Fletcher Nicholas D, Bellaire Laura L, Dilbone Eric S, Ward Laura A, Bruce Robert W
Children's Healthcare of Atlanta, 1400 Tullie Rd, Atlanta, GA, 30329, USA.
American Family Children's Hospital, 1675 Highland Ave., Madison, WI, 53792, USA.
Spine Deform. 2020 Aug;8(4):725-732. doi: 10.1007/s43390-020-00081-w. Epub 2020 Feb 14.
Patients with neuromuscular scoliosis (NMS) who undergo posterior spinal fusion (PSF) often have long, protracted hospital stays because of numerous comorbidities. Coordinated perioperative pathways can reduce length of hospitalization (LOH) without increasing complications; however, a subset of patients may not be suited to rapid mobilization and early discharge.
197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Average LOH was 4.9 days for all patients. Patients were divided into quartiles (< 3 days, 3-5 days, 5-7 days, > 7 days) based on their LOH, and their charts were retrospectively reviewed for preoperative, intraoperative, and postoperative factors associated with their LOH.
Age at surgery, gender, the need for tube feeds, and specific underlying neuromuscular disorder were not significant predictors of LOH; however, severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients (p = 0.02). Radiographic predictors of LOH included major coronal Cobb angle (p = 0.002) and pelvic obliquity (p = 0.02). Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion (p < 0.05). The need for ICU admission and development of a pulmonary complication were significantly more likely to fall into the extended LOH group (p < 0.05).
Several variables have been identified as significant predictors of LOH after PSF for NMS in the setting of a standardized discharge pathway. Patients with smaller curves and less complex surgeries were more amenable to accelerated discharge. Conversely, patients with severe CP with large curves and pelvic obliquity requiring longer surgeries with more blood loss may not be ideal candidates. These data can be used to inform providers' and families' post-operative expectations.
Therapeutic Level III.
因多种合并症，接受后路脊柱融合术（PSF）的神经肌肉型脊柱侧弯（NMS）患者通常住院时间长且迁延不愈。协调的围手术期路径可缩短住院时间（LOH）而不增加并发症；然而，一部分患者可能不适合快速活动和早期出院。
197例NMS患者在一家医院由两位外科医生进行PSF手术，术后护理路径强调早期活动、快速过渡到肠内营养以及在首次排便前出院。所有患者的平均住院时间为4.9天。根据住院时间将患者分为四分位数组（<3天、3 - 5天、5 - 7天、>7天），并对其病历进行回顾性审查，以分析与住院时间相关的术前、术中和术后因素。
手术年龄、性别、是否需要管饲以及特定的潜在神经肌肉疾病不是住院时间的显著预测因素；然而，重度脑瘫（CP）患者（GMFCS 4/5）比GMFCS 1 - 3级患者更有可能延长住院时间（p = 0.02）。住院时间的影像学预测因素包括冠状面Cobb角较大（p = 0.002）和骨盆倾斜度（p = 0.02）。术中预测因素包括手术时间较长、融合节段较多以及术中或术后需要输血（p < 0.05）。入住重症监护病房的必要性和发生肺部并发症的情况更有可能出现在延长住院时间组（p < 0.05）。
在标准化出院路径的背景下，已确定几个变量是NMS患者PSF术后住院时间的显著预测因素。曲线较小且手术不太复杂的患者更适合加速出院。相反，患有严重CP、曲线大且骨盆倾斜、需要更长手术时间且失血更多的患者可能不是理想的候选者。这些数据可用于告知医护人员和患者家属术后预期。
治疗性三级证据
