Safety of early discharge after elective lumbar spine surgery with subfascial drains and association with significant reduction in length of stay.

OBJECTIVE: After lumbar spine surgery, postoperative drain removal often delays discharge. Whether inpatient drain removal reduces the risk of surgical site infection (SSI) or hematoma remains controversial. Therefore, in patients undergoing elective lumbar spine surgery, the authors sought to determine the impact of inpatient versus outpatient drain removal on the following variables: 1) length of hospital stay (LOS), and 2) postoperative complications. METHODS: A single-center retrospective cohort study in which the authors used prospectively collected data of patients undergoing primary, elective, 1- or 2-level lumbar spine decompression and/or fusion was undertaken between 2016 and 2022. Patients with intraoperative or postoperative CSF leaks were excluded. The primary exposure variable was inpatient versus outpatient drain removal. The primary outcome was LOS, and secondary outcomes were postoperative complications, including 90-day postoperative SSI or hematoma. Multivariable logistic and linear regression were performed, controlling for age, body mass index, instrumentation, number of levels, antibiotics at discharge, and surgeons involved. RESULTS: Of 483 patients included, 325 (67.3%) had inpatient drain removal and 158 (32.7%) had outpatient drain removal. Patients with outpatient drain removal were significantly younger (58.6 ± 12.4 vs 61.2 ± 13.2 years, p = 0.040); more likely to have 1-level surgery (75.9% vs 56.6%, p < 0.001); and less likely to receive instrumentation (50.6% vs 69.5%, p < 0.001). Postoperatively, patients with outpatient drain removal had a shorter LOS (0.7 ± 0.6 vs 2.3 ± 1.6 days, p < 0.001); were more likely to be discharged home (98.1% vs 92.3%, p = 0.015); were more likely to be discharged on antibiotics (76.6% vs 3.1%, p < 0.001); were less likely to be on opioids (32.3% vs 88.3%, p < 0.001); and were more likely to have Jackson-Pratt compared to Hemovac drains (96.2% vs 34.5%, p < 0.001). No difference was found in SSI (3.7% vs 3.8%, p > 0.999) or hematoma (0.9% vs 0.6%, p > 0.999), as well as reoperation or readmission due to SSI or hematoma. On multivariable regression, outpatient drain removal was significantly associated with shorter LOS (ß = -1.15, 95% CI -1.56 to -0.73, p < 0.001). No association was found with SSI/hematoma (p > 0.05). CONCLUSIONS: Outpatient drain removal after elective lumbar spine surgery was associated with a significantly decreased LOS without a significant increase in postoperative SSI or hematoma. Although the choice of drain removal and the LOS may be subject to surgeons' preference, these results may support the feasibility and safety of outpatient drain removal, and the potential cost savings resulting from shortened hospital stays. Drawbacks may exist regarding added burden to the patient and the surgeon's team to accommodate 1-week follow-up appointments for drain removal.

Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI).

BACKGROUND: Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. METHODS: A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. RESULTS: A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). CONCLUSION: A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.

Early Self-directed Home Exercise Program After Anterior Cervical Discectomy and Fusion: A Pilot Study.

STUDY DESIGN: Pilot randomized controlled trial. OBJECTIVE: To examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Little is known regarding optimal postoperative management after ACDF. METHODS: Thirty patients (mean ±â€Šstandard deviation, age = 50.6 ±â€Š11.0 years, 16 women) undergoing ACDF were randomized to receive an early HEP (n = 15) or usual care (n = 15). The early HEP was a 6-week self-directed program with weekly supportive telephone calls to reduce pain and improve activity. Treatment acceptability was assessed after the intervention period (6 weeks after surgery). Safety (adverse events, radiographic fusion, revision surgery) was determined at routine postoperative visits. Disability (Neck Disability Index), pain intensity (Numeric Rating Scale for neck and arm pain), physical and mental health (SF-12), and opioid use were assessed preoperatively, and at 6 weeks and 6 and 12 months after surgery by an evaluator blinded to group assignment. RESULTS: Participants reported high levels of acceptability and no serious adverse events with the early HEP. No difference in fusion rate was observed between groups (P > 0.05) and no participants underwent revision surgery. The early self-directed HEP group reported lower 6-week neck pain than the usual care group (F = 3.3, P = 0.04, r = 0.3, mean difference = -1.7 [-3.4; -0.05]) and lower proportion of individuals (13% vs. 47%) using opioids at 12 months (P = 0.05). No other between-group outcome differences were observed (P > 0.05). CONCLUSION: An early self-directed HEP program was acceptable to patients and has the potential to be safely administered to patients immediately after ACDF. Benefits were noted for short-term neck pain and long-term opioid utilization. However, larger trials are needed to confirm safety with standardized and long-term radiograph assessment and treatment efficacy. LEVEL OF EVIDENCE: 2.