Download Neurosurgery 69:119-127, 2011

RESEARCH—HUMAN—CLINICAL STUDIES
TOPIC
RESEARCH—HUMAN—CLINICAL STUDIES
Outpatient Brain Tumor Surgery and Spinal
Decompression: A Prospective Study of
1003 Patients
Teresa Purzner, MD
Jamie Purzner, MD
Eric M. Massicotte, MD
Mark Bernstein, MD
Division of Neurosurgery, Toronto Western
Hospital, University Health Network,
University of Toronto, Toronto, Ontario,
Canada
Correspondence:
Mark Bernstein, MD,
Division of Neurosurgery,
Toronto Western Hospital,
West Wing 4W-451,
399 Bathurst Street,
Toronto, Ontario M5T2S8, Canada.
E-mail: [email protected]
Received, June 1, 2010.
Accepted, January 4, 2011.
Published Online, March 17, 2011.
Copyright ª 2011 by the
Congress of Neurological Surgeons
BACKGROUND: Outpatient craniotomy, biopsy, and spinal decompression have been
performed at our center for more than a decade. Early feasibility studies suggest that
they are safe, successful, cost-effective, and well-tolerated by patients. However, a largescale study of this magnitude has not been performed.
OBJECTIVE: To characterize postoperative complications and the rate of successful
discharge from the day surgery unit (DSU). We also discuss patient satisfaction and
benefits to flow of care.
METHODS: From August 1996 to December 2009, 1003 consecutive patients were
prospectively selected as outpatient candidates. Retrospective chart review was performed for all procedures and analyzed by intent to treat.
RESULTS: Of 249 patients who underwent a craniotomy, 92.8% were successfully discharged from the DSU, 5.2% were admitted from the DSU, and 2.0% were discharged and
later readmitted. Of 602 patients who underwent spinal decompression, 97.3% were
successfully discharged from the DSU, 2.5% were admitted from the DSU, and 0.2% were
discharged and readmitted at a later date. Of 152 patients who underwent a brain
biopsy, 94.1% were successfully discharged from the DSU, 4.6% were admitted from the
DSU, and 1.3% were discharged and later readmitted. No patients experienced a negative outcome as a result of early discharge.
CONCLUSION: Outpatient craniotomy, biopsy, and spinal decompression are safe,
successful, and cost-effective.
KEY WORDS: Biopsy, Craniotomy, Day surgery, Discectomy, Outpatient, Safety
Neurosurgery 69:119–127, 2011
DOI: 10.1227/NEU.0b013e318215a270
N
eurosurgery has undergone considerable
advancement over the past several decades with the introduction of minimal
access spine surgery, endovascular management
of vascular disease, intraoperative navigation,
and endoscopic techniques for cranial base and
ventricular surgery. These novel approaches to
traditionally highly invasive procedures have
allowed neurosurgeons to operate with lower
morbidity and mortality than previously possible.
Postoperative hospitalization times are shortening, and many procedures now require a single
ABBREVIATIONS: ACDF, anterior cervical discectomy and fusion; DSU, day surgery unit; ICH,
intracerebral hemorrhage
NEUROSURGERY
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overnight stay. The possibility of outpatient
neurosurgery has recently emerged.
Spinal decompression, brain biopsy, and
craniotomy for intra-axial tumors were some of
the first procedures considered for outpatient
surgery. They are frequently performed operations, have an excellent safety profile, and the
timing and frequency of their postoperative
complications have been well characterized.1-7
Several large-scale reports have shown that serious postoperative complications associated with
biopsy and craniotomy (in particular, intracerebral hemorrhage) occur usually either
within 6 hours or more than 24 hours postoperatively.3,8 This is an important consideration when determining whether keeping
a patient overnight provides additional benefit
to discharging a patient after 6 hours of
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PURZNER ET AL
observation, as is routine in day surgery. Similarly, neck hematomas after anterior cervical discectomy and fusion (ACDF),
another potentially catastrophic complication, usually occur either within 6 hours or more than 24 hours postoperatively.6,9
In the first series specifically examining the safety of outpatient
craniotomy and biopsy, no patient experienced an adverse outcome as a result of early discharge. Complication rates were
comparable to those expected in their inpatient counterparts, and
success rates ranged from 89% to 98%.10,11 Similarly, the success
and safety of outpatient lumbar microdiscectomy have been
supported by multiple studies.12-16 Again, no patient has yet to
experience a negative outcome as a result of early discharge.
Despite preliminary studies suggesting its safety, outpatient
neurosurgery has been slow to be adopted by practicing neurosurgeons. This may reflect the continued perception that delayed
neurological deterioration occurs at a high enough frequency that
close observation longer than 6 hours is warranted. Rare but
severe consequences of missed postoperative complications may
not have been experienced in previous smaller studies. In this
study, we examined 1003 outpatient surgery cases of prospectively selected patients undergoing craniotomy for intra-axial
tumor, brain biopsy, or spinal decompression. The primary focus
of this report is the characterization of postoperative complications and the rate of successful discharge from the day surgery
unit (DSU). We also discuss cost savings, patient satisfaction, and
benefits to the flow of care. A study of this magnitude has not
been performed or reported.
