruments and anatomical landmarks in real time with higher reliability (2). Amiot et al. and Yu et al. (3,4). both demonstrated that freehand pedicle screw (PS) placement had a higher rate of error and reoperation compared to navigation assisted placement. The same results were reflected in a meta-analysis of 12 studies conducted by Shin et al. (5) However, many other meta-analyses in the literature have failed to demonstrate superiority of computer assisted navigation to free hand PS instrumentation perhaps due to the heterogeneity of studies included. The accuracy of navigation has also undergone a lot of progress. In additional to higher quality registration, the use of stereotactic 3D cameras allows the system to predict relative position between instruments and anatomical landmarks in real time with higher reliability (2). Amiot et al. and Yu et al. (3,4) both demonstrated that freehand PS placement had a higher rate of error and reoperation compared to navigation assisted placement. Shin et al. completed a meta-analysis of 12 studies which also reflected the same results (5). However, many other meta-analyses in the literature have failed to demonstrate superiority of computer assisted navigation to free hand PS instrumentation perhaps due to the heterogeneity of studies included.Navigation systems rely on the use of reference trackers to keep the registration image in sync throughout the operation regardless of the positioning of the patient. Multiple modalities of anatomic tracking are in use. Pin trackers that are inserted into bony landmarks allow for accurate mapping with relatively few trackers, however
BACKGROUND Sagittal alignment is an important consideration in spine surgery. The literature is conflicted regarding the effect of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) on sagittal parameters and the role of expandable cage technology. OBJECTIVE To compare lordosis generated by static and expandable cages and to determine what factors affect postoperative sagittal parameters. METHODS Preoperative regional lordosis (RL), segmental lordosis (SL), and posterior disc height (PDH) were compared to postoperative values in single-level MI-TLIF performed using expandable or static cages. Patients were stratified based on preoperative SL: low lordosis (<15 degrees), moderate lordosis (15-25 degrees), and high lordosis (>25 degrees). Regression analyses were conducted to determine factors associated with postoperative SL and PDH. RESULTS Of the 171 patients included, 111 were in the static and 60 in the expandable cohorts. Patients with low preoperative lordosis experienced an increase in SL and maintained RL regardless of cage type. Those with moderate to high preoperative lordosis experienced a decrease in SL and RL with the static cage, but maintained SL and RL with the expandable cage. Although both cohorts showed an increase in PDH, the increase in the expandable cohort was greater. Preoperative SL was predictive of postoperative SL; preoperative SL, preoperative PDH, and cage type were predictive of postoperative PDH. CONCLUSION Expandable cages showed favorable results in restoring disc height and maintaining lordosis in the immediate postoperative period. Preoperative SL was the most significant predictor of postoperative SL. Thus, preoperative radiographic parameters and goals of surgery should be important considerations in surgical planning.
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