A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion

Abstract

Study Design

Retrospective comparative cohort.

Objectives

To determine if a standardized multimodal analgesic and rehabilitation protocol (rapid recovery pathway [RRP]) in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) could improve pain control, reduce opioid-related complications, and expedite early mobilization.

Background

Several reports have described postoperative recovery pathways for AIS patients undergoing PSF that shorten length of stay (LOS) without reporting the impact such pathways might have on patients' pain or quality of recovery.

Methods

We compared two high-volume surgeons' patients managed on our conventional pathway (CP) or our RRP. The CP analgesia consisted of intraoperative methadone and postoperative patient-controlled analgesia (PCA) until tolerating oral analgesics, with adjunctive diazepam. Analgesia on the RRP includes intraoperative methadone and postoperative PCA; patients also receive preoperative gabapentin and acetaminophen, intraoperative intravenous acetaminophen, and postoperative diazepam, gabapentin, acetaminophen, and ketorolac. Ambulation and full diet are permitted beginning postoperative day 1. The primary outcome was mean daily pain scores. Secondary outcomes were LOS, time to pathway milestone completions, and frequency of opioid-related side effects requiring treatment.

Results

There were 58 patients in the RRP group and 80 patients in the CP group. Patients on RRP had improved mean daily pain scores on postoperative days 0 (p = .027), 1 (p < .001) and 2 (p = .004). RRP patients were discharged home 31% earlier, discontinued from PCA 34% earlier and had their urinary catheters removed 26% earlier. Total opioid consumption decreased on postoperative day 0 (p < .001), but not postoperative day 1 (p = .773) or 2 (p = .343). Fewer patients on the RRP required medication for opioid-induced pruritus (p = .001), but there was no difference in the frequency of odansetron administration (p = .566). There were no differences in 30-day rates of readmission (p = .407).

Conclusion

Implementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.

Introduction

Adolescent idiopathic scoliosis (AIS) affects approximately 3% of children and is the most common pediatric spinal disorder in North America, with more than 5,000 AIS spinal fusions performed in 2011 [1], [2]. At its inception, spinal fusion often required a prolonged hospitalization of up to 3 weeks [3]. More recently, mean length of hospitalization has been approximately 5–6 days [2], [4], [5], [6], [7]. Historically, major challenges in postoperative care after posterior spinal fusion (PSF) for AIS have included adequate pain control, effective management of opioid-related side effects, and delayed mobilization [8]. Other barriers to patient discharge may include adverse in-hospital outcomes such as postoperative hemorrhage, infection, or procedure-related complications, with overall complication rates averaging approximately 9% to 15% [5], [6], [7], [9].

Recent work across the medical and orthopedic literature has focused on value-based health care delivery. Driven primarily by implant expense, followed by length of stay (LOS), the mean cost of AIS spinal fusions has more than doubled since 2001 to more than $150,000 in 2011 [2], [10]. Fletcher [11], [12] described an accelerated discharge pathway for AIS patients that expedited mobilization and resulted in early discharge. However, the authors did not document pain control or other patient-reported outcomes. Recently, the use of multimodal pain management strategies has been shown to reduce opioid consumption and time to mobilization, but not length of stay, after multi-level spinal fusion in adults [13]. To our knowledge, no group has reported on the use of a comprehensive multimodal analgesic protocol for postoperative management of pediatric spinal fusion patients. In the setting of a large, hospital-wide quality-improvement initiative studying the implementation of a standardized rapid recovery pathway (RRP) for all AIS patients undergoing PSF at our institution, the aim of this study was to perform a rigorous comparison between a population of pre- and post-pathway patients managed by two high-volume surgeons with a focus on both value-based outcomes such as length of stay and quality-based, patient-oriented outcomes, including patient-reported pain and opioid-induced side effects.