TABLE 1. Inclusion and Exclusion Criteria for Day Surgery
Craniotomy and Biopsy
Inclusion criteria
1. Available caregiver for overnight observation
2. Intra-axial supratentorial tumor
3. Patient relative proximity to the hospital
Exclusion criteria
1. Severe obesity or significant comorbidities (cardiac/respiratory)
2. Anticipated difficult airway
3. Already inpatient
4. Uncontrolled epilepsy or poor neurological status
5. Expected long surgery or procedure ending later than 1:00 PM
6. Neuropsychological unsuitability
7. Patient preference
other than in light of total operative time (when the operation will not be
completed in time for proper postoperative observation).
Patient Education
Preoperative education was found to be a key feature in overall patient
satisfaction with outpatient surgery.6 In the presurgical office visit, patients were educated on the expected course of events and potential
complications. Informed consent was obtained. The neurosurgeon and
anesthetist explained the unique aspects of day surgery and modified
anesthetic technique, particularly emphasizing expected experiences for
those patients undergoing awake craniotomy. Patients were provided
with an information pamphlet and given contact information for
additional questions or office visits, as required.
PATIENTS AND METHODS
Definition, Study Design, Patient Selection, and Ethics
Outpatient surgery is defined here as surgery performed on a patient
who is admitted the morning of the operation and discharged later that
day without having stayed overnight in hospital. Patients were selected as
outpatient candidates prospectively and consecutively. All patients were
assessed in clinic and booked on an elective basis. Patients who underwent emergency surgery did not enter the day surgery program.
Retrospective chart review was analyzed by intent to treat. No patients
were lost to follow-up at the first postoperative visit. All procedures were
performed by the 2 senior authors at a tertiary care center with a designated DSU. Residents and other training staff assisted in the care of the
patients. The protocol used in this institution for outpatient craniotomy
and biopsy is well described by Carrabba et al.17 Inclusion and exclusion
criteria are outlined in Table 1. Exclusion criteria include significant
medical comorbidities (including obesity, cardiovascular and respiratory
compromise, or difficult airway), poor neurological status or uncontrolled seizures before the operation, and patients already admitted as
an inpatient. All patients were assessed by anesthesia before the surgery,
and decisions to proceed with day surgery were made in a collaborative
fashion. Nonmedical concerns that would prevent the patient from a safe
discharge or swift readmission were also reasons for exclusion. Examples
include patients who live alone, patients who live a significant distance
from the hospital, and procedures ending later than 1:00 PM, thereby not
allowing a full 6 hours of postoperative monitoring in the DSU.
Importantly, size and location of the tumor are not contraindications,
120 | VOLUME 69 | NUMBER 1 | JULY 2011
Surgical Technique
Spine
Lumbar microdiscectomy. Patients are admitted to the DSU at 6:30 AM
the morning of the surgery. A detailed surgical description was previously
reported.18 Prophylactic antibiotics are routinely given. As a standard,
somatosensory evoked potentials or electromyography is used for electrophysiological monitoring. General endotracheal anesthesia is administered and patients are positioned. A microsurgical lumbar discectomy and
foraminotomy are performed, ensuring removal of any free fragments.
Both traditional microdiscectomy and minimal access spine surgery are
performed. Postoperatively, patients are monitored for 60 to 90 minutes in
the postoperative care unit and then transferred to the DSU where they are
observed for a minimum of 2 hours. All patients are examined by the
senior surgeon who determines whether they are safe for discharge. Before
discharge, patients must demonstrate an ability to drink, void, and ambulate and to have adequate pain control, wound hemostasis, and stable
neurological status. Urinary retention is assessed initially on a clinical basis.
If patients urinate well and have no distention or feelings of incomplete
voiding, then no further investigations are done. If, however, patients
produce an inadequate volume or have feelings of urgency or fullness, then
a bladder scanner is used to assess postvoid residuals. Patients can be
discharged when postvoid residuals have normalized. They require the
presence of a family member or close friend who will monitor them
overnight. Patients were given a prescription for analgesics and clear
written instructions concerning pain control, symptoms, and future
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OUTPATIENT BRAIN TUMOR, SPINAL SURGERY
clinic visits. The patients are told explicitly to return to the emergency
department if they experience any clinical deterioration. Follow-up
appointments are between 4 and 6 weeks postoperatively.
Anterior cervical discectomy and fusion. Patients are admitted to the
DSU at 6:30 AM the morning of the surgery. A detailed surgical
description was previously reported.19 Prophylactic antibiotics are routinely given. As a standard, somatosensory evoked potentials or electromyography is used for electrophysiological monitoring. General
endotracheal anesthesