LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES
s u gr ery protocol required readmission to our hospital or any other
prior to electively scheduled follow-up. Only two patients
required medical attention prior to follow-up. One patient with a
the surgery as an outpatient procedure. Another possible benefit
of outpatient discectomy is decreasing the chance of cancellation
of an elective surgical procedure due to lack of availability of
nursed beds on any given day with possible resultant decrease in
waiting times for surgery.
“red wound” was seen by a family doctor and given a short course
of oral antibiotics; at follow-up in our clinic, no signs of a wound
infection were noted. A second patient developed an early
postoperative foot drop, despite having had an L5/S1 discectomy.
An urgent MRI was obtained, which revealed an adequate
discectomy and no visible cause of the foot drop. Overall, in the
There are excellent reviews of the complication rate of
lumbar discectomy.2
3,24
In Ramirez’ study, after a review of
23
28,395 cases, the mortality rate was found to be 5.9 per 10,000.
These 16 deaths were caused by septicemia, pulmonary
embolism and myocardial infarction. In general, patients must be
educated as to the signs and symptoms of these conditions, and
be told to return if they develop. It is worth noting that these
complications are most commonly seen after the first 24 hours,
and that a routine one night admission would not necessarily
decrease the incidence, or mortality rates associated with these
complications.
116 patients, no complications of early discharge were noted.
For comparison purposes, we analyzed the length of hospital
stay in the 50 lumbar microdiscectomy patients (elective cases
only) prior to the commencement of the study. This showed that
the average length of stay, in nights, was 1.6. In the 150 elective
lumbar microdiscectomy cases performed during this study
period, the mean length of stay was 0.4 nights (66 nights in 150
cases), a reduction of 1.2 nights per patient (ie. 1.6 - 0.4). This
number gives an estimate of the reduction that might be expected
by the implementation of this protocol, in the real world setting
where some patients may not be suitable for outpatient lumbar
discectomy. In our hospital, the cost of one night in a surgical
ward bed is estimated to be $1200 CDN so the savings according
to the above analysis would be $1440 CDN per patient.
One rare, but important complication is major vascular injury,
2
3
after breach of the anterior longitudinal ligament. Ramirez
reported an incidence of 1.6/10,000 of this complication. If this
complication is not recognized intraoperatively, then the post-
operative examination in the DSU must consider this possibility.
Patients must again be educated regarding the symptoms of this
complication and told to return if they develop. Another
complication of lumbar discectomy is urinary retention.
Observation in the DSU would be quite sensitive to this
complication and patients are not discharged until they can void.
We conclude that lumbar microdiscectomy can be performed
safely as an outpatient procedure. Out of 150 elective cases, 122
were selected for outpatient surgery and 116 were successfully
discharged on the day of surgery. Compared with the same
surgeon’s practice prior to the commencement of this study, there
was a reduction in hospitalization of 1.2 nights per elective
procedure with concomitant significant cost savings to the
hospital and system. Detailed satisfaction surveys are needed to
make sure there are no hidden human costs of outpatient lumbar
microdiscectomy.
DISCUSSION
The feasibility of outpatient lumbar microdiscectomy has
been demonstrated by this prospective case series. A previous
series of 75 patients demonstrated this for outpatient
2
2
conventional discectomy. However, in that study no re-
operative cases were considered, older patients were excluded,
and only “relatively stoic” patients were included. Another study
described the transition from inpatient to outpatient surgery and
performed a cohort analysis suggesting that patient education
and low-dose perioperative narcotics were the main factors in
14
patients successfully completing a day-surgery protocol. One
prospective study in the literature aims to quantify the savings to
third party reimbursers.15 Our study was performed in a
nationalized health care system, with a single payer. We have
attempted to specifically examine the savings, in terms of
hospitalization nights, realized in a single surgeon’s practice,
over a non-outpatient approach to this procedure. Our study
demonstrates that the majority of patients can be selected for the
day-surgery protocol and that the benefit, in terms of
hospitalization, when examined in the entire elective case
population, is substantial, with a reduction of 1.2 nights per
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This study was not specifically designed to gauge patient
satisfaction with the use of a validated instrument, but it is worth
noting that none of the 116 patients who completed the protocol
openly expressed dissatisfaction with their treatment, only four
patients declined to participate, and numerous patients
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