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Ambulatory Microsurgery for Ruptured Lumbar Discs: Report of Ten Cases
Departments of Neurosurgery, Orthopedics, Neurology, and Anesthesiology, Newton- Wellesley Hospital, Newton, MassachusettsAdvances in microsurgical techniques combined with a widening interest in same-day surgery led us to investigate ambulatory lumbar discectomy. We could find no precedent in the literature. Ten patients with classic ruptured lumbar discs confirmed by computed tomography chose to participate. They were aged 31 to 5 1, seven men and three women, in excellent general health. A microsurgical approach through a 25-mm skin incision was performed. The technique emphasized removal of sufficient medial facet to allow excision of the disc with minimal or no root retraction. Once awake in the recovery room, patients were transferred to a separate ambulatory step-down unit. They were discharged only after they had voided, ambulated, taken oral nourishment, and been examined by the surgeon. A visiting nurse checked the patient at home the evening of operation and the next day. All returned to their usual occupation between 3 and 14 days postoperatively. All were satisfied and would choose the outpatient program again. Our experience indicates that ambulatory lumbar microdiscectomy can be a safe, effective option for selected patients. (Neurosurgery 22:523-526, 1988)
Keywords: Ambulatory surgery, Intervertebral disc surgery, Lumbar vertebra, Microsurgery
Early postoperative mobilization (12), improved microsurgical technique (3), and widening interest in same-day surgery led us to investigate ambulatory lumbar discectomy. We report our initial experience with 10 patients. We could find no previous reports in the literature.
MATERIALS AND METHODS
Clinical Characteristics of Patient Population
aAbbreviations: AJ, ankle jerk; EHL, extensor hallucis longus.
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Care after discharge
A visiting nurse saw the patient at home and either the patient or the visiting nurse telephoned the surgeon during the evening of operation and on the next day. Further telephone contact with the surgeon was encouraged. Patients returned to the surgeon's office within a week for removal of the vapor-permeable dressing and postoperative evaluation.
Five patients had free fragments at operation. All patients were relieved of leg pain, all were satisfied, and all were back at their usual occupations in 3 to 14 days (Table 2). No patient had wound hematoma or infection, urinary retention, or thromboembolic disease. One patient had a fever of 101 *F on the night of operation; it resolved by the next morning. No patient required hospitalization on the day of operation or later. Patient compliance approached 100%. Each patient, when asked, stated that he or she would choose the outpatient mode again.
Intraoperative and Postoperative Narcotics and Analgesics
Case Narcotics Intraoperative Time in Recovery Room (min) Pain/Nausea Medication
in Recovery Room
Time in Stepdown
1 Morphine, 5 mg None 75 None 130 Acetominophen 2 None 100 Propoxyphene 65 170 None 3 Fentanyl, 0.05 mg 60 None 300 Acetominophen 4 None 120 None 215 Acetominophen 5
Fentanyl, 0.2 mg
80 Oxycodone 180 Oxycodone 6 Fentanyl, 0.05 mg 120 Inapsine 190 None 7 Fentanyl, 0.05 mg 110 None 115 Acetominophen 8 Fentanyl, 0.05 mg 120 None 175 None 9 Fentanyl, 0.05 mg 120 None 130 Acetominophen 10 Fentanyl, 0.2 mg 90 Oxycodone 150 None
Patient safety was a paramount concern. Four safeguards were incorporated in the program's design. Patients were carefully screened, and those with the slightest potential medical problem were excluded. For example, one candidate only 33 years old and in excellent general health was excluded because he had a brother who had died at 31 of a myocardial infarction. The surgical team was sufficiently experienced so as to discern the slightest deviation from an optimal intraoperative or postoperative course. Our own and published experience suggests that serious complications are likely either to be manifest in the recovery room (such as great vessel injury) or to remain obscure for several days (such as wound infection) (2). Thromboembolic disease is reported rarely (less than 1% (12)), if at all (3), and we hope that it was minimized by the outpatient format. Had the slightest concern on the part of the patient, physician, or visiting nurse arisen as to added risk at any stage, the patient would have been hospitalized. With these safeguards, the outpatient format did not expose patients to additional risk. Incidentally, we did not provide for physician house calls in our protocol because this would be a distortion of the outpatient format.
Patient comfort was also a concern. Few patients needed parenteral medication after leaving the recovery room after unilateral lumbar disc operation. Less sedated patients feel more in control and are less likely to ask for pain medication (10). Outpatients in this study had the same analgesics as our inpatients. At first, we infiltrated the wound with bupivacaine before closing (8), but we did not use it as a rule and found no difference when this step was omitted.
Some patients find confinement in the hospital, with enforced isolation from family and friends and the imposition of an alien routine, more frightening and stressful than being home in a familiar, private environment. This seemed to play a role in the motivation of the patients in this study. Each patient's choice of the outpatient program was voluntary from the outset and remained so; at any time, a patient was free to change his or her mind about going home.
The relative merits of microsurgery vs. a more traditional approach have been discussed elsewhere (15). We think that microsurgery allows a safer operation and, with a smaller incision, there seems to be less of a perceived sense of bodily violation.
The patients in this study came from three Massachusetts counties, underwent operation at three different hospitals, and were served by a variety of visiting nurse associations. This approach is well within the capabilities of existing facilities.
