Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

Laura L Bellaire; Robert W Bruce Jr; Laura A Ward; Christine A Bowman; Nicholas D Fletcher

doi:10.1016/j.jspd.2019.02.002

Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

Spine Deform. 2019 Sep;7(5):804-811. doi: 10.1016/j.jspd.2019.02.002.

Authors

Laura L Bellaire¹, Robert W Bruce Jr¹, Laura A Ward², Christine A Bowman³, Nicholas D Fletcher⁴

Affiliations

¹ Emory University Department of Orthopaedics, 59 Executive Park South, NE, Suite 2000, Atlanta, GA 30329, USA.
² Emory University Department of Statistics, 201 Dowman Drive, Atlanta, GA 30322, USA.
³ Department of Orthopaedics, Western Michigan University, 1000 Oakland Drive, Kalamazoo, MI 49008, USA.
⁴ Emory University Department of Orthopaedics, 59 Executive Park South, NE, Suite 2000, Atlanta, GA 30329, USA. Electronic address: Nicholas.d.fletcher@emory.edu.

PMID: 31495482
DOI: 10.1016/j.jspd.2019.02.002

Abstract

Background: Implementation of a coordinated multidisciplinary postoperative pathway has been shown to reduce length of stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis. This study sought to compare the outcomes of nonambulatory cerebral palsy (CP) patients treated with PSF and cared for using an accelerated discharge (AD) pathway with those using a more traditional discharge (TD) pathway.

Methods: A total of 74 patients with Gross Motor Function Classification System (GMFCS) class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a TD pathway, and 44 patients were subsequently treated using an AD pathway. The cohorts were then evaluated for postoperative complications and length of stay.

Results: Length of stay (LOS) was 19% shorter in patients managed with the AD pathway (AD 4.0 days [95% CI 2.5-5.5] vs. TD 4.9 days [95% CI 3.5-6.3], p = .01). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. Length of stay remained significantly shorter in the AD group by 0.9 days when controlling for estimated blood loss (EBL) and length of surgery. Complication rates trended lower in the AD group (33% AD vs. 52% TD, p = .12), including pulmonary complications (21% AD vs. 38% TD, p = .13). There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.

Conclusions: Adoption of a standardized postoperative pathway reduced LOS by 19% in nonambulatory CP patients. Overall, complications, including pulmonary, trended lower in the AD group. Early discharge appears to be possible in this challenging patient population. Although the AD pathway may not be appropriate for all patients, the utility of the AD pathway in optimizing care for more routine PSF for this patient subset appears to be worthwhile.

Level of evidence: Level III, therapeutic.

Keywords: Accelerated discharge; Cerebral palsy; Neuromuscular scoliosis; Pathway; Posterior spinal fusion.

MeSH terms

Adolescent
Cerebral Palsy / complications*
Child
Female
Humans
Male
Patient Discharge*
Postoperative Complications
Retrospective Studies
Scoliosis* / complications
Scoliosis* / surgery
Spinal Fusion* / adverse effects
Spinal Fusion* / methods
Spinal Fusion* / statistics & numerical data