|Year : 2021 | Volume
| Issue : 1 | Page : 99-104
A prospective comparative study between day care spine surgery and conventional spine surgery
Chandra Kumar Thounaojam, Sachin A Borkar, Ravi Sharma, Manoj Phalak, Rajeev Sharma, Shashank Sharad Kale
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||24-Jun-2019|
|Date of Decision||23-Aug-2019|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||01-Oct-2020|
Sachin A Borkar
Department of Neurosurgery & Gamma Knife, All India Institute of Medical Sciences & Jai Prakash Narayan Apex Trauma Center, New Delhi.
Source of Support: None, Conflict of Interest: None
Background: Day care spine surgery though practiced in many centers around the world, is still relatively an unchartered territory here in India, with very few centers performing spine surgeries in a day care setup. Our study was conducted to assess the feasibility of day care spine surgery in our setup. Materials and Methods: This is a prospective observational study in which patients who had undergone spinal surgery (lumbar discectomies, intradural-extramedullary lesions [IDEMs] and extradural space-occupying lesions [SOLs] extending up to one and a half vertebral levels, and one or two level anterior cervical discectomy and fusion [ACDF] in a day care setting) in our department from March 2018 to December 2018, were recruited. Of the 68 patients recruited, 33 were in the day care group and 35 were in the routine group. Data was collected on type of pathology, comorbidities, spinal segment involved, type of surgical procedure; visual analog scale (VAS) score in the preoperative period, immediately after surgery, 12h after the discharge, and at suture removal, length of hospital stay, cost, conversion of the day care to a routine admission, and disability/functional outcome. Results: We found comparable surgical results and postoperative pain profile in both the groups; median VAS in the immediate post-op period was found to be 5 in the day care and 4 in the routine group, at 12h after discharge, it was found to be 4 in both the groups, and at suture removal, it was found to be 2 in both the groups. There was statistically significant decrease in hospital stay and cost with a P value of 0.001 for both. Mean length of hospital stay was 1.15 ± 0.36 days in the day care and 9.66 ± 4.76 in the routine group. Mean cost was 2142.97 rupees in the day care, whereas it was 17971.94 rupees in the routine group. There were no new onset neurological deficits in the day care group. Five cases were converted from the day care group due to various reasons. Conclusion: One and two level lumbar prolapsed intervertebral discs (PIVDs)/canal stenosis, cervical PIVDs, especially single-level PIVD, IDEMs, and extradural SOLs can be performed in a day care setting.
Keywords: Day care surgery, minimally invasive spine surgery, outpatient care, spine surgery
|How to cite this article:|
Thounaojam CK, Borkar SA, Sharma R, Phalak M, Sharma R, Sharad Kale S. A prospective comparative study between day care spine surgery and conventional spine surgery. Indian Spine J 2021;4:99-104
|How to cite this URL:|
Thounaojam CK, Borkar SA, Sharma R, Phalak M, Sharma R, Sharad Kale S. A prospective comparative study between day care spine surgery and conventional spine surgery. Indian Spine J [serial online] 2021 [cited 2021 Feb 26];4:99-104. Available from: https://www.isjonline.com/text.asp?2021/4/1/99/308212
| Introduction|| |
Day care spine surgery is still relatively an unchartered territory here in India, with very few centers performing surgeries of the spine in a day care setup. The advancements in the field of anesthesiology and surgical technologies have contributed to the rise of day care spine surgery. But with the present patient load and the waiting list getting longer and longer, especially in government hospitals, we need to consider surgical alternatives to help ease the current situation.
