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

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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.

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Author information

Authors and Affiliations

  1. Emory University Department of Orthopaedics, 59 Executive Park South, NE, Suite 2000, 30329, Atlanta, GA, USA

    Laura L. Bellaire MD, Robert W. Bruce Jr. MD & Nicholas D. Fletcher MD

  2. Emory University Department of Statistics, 201 Dowman Drive, 30322, Atlanta, GA, USA

    Laura A. Ward MSPH

  3. Department of Orthopaedics, Western Michigan University, 1000 Oakland Drive, 49008, Kalamazoo, MI, USA

    Christine A. Bowman MD

Authors
  1. Laura L. Bellaire MD
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  2. Robert W. Bruce Jr. MD
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  3. Laura A. Ward MSPH
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  4. Christine A. Bowman MD
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  5. Nicholas D. Fletcher MD
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Corresponding author

Correspondence to Nicholas D. Fletcher MD.

Additional information

Author disclosures: LLB (none), RWB (grants from Susan and Luther Harrison Foundation, outside the submitted work; consultant for Medtronic; Speaker’s Bureau for Orthopaediatrics and Zimmer Biomet), LAW (none), CAB (none), NDF (personal fees from Orthopaediatrics, personal fees from Medtronic, personal fees from Biomet Spine, outside the submitted work).

IRB approval: IRB approval was received for this study.

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Bellaire, L.L., Bruce, R.W., Ward, L.A. et al. Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis. Spine Deform 7, 804–811 (2019). https://doi.org/10.1016/j.jspd.2019.02.002

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  • DOI: https://doi.org/10.1016/j.jspd.2019.02.002

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