Accelerated Recovery Program for Patients with Polysegmental Degenerative Lumbar Spine Disease

Abstract

The aim of the study was to evaluate the effectiveness of the accelerated recovery program for patients with polysegmental degenerative diseases of the lumbar spine.Materials and Methods. This prospective study included 53 patients who underwent two-level transforaminal interbody fusion in the L II -S I segments. Two groups were identified: in group 1 (n=24), operations were performed using the accelerated recovery program; in group 2 (n=29), open rigid stabilization was used under traditional intravenous anesthesia. The end-point parameters were the number of bed-days spent in the hospital after the operation, the number of perioperative surgical complications and adverse effects of anesthesia, and the number of re-hospitalizations within 90 days. We also recorded the time of patient activation, the level of pain around the operated zone (using a visual analogue scale), and the quality of life in the long-term postoperative period (median 18 months); the latter was assessed using the SF-36 questionnaire (physical and psychological components of health).Results. Patients under the accelerated recovery program were found to have a shorter duration of surgery and anesthesia, less blood loss, lower amounts of injected opioids, faster verticalization, and a reduced period of inpatient treatment (p<0.05 for all parameters). As compared to group 2, patients in group 1 had a lower level of pain in the surgery zone (p<0.05), better long-term indicators of the physical and psychological components of health (p<0.05), a lower number of anesthesia-associated adverse events (p<0.05), and a lower rate of postoperative complications (p<0.05). During the 90-day postoperative observation, four patients of group 2 (13.8%) were urgently referred to a medical institution for additional medical care.Conclusion. The accelerated recovery program for two-level interbody fusion showed its safety and high clinical efficiency in the treatment of patients with polysegmental degenerative diseases of the lumbar spine. The program can be used in any center for spine surgery where effective interaction between polyvalent medical and nursing teams is maintained.

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.…”

“…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).…”

“…=90-day opioid consumption, EBL, operative time, LOS Julien-Marsollier et al 2020 [ 38 ] Retrospective 163 patients (< 18 age): -Fast-track group ( n = 81, mean age 15 ± 2, 81.5% females); −Non-fast-track group ( n = 82, mean age 15.3 ± 1.8, 82.9% females) Yes Posterior fusion for AIS NR NR NR 4 days Opioid side effects (56.8% constipation, PONV), pain intensity, wound infection NR 30 days ↓LOS (4 vs. 7 days), morphine consumption (25 and 35% at days 2 and 3), constipation at day 3 (56.8% vs. 73.2%), pain intensity at rest and movement at days 2 and 3 in fast-track group vs. non-fast-track group. =morphine consumption at day 1, PONV, wound infection Kalinin et al 2021 [ 39 ] Prospective 53 patients: -Fast-track group (n = 24, mean age 58, 10 females); −Non-fast-track group ( n = 29, mean age 55, 11 females) Yes Two-level transforaminal interbody fusion (dorsal decompression and stabilization surgeries) for polysegmental degenerative diseases of the lumbar spine (lower back pain and radicular clinical symptoms, involvement of two adjacent vertebral segments, and absence of improvement after conservative treatment for 6–8 weeks) L2, L3, L4, L5, L6, S1 Diabetes, arterial hypertension, kidney diseases, lung diseases, coronary artery disease NR NR 1 bradycardia, 1 dizziness, 1 nausea, 1 venous thromboembolic complication, pseudoarthrosis No re-hospitalization 18 months ↓Operative time (168 vs. 256 min), anesthesia time (185 vs. 270 min), EBL (75 vs. 180 ml), agents administered for anesthesia-0.005% fentanyl (20.0 vs. 31 ml), verticalization time (1 vs. 2 days), duration of inpatient treatment (9 vs. 10 days), pain, complication, ICU and ↑quality of life indicators, physical and psychological components of health in fast-track group vs. non-fast-track group Kerolus et al 2021 [ 40 ] Retrospective 299 patients: -Fast-track group ( n = 87, mean age 62.44 ± 11.66, 51 females); −Non-fast-track group ( n = 212, mean age 60.17 ± 13.21, 116 females) Yes Elective single-level MIS-TLIF (with bilateral pedicle screw fixation) for degenerative disease NR NR NR 3.13 ± 1.53 days 12.6% delirium, 48.3% urinary retention 0 90 days reoperation, 5.7% 30 days readmission 20 months ↓LOS (3.13 ± 1.53 vs. 3.71 ± 2.07 days), total daily average MME (50.55 ± 63.48 vs. 91.18 ± 99.76 MME), total admission MME (252.74 ± 317.38 vs. 455.91 ± 498.78), opioid consumption...…”