The advantages of day care spine surgery are as follows:
- Smaller incision and less tissue trauma
- Minimal blood loss
- Earlier return to activities and work
- Easier revision surgery because of less scar tissue in the access portal
- Less postoperative pain
- Can be carried out under general or local anesthesia with conscious sedation
- Lower cost due to shorter operating time and shorter hospital stay
- Improved utilization of hospital beds, especially in a busy clinical setup
- Lesser nosocomial infections
The various procedures of the spine that are carried out routinely in a day care setting are lumbar discectomies (microscopic/percutaneous) and anterior cervical discectomy and fusion (ACDF).,, The ACDF procedure, usually at the single level has been performed in an outpatient setting since at least the mid-nineties. It is now increasingly being carried out routinely in a day care setup, with two level ACDFs also being performed in a day care setup. In this study, we attempted to compare the outcome of day care procedure versus routine admission.
| Materials and Methods|| |
After the approval of the institutional ethics committee, a prospective observational study in which patients who had undergone spinal surgery (lumbar discectomies, intradural-extramedullary lesions [IDEMs] and extradural space-occupying lesions [SOLs] extending up to one and a half vertebral levels, and one or two level ACDF in a day care setting under general anesthesia) in our department between March 2018 and December 2018, were recruited.
Patients of both gender, older than 18 years of age with lumbar/cervical prolapsed intervertebral disc (PIVD), IDEMs, and extradural SOLs extending up to one and a half vertebral levels were included. Patients with more than two level PIVD and IDEM or extradural SOLs extending more than one and a half vertebral levels and ventrally placed in relation to the spinal cord and patients requiring redo surgery were excluded. Overall 68 patients, 33 subjects in the day care group and 35 in the routine group, satisfying the eligibility criteria were included in the study.
The subjects were screened in the outpatient department (OPD) and were allotted dates for day care surgery and subsequently followed up. The control group was recruited from the patients with similar pathology, undergoing similar procedure on a routine admission basis. These patients in the routine group had received dates for surgery before starting this study.
All of the recruited subjects were reviewed for age and sex distribution, duration of complaints, type of pathology, spinal segment involved, type of surgical procedure done; visual analog scale (VAS) score in the preoperative period, immediately after surgery, 12h after the discharge, and at suture removal; and length of hospital stay, cost incurred, conversion of the day care to a routine admission, and disability/functional outcome using standard tools such as Oswestry Disability Index (ODI) and Neck Disability Index (NDI). The conversion of the day care to a routine admission with reasons thereof and disability/functional outcome were also assessed.
Statistical analysis: Data for disability/functional outcome were collected using structured tools and were entered using CSpro (Census and Survey Processing System), U.S. Census Bureau, ICF International. Scoring system of ODI and NDI was used. All statistical data analysis was performed using STATA version 14.0 (StataCorp, College Station, Texas). Paired t test, proportion test was carried out with 5% level of significance. Rest of the parameters was assessed using Microsoft Office Excel datasheet 2016.
| Results|| |
In our study, we had 33 patients operated for various spinal pathologies on a day care basis and 35 patients on a routine basis. The bulk of the cases were lumbar PIVD or lumbar canal stenosis (LCS) in both the groups, 21 (63.64%) and 24 (68.57%), respectively, in the day care and routine group; the rest of the cases were distributed as given in [Table 1]. When the two groups were compared for age and comorbidities, the mean age in the day care group and the routine group was found to be 38.84 and 45.51 years, respectively, with a nonsignificant P value of 0.061; it was also noticed that the number of patients with comorbidities were higher in the routine group with 11 (31.43%) of the 35 cases having a chronic disease, whereas it was 4 (12.12%) of the 33 cases in the day care group as shown in [Table 2].
The VAS score was assessed before the surgery, immediately after the surgery, 12h after the discharge, and at suture removal. The median VAS in the pre-op period was found to be 9 in both day care and routine group. In the immediate post-op period, it was found to be 5 in the day care group and 4 in the routine group. At 12h after discharge, it was found to be 4 in both day care and routine group. At suture removal, it was found to be 2 in both day care and routine group. The P values were 0.989, 0.494, 0.080, and 0.925, respectively. The difference between the two groups was found to be nonsignificant [Table 3].
The mean length of hospital stay was 1.15 ± 0.36 in the day care group as five of the patients had to be converted to long admission, due to delayed extubation in three cases, severe postoperative pain in one case, and urinary retention in one case. The mean length of hospital stay was 9.66 ± 4.76 in the routine group. The P value was a significant 0.001 [Table 3]. The mean waiting period was 42.88 ± 20.89 days in the day care group, whereas it was 202.89 ± 186.47 days in the routine group. The P value was a significant 0.001 [Table 3].
