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Because of improvements in anesthesia and surgical techniques, a number
of surgical procedures previously thought to require hospitalization
are now routinely offered on an outpatient or overnight basis. Cost
containment with limited hospital stays is an increasingly significant
factor in today's health care system. The treatment of cervical and
lumbar radiculopathy caused by disc herniation or degenerative
osteophyte formation has been the subject of neurosurgical attention
for many years. Outpatient lumbar surgery has been reported and used
safely in selected patients. Percutaneous lumbar discectomy techniques
have been performed and are considered advantageous by some surgeons because
of the short hospital stays that are involved. The successful treament of
cervical radiculopathy by posterior laminoforaminotomy has been published
extensively in the literature. In this paper, we describe a group of patients
who underwent conventional limited posterior procedures for cervical
nerve root compression in the outpatent setting.
Clinical Material and Methods
Patient Population and Treatment
Between January 1993 and May 1996, 502 patients underwent posterior surgical
treatment for cervical radiculopathy. During this period, 200 patients (39.8%)
opted for outpatient surgery. Of these 200 patients, 183 individuals could be reached
for follow-up review. Because two of the patients required a second posterior operation,
our study focuses on a total of 185 procedures in 183 patients treated on an outpatient
basis. There were 114 men and 69 women in this group, with a median age of 46.1 years
(range 27-68 years). Table 1 (not shown in this format) provides a summary of the
particular levels involved in the surgeries. Follow-up review of the patients ranged
from 3 to 43 months, with a mean of 19 months. All patients had a clear clinical
syndrome with pain radiating into an extremity and appropriate physical findings. Pain
was located in the neck, frequently the medial scapula, and patients had an
accompanying deep aching pain in an upper extremity, with or without paresthesias.
Reflex changes, with or without weakness in the appropriate muscle associated with a
positive foraminal closing sign, were considered significant findings.
Each patient had undergone imaging studies (magnetic resonance imaging or water-soluble
contrast myelography followed by computerized tomography scanning) that
demonstrated nerve root compression due either to a soft ruptured disc or osteophyte
formation appropriate to the clinical level. Exclusionary criteria included medical
conditions requiring inpatient monitoring and patient selection of inpatient surgery.
Patients who had traveled long distances for surgery stayed overnight at hotels close
to the medical center. All patients had the option to choose inpatient care at any time.
All surgeries were performed in the usual neurosurgical operating rooms using
general anesthetic techniques. Postoperatively the patients were transferred to
the post-anesthesia care unit and observed for any immediate complications. After
remaining in this setting for the standard observation time, the patients were transferred
to the outpatient surgical area. All patients were observed for at least 4 hours prior
to discharge. No bladder catheters were used intraoperatively and the patients were
required to void and take liquids orally before discharge. In addition, the
patients were required to walk without assistance before leaving the hospital.
Standard hospital criteria for outpatient surgery were observed, including the
presence of a responsible adult to drive the patient home (to to the hotel) and remain
with the patient the 1st night. The patients were given preoperative instruction that
included criteria that merited concern and instructions for contacting the surgeon. No
patient returned to the hospital, including the emergency department, after discharge.
Discharge courses of medications varied depending on the surgeon: one prescribed a
methylprednisolone pack to be taken as directed; one, 0.75 mg dexamenthasone twice
daily for 4 days. All patients were discharged with hydrocodone to be used for
postoperative pain control. Postoperative follow-up evaluations varied from office
visits to telephone follow-up conversations for patients from distant cities.
Operative Technique
The three surgeons (J.B.B., W.D.P., and R.L.H.) selected different surgical strategies;
however, all procedures were performed using small incisions estimated to range between
1.2 cm and 3 cm, depending on patient size and the levels surgically treated. An
intraoperative lateral cervical x-ray study was used to confirm the correct level. Two
surgeons performed the operation with the patient in the sitting position, constrained
by nonpenetrating head-holding devices. One of these surgeons used a drill for the
foraminatomy and the other used a small punch. The third surgeon performed the procedure
with the patient prone, restrained by a penetrating head holder; this surgeon used
a drill for the foraminotomy. All patients received anti-biotic agents prior to the skin
incision and 2 to 4 mg of dexamethasone; some patients were given 4 mg of ondansetron
hydrochloride (Zofran) intraoperatively.
Two surgeons used posterior Caspar retractors and one used a modified Williams
retractor. One surgeon used an operating microscope, one used 4.5 loupe
magnification, and one used no magnification. Key-hole laminoforaminotomies
were performed with approximately 5 mm of bone removed from the interior and
superior edges of adjacent lamina and medial facet. Bone nerve root decomression
and removal of intervetebral disc material that extended beyond the ruptured
fragment was not attempted.
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Careful attention was paid to meticulous
hemostasis and minimal manipulation of the nerve root. The cervical surgery
performed in each case was the same procedure that each surgeon performs on
patients electing to have inpatient surgery.
Statistical Analysis
The Mann-Whitney rank sum test was used to compare outcomes between male versus
female patients and between male versus female patients and between cases that
involved Workers' Compensation claims versus those that did not. Computations
were made using a commercially available software program (Sigmastat; Jandel
Scientific Software, San Rafael, CA) and statistical significance was assumed
at the 5% level.
Results
Patient outcome was determined by reviewing complications, the incidence of
recurrent radiculopathy, functional outcome, and the time between surgery and return
to full-duty work or equivalent activity. There were no infections or other
significant medical complications after outpatient surgery. There were no
infections or other significant medical complications after outpatient surgery. No
patient required hospital readmission or an office visit prior to the scheduled
follow-up appointment. Reviewed retrospectively, only three of the 183 patients
expressed a complaint related to early discharge. Each of these three noted mild
nausea after returning home. Table 2 (not shown) lists the criteria for assessing
functional outcome. The mean follow-up review was 19 months (range 3-43 months);
patients were contacted by telephone following their initial office visits.
In the 167 cases that did not involve Workers' Compensation claims, 154 patients
(92.8%) reported an excellent or good outcome, seven (4.2%) a satisfactory outcome,
and five patients (3%) a poor outcome. One patient with a poor outcome underwent
a second posterior procedure and received a good grade at 1-year follow-up review. One
other patient with a poor outcome opted for an anterior cervical procedure. Individuals
for whom Workers' Compensation did not apply returned to work at a mean of 2.9 weeks
(range 2 days-12 weeks).
In the 18 cases involving Workers' Compensation claims, 14 patients (77.8%) reported an
excellent or good outcome, two (11.1%) a satisfactory outcome, and two underwent
a second posterior procedure and noted a good result at 4-month follow-up review.
Patients in this group returned to work at a mean of 7.6 weeks (range 2-12 weeks). One
patient in whom a satisfactory result was obtained and one with a poor outcome did not
return to work.
Overall, at the time of follow-up review, five of the seven patients with poor outcomes
had disability claims or litigation pending. Tables 2 and 3 (not shown) provide
summaries of outcomes and return-to-work internals. There was no difference in outcome
with regard to gender. As expected, there was a statistically significant difference
in out-come between cases that involved Workers' Compensation claims and those that did
not (p = 0.0084).
Discussion
Improved anesthesia and operative techniques, as well as cost containment and
societal acceptance, have changed the approach to surgical care in many specialties.
General anesthetic agents in the outpatient setting are widely accepted as safe and
are considered a standard choice in today's surgical practice. In the last decade,
smaller surgical incisions and precision dissections have led to decreased postoperative
pain, earlier mobilization, and a decrease in hospital stay. Neurosurgical management
of radiculopathy is an ideal outpatient procedure because of the brevity of the surgery,
the ability to perform limited incisions and dissections, and a low immediate
complication rate.
As surgeons, we vary in our choice of surgical technique. Regardless of the
method preferred, the key in the outpatient setting is limited dissection and
meticulous hemostasis. Exact localization of the incision and precise adherence
to appropriate anatomical dissection planes are paramount considerations. This
results in limited musculoskeletal pain, thus allowing outpatient management. The
surgeon must remain flexible and vigilant when working in the outpatient setting. In
our cases, all patients were required to walk unassisted, take liquids orally, and void
before they were discharged. The patients had to be free of nausea and vomiting
and a responsible adult was required to stay with them the 1st night. Patient
satisfaction was high and many patients were happy to avoid hospitalization. We
are currently experiencing a higher percentage of patients choosing outpatient surgery and
we find that many patients who have traveled long distances prefer to stay at their
hotel than at a hospital following the procedure.
Carefully addressing patients' concerns about postoperative pain and assuring them
of the surgeon's availability increases their confidence in accepting outpatient
surgery. Immediate resolution of radicular pain further bolsters the patient's
confidence in returning home the day of surgery. However, caution must be excercised
when discussing outpatient spine surgery because many patients are not candidates. We
do not advocate abandoning inpatient care for the treatment of cervical radiculopathy;
however, we do believe that a substantial subgroup of the total population can be
safely managed as outpatients. The points that we believe are important include the
absence of complications in the immediate postoperative period and long-term results
comparable to the inpatient surgical management of cervical radiculopathy.
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