Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Neurosurgery, The Hospital of the University of Pennsylvania & Pennsylvania Hospital, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
World Neurosurg. 2014 Nov;82(5):897-901. doi: 10.1016/j.wneu.2014.05.035. Epub 2014 Jun 5.
Traditionally, lumbar discectomy has involved overnight hospital admission. Recent literature supports the shift to same-day lumbar discectomy because of improved outcomes and better patient satisfaction scores. A successful protocol for outpatient lumbar discectomies was proposed and implemented at a single institution. The aim of this study is to perform a quantitative and qualitative analysis of this institutional model.
Retrospective clinical data were collected for patients who underwent a lumbar discectomy during the period 2008-2012. Admission and readmission rates, emergency department (ED) visit rates, surgical complications, and differences between neurosurgeons specializing in spinal procedures and neurosurgeons not specializing in spinal procedures were analyzed before and after implementation of the outpatient surgery protocol.
Of 1011 cases identified, 643 cases of lumbar discectomy were performed before the implementation of the protocol, and 368 cases were performed after implementation. The admission rate before the start date of the outpatient protocol was 96.4% versus 50.3% after implementation. After protocol implementation, the most common reasons for admission were uncontrolled pain (18.9%), late operative start times (14.1%), comorbidities (13%), and intraoperative operating room complications (11.9%). Intraoperative complications consisted almost exclusively of dural tears. The 30-day readmission rate after protocol initiation was 4.6% (n = 17 of 368) versus 2.3% (n = 15 of 643) before initiation (P = 0.046), and ED visit rate not requiring an admission was 2.2% (n = 8 of 368) versus 1.1% (n = 7 of 643) before initiation (P = 0.170).
Our data demonstrate that a collaborative protocol for outpatient discectomy can be implemented in a safe and effective manner despite a statistical increase in hospital readmissions. The percentage rates of readmissions and ED visits accounted for a very small percentage of the overall number of cases after protocol implementation. Improvements in perioperative pain management and ensuring that outpatient lumbar discectomies are scheduled early in the day may further decrease the number of admissions. Future studies should examine the societal and financial impact of same-day discectomy versus overnight hospital stays.
传统上，腰椎间盘切除术需要住院过夜。最近的文献支持将腰椎间盘切除术转为日间手术，因为这样可以改善治疗效果和提高患者满意度评分。一家医疗机构提出并实施了门诊腰椎间盘切除术的成功方案。本研究旨在对该机构模式进行定量和定性分析。
收集 2008 年至 2012 年间行腰椎间盘切除术患者的回顾性临床数据。分析实施门诊手术方案前后，住院率和再入院率、急诊就诊率、手术并发症以及专门从事脊柱手术的神经外科医生与非专门从事脊柱手术的神经外科医生之间的差异。
在确定的 1011 例病例中，有 643 例腰椎间盘切除术在实施方案前进行，368 例在实施后进行。门诊方案开始前的住院率为 96.4%，实施后为 50.3%。方案实施后，住院的最常见原因是疼痛控制不佳（18.9%）、手术开始时间延迟（14.1%）、合并症（13%）和术中手术室并发症（11.9%）。术中并发症几乎全部为硬脊膜撕裂。方案启动后 30 天内再入院率为 4.6%（368 例中有 17 例），启动前为 2.3%（643 例中有 15 例）（P=0.046），无需住院的急诊就诊率为 2.2%（368 例中有 8 例），启动前为 1.1%（643 例中有 7 例）（P=0.170）。
我们的数据表明，尽管住院再入院率统计上有所增加，但安全有效地实施门诊椎间盘切除术的协作方案是可行的。方案实施后，再入院率和急诊就诊率占总病例数的比例非常小。改善围手术期疼痛管理并确保门诊腰椎间盘切除术尽早安排，可能会进一步降低住院人数。未来的研究应考察日间椎间盘切除术与住院过夜治疗的社会和经济影响。