The cost analysis was carried out according to a study conducted by the department of hospital administration at our institute in 2008. As per this study entitled “Cost analysis of in-patient care service,” the average cost per day for inpatients across all specialties in our institute is 1861 rupees. Even if we consider this as a standard without taking into consideration the inflation, the mean cost was 2,142.97 rupees in the day care group, whereas it was 17,971.94 rupees in the routine group. The P value was significant at 0.001 [Table 3]. There was no significant difference in the age, sex distribution, duration of complaints, blood loss, and duration of surgery [Table 3]. None of the patients in both the groups had wound infection, deterioration of the neurological status, or any other major complications.
Conversion to long admission
Results when analyzed, showed that five cases were converted to long admission from the day care surgery initially planned. Three cases were cervical PIVD cases, one dorsal IDEM, and one dorsal extradural SOL.
Of the three cervical PIVD cases that were converted to long admission, two were two level PIVDs, and the other patient was a 53-year-old male with diabetes with C 5/6 PIVD. The two patients with two level PIVDs were planned for two level ACDF but one underwent corpectomy as the operating surgeon felt the need for corpectomy in the intra-op period [Figure 1]. All the three cases could not be extubated after the surgery and had to be subsequently extubated in the intensive care unit (ICU) after a period of observation. The dorsal IDEM patient was not discharged as he had urinary retention and was subsequently discharged the next day. The dorsal extradural SOL had severe postoperative pain and so was discharged the next day after ensuring adequate pain relief. This observation in retrospect makes us realize that patients with diabetes and patients who were planned for corpectomy are not good candidates for day care surgery, and therefore proper patient selection should be done before planning a day care surgery.
|Figure 1: Computed tomography scan of the patient who underwent C6 corpectomy, showing segmental ossified posterior longitudinal ligament. This patient initially planned as two level anterior cervical discectomy and fusion as a day care case had to be converted to long admission|
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The disability/functional outcomes were assessed using ODI and NDI for lumbar and cervical cases, respectively. We have omitted section 8 of the ODI questionnaire, which deals with sex life, and section 8 of the NDI questionnaire, which deals with driving.
In evaluation of the day care patients, there was statistically significant increase in ODI in the minimal category in the postoperative period [Table 4] and [Table 5]. Even though not statistically significant, there was a decrease in the number of patients who had moderate, severe disability, and from the crippled category too, which reflects an improvement in the postoperative period. We had a similar result in the routine group too with significant increase in the minimal category in the postoperative period and decrease in the number of patients in the moderate and severe disability group.
In the assessment of NDI of the day care cases, there were four patients in the moderate disability and two patients in the severe disability category in the pre-op period, which improved, and in the post-op period, there were three each in the no disability and mild disability group. In the routine surgery group, there was one patient in the no disability group, two patients in the mild disability group, one patient in the moderate disability group, and two patients in the severe disability group. All the patients improved in the post-op period, and there were six patients in the no disability group.
| Discussion|| |
Disc herniations of the lumbar and cervical spine are common and increasingly prevalent conditions. Spinal IDEM, though less common in comparison to disc herniations, is a pathology that can be performed in a day care setting with careful patient selection. The improvements in the field of anesthesia and minimally invasive neurosurgery have led to the popularity of day care procedures.
In a study by Jaiswal et al. on 58 patients, operated between July 2016 and November 2017, to verify the feasibility and safety of outpatient microscopic lumbar discectomy (MLD) in a developing country, the successful discharge rate was 100%. They concluded that outpatient MLD can be safely performed with success, even in the setting of a developing country, if the prerequisites of appropriate patient selection, arduous adherence to outpatient surgery protocol, competent surgical/anesthetic team, and infrastructure needed for conduction of microsurgery are met.
In a study by Kaushal and Sen on 300 patients operated between January 2002 and December 2008, with endoscopic lumbar discectomy, under day care setup, more than 90% patients had good outcome and early return to work. They concluded that day care discectomy provides minimal access corridor for lumbar discectomy with good functional recovery.
Adamson et al. in an analysis of 1000 consecutive patients who underwent ACDF (both one level and two level) in day care setting had low complication rate (1%) and could be easily managed in a 4h post anesthesia care window. The authors concluded that day care ACDF can be conducted without compromising patient safety.
In this study, we have operated PIVDs both lumbar and cervical along with selected IDEMs [Figure 2] and extradural SOLs, whereas the studies in review,, were concentrated on lumbar and cervical PIVDs. VAS scores were used as a means of assessment of pain relief in the previous studies., Our study showed a comparable decrease in the VAS score in both the day care and the routine group, establishing that the day care surgery is as effective in relieving pain as the routine surgery group.
|Figure 2: T2 sagittal and axial image of a patient with L1/2 intradural-extramedullary lesions|
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Of our day care patients, 22 were operated with the minimally invasive spine procedure, using the tubular retractor for 20 cases and the endoscope for two cases. We had 14 patients who were operated with minimally invasive spine surgery (MISS) from the routine group, 11 patients using the tubular retractor [Figure 3], and three cases with endoscopic discectomy. All of the patients operated with the MISS procedure had good postoperative pain relief without any new-onset neurological deficits and could subsequently be discharged the same day in the day care group with no further complications. This also helps us come to a conclusion that MISS procedure helps in the day care setup with lesser tissue trauma [Figure 4].
|Figure 3: Use of tubular retractors for minimally invasive spine surgery L1-L2 intradural-extramedullary lesions|
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|Figure 4: Incision for a L1-L2 minimally invasive spine surgery intradural-extramedullary lesions excision|
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The length of hospital stay was also significantly low in the day care group in our study as compared to the routine admission group. This is also supported by the study done by Adamson et al. The waiting period of a patient to get admitted to the hospital for the surgery is one aspect of our study that we focused on, considering the current patient load in our setup, and the long waiting list for neurosurgery cases, especially the spinal cases. We found a significant difference with almost all the patients of the day care group getting admitted with a shorter waiting period when compared to the routine group.
Cost borne by the institute was another factor we studied to ensure adequate and proper utilization of resources. We found a significant difference in the two groups, which helps us conclude that there is better utilization of resources with decreased cost borne by the institute with day care surgery. The disability/functional outcomes were assessed using ODI and NDI for lumbar and cervical cases, respectively, where we found comparable improvement in both the day care and the routine group.
The small number of patients converted to long admission in the day care group makes us realize that proper patient selection is necessary to plan a day care surgery and that comorbidity if present should be taken into consideration while selecting a case. Also, accurate preoperative planning for the procedure to be executed is crucial for the success of day care surgery.
| Conclusion|| |
Our study showed similar postoperative results in the day care group in comparison with the routine group with similar relief in the pain and with similar functional outcome along with decreased waiting period and cost borne by the institute in the day care group. We conclude that one and two level lumbar PIVDs/LCS can be done routinely in a day care setup with no serious complications associated with it. Cervical PIVDs, especially single level PIVD, can be carried out in a day care setup with careful patient selection and type of surgery. IDEMs and extradural SOLs projecting posteriorly/posterolaterally extending up to one and half vertebral levels can also be done in a day care setting with proper case selection and planning. The establishment of a special day care facility will help decongest the current patient load and reduce the cost borne by the patient and the institute.
We acknowledge Dr. Khangembam Jitenkumar Singh (MSc.) for statistical analysis. We acknowledge Dr. Shweta Kedia, Dr. Amol Raheja, Dr. Vivek Tandon, Dr. Dattaraj Sawarkar, Dr. Deepak Gupta, and Dr. Manmohan Singh for contributing in the facilitation and completion of this study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Jaiswal A, Kumar S, Reddy S, Jaiswal P Feasibility and safety of outpatient lumbar microscopic discectomy in a developing country. Asian Spine J 2019;13:1-9.
Kaushal M, Sen R Posterior endoscopic discectomy: Results in 300 patients. Ind J Orthop 2012;46:81-5.
Adamson T, Godil SS, Mehrlich M, Mendenhall S, Asher AL, McGrit MJ Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: Analysis of 1000 consecutive cases. J Neurosurg Spine 2016;24:878-84.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]