“…Pain management (> 30 MED of opioids for > 4 weeks), sleep medicine (scoring > 2 on STOP-BANG questionnaire), endocrine clearance (serum glucose > 200 g/dl or HbA1c > 8%), nutritional consultation (BMI < 18.5 or > 25 kg/m2 or with serum albumin level < 3.5 g/dL) NR Carbohydrate load (gatorade, day before surgery and 2 h before arriving at hospital) NR NR Anesthesia, multimodal pain therapy (gabapentin 600 mg at day 0), catheters limited NR NR Jazini et al 2021 [ 37 ] General informations and no smoking. Medical, cardiology, nutritional, pain management physicians consultations NR Yes 600 mg gabapentin, 1000 mg acetaminophen, 200 mg celecoxib, 750 mg methocarbamol, 15 mg extended-release morphine Carbohydrate rich drinks the night before surgery and 4 h prior to surgery, clear liquids until 2 h prior to surgery Anesthesia monitored (transversus abdominis plane blocks) or TIVA if necessary, antibiotics, local anesthetics, 0.25% bupivacaine with epinephrine (into local subcutaneous and intramuscular tissues), long-acting opioids, opioid patient-controlled analgesia, IV opioid analgesia for breakthrough pain Normothermia (35 °C), 2 g IV magnesium bolus, 10 mg/kg TXA bolus (EBL > 200 cc), IV lidocaine and ketamine drips, normoeuvolemia (hemodynamic monitoring, goal-directed fluids, lactated ringers) 4 mg ondansetron, scopolamine patch Julien-Marsollier et al 2020 [ 38 ] General informations NR Fasting minimization, systematic iron supplementation (if hemoglobin < 14 g dl-1), recombinant erythropoietin Oral 800 mg gabapentin Clear-liquid carbohydrate loading (apple juice and water until 2 h prior to surgery), antibiotics Anesthesia (dexmedetomidine and ketamine) and maintenance (sevoflurane in a 50% mixture of O 2 /N 2 O, bispectral index values 40–60), nonopioid analgesia (30 min before the end of surgery, IV or oral paracetamol 15 mg kg-1 6 h, IV ketoprofen 1 mg kg − 1 8 h or oral ibuprofen 10 mg kg − 1 6 h, nefopam 0.25 mg kg − 1 6 h, dexamethasone 0.15 mg kg − 1, 5μgkg − 1 intrathecal morphine) TXA 10 mgkg − 1 and continuous infusion of 5mgkg − 1 h − 1, muscle relaxant, maintenance IV fluid (Ringer’s lactate), normothermia (36.5°-37 °C, double warmer system), sufentanil boluses (arterial pressure and heart rate within 20% of preoperative values), transfusion target Hb = 8gdL − 1 Ondansetron 0.1 mg kg − 1 8 h Kalinin et al 2021 [ 39 ] General informations and no smoking. Anesthesiologist consultation NR Fasting Avoid premedication Solid food 6 h before surgery, fluids 2 h before, antibiotic prophylaxis (2 h before the first incision) Dexmedetomidine (to control depth of anesthesia), sugammadex (for fast and effective reversal...…”

Patients Older Than 75 Years Undergoing Polysegmental Lumbar Fusion Surgery Can also Benefit from Enhanced Recovery After Surgery Program

“…As a result, the number of multi-segment lumbar fusion surgery is gradually increasing. 20 , 23 , 24 However, multi-segment lumbar fusion is often associated with intense stress responses caused by surgery and delayed long-term functional recovery. Notably, there is an increased risk of postoperative complications.…”