The performance of lumbar disc operation on ambulatory patients is a logical projection of current trends (4, 13). According to the Commission on Professional and Hospital Activities (1), the mean length of stay for simple lumbar disc excision in patients between 20 and 55 years of age decreased from 9.0 days in 1981 to 7.9 days in 1985, the most recent year of available data. No national figures are available specifically for postoperative length of stay but, in our Health Service Area (greater Boston), the average postoperative length of stay for patients undergoing unilateral lumbar disc excision in acute care, nonfederal hospitals in 1984 was 5.6 days (7).
Not every patient is a suitable candidate for outpatient discectomy, and not every medically suitable patient will choose it. The existence of an outpatient option, however, should influence the perspective of patients requiring lumbar disc surgery. Consumer demand for what appears as a less invasive alternative was demonstrated in the enthusiasm for chemonucleolysis (9) and should not be underestimated. Preliminary experience indicates that ambulatory lumbar microdiscectomy is a safe, effective option for selected patients.
The authors thank Howard Richter, M.D., and Claudette Healey, C.R.N.A., for assistance in preparation of the manuscript. The authors also thank Nicholas Zervas, M.D., for reviewing the manuscript.
Received for publication, June 27, 1987; accepted, September 16, 1987.
Reprint requests: Herbert L. Cares, M.D., 2000 Washington Street, Suite 220, Newton, MA 02162.
1. Commission on Professional and Hospital Activities: Length of Stay by Operation, United States, Northeastern Region, 1984. CPHA, 1985.
2. Horwitz NH, Rizzoli, HV: Postoperative Complications in Neurosurgical Practice. Baltimore, Williams and Wilkins, 1967, pp 237-257.
3. Hudgins RW: The role of microdiscectomy. Orthop Clin North
Am 14:589-603, 1983.
4. Hudgins RW: Comment. Neurosurgery 16:147, 1985.
5. Lichtiger M, Wetchler BV, Philip BK: The adult and geriatric patient, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery. Philadelphia, JB Lippincott, 1985, pp 175-224.
6. Maroon JC, Abla A: Microdiscectomy versus chemonucleolysis.
Neurosurgery 16:644-649, 1985.
7. Massachusetts Health Data Consortium, Inc: Post-Operative Stay, Patients Ages 20-55, Excision of Intervertebral Disc 1984. Report, Oct 15, 1986.
8. Mullen JB, Cook WA: Reduction of postoperative lumbar hemilaminectomy pain with Marcaine. J Neurosurg 51:126-127, 1979.
9. Nordby EJ: A comparison of discectomy and chemonucleolysis.
Clin Orthop Res 279-283, 1985.
10. O'Donovan TR, O'Donovan PG: The future is now, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery. Philadelphia, JB Lippincott, 1985, pp 1-32.
11. Orkin FK: Selection, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery. Philadelphia, JB Lippincott, 1985, ch 3, pp 77123.
12. Sachdev VP: Microsurgical lumbar discectomy: A personal series of 300 with at least I year of follow-up. Microsurgery 7:55-62, 1986.
13. Scoville WB, Corkill G: Lumbar disc surgery: Technique of radical removal and early mobilization. J Neurosurg 39:265-269, 1973.
14. Wetchler BV: Problem solving in the postanesthesia care unit, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery. Philadelphia, JB Lippincott, 1985, ch 7, pp 275-320.
15. Wilson DH, Harbaugh R: Microsurgical and standard removal of the protruded lumbar disc: A comparative study. Neurosurgery 8:422-427, 1981.
The authors have demonstrated what many experienced spine surgeons have recognized as possible, but had no incentive to do. They have performed outpatient microdiscectomies in highly selected, healthy, young adults with no other medical problems and classical clinical and radiographic findings. They also were highly motivated patients who were not on compensation.
On several occasions, we have discharged patients within 24 hours of microdiscectomy with similar good results. As we reported, the average postoperative stay for our patients is 3 days, but in retrospect we estimate that 10 to 20% of our patients could be safely discharged on the same evening or the next day if there was follow-up care by a visiting nurse and, psychologically, the patients were well prepared and informed of all aspects of their treatment and care.
With the refinement in surgical technique and the elimination in many cases of invasive diagnostic procedures, outpatient microdiscectomy seems to be a reasonable option in the highly selected and informed patient. As the authors state, however, every patient is not a suitable candidate for outpatient discectomy. Although insurance carriers undoubtedly
Neurosurgery, Vol. 22, No. 3
would be delighted to see this done routinely, physicians must constantly bear in mind that many patients consider any invasive procedure and, in particular, "back surgery" a serious undertaking. Many patients require the psychological and medical support available in a hospital.
Joseph C. Maroon
The authors have satisfactorily demonstrated in this small group of selected patients that surgery for ruptured disc can be accomplished in an ambulatory setting. This is not only commendable, but also proves once again that open operation is less traumatic and allows a better recovery than intradiscal therapy.
In my opinion, however, the reason for their success, is not microdiscectomy but rather the selection of appropriate patients. My personal opposition to the operation known as lumbar microdiscectomy stems from the fact that there is inadequate exposure and unsatisfactory decompression for the massive ruptured disc. In a number of cases where further bone removal would be advantageous, there is a high rate of complications, especially dural tears, in the large series reported. Furthermore, I have reoperated on some patients who have had this procedure to remove retained, undetected fragments of extruded disc (1).
The majority of patients who undergo operation for ruptured disc at our institution are hospitalized for I night, many of these because they must travel significant distances to their homes. They are, of course, ambulatory on the afternoon of operation and require only oral analgesics, although their skin incisions are more likely to approximate 250 mm than 25 mm.
Charles A. Fager
1. Fager CA: Lumbar microdiscectomy: A contrary opinion. Clin Neurosurg 33: 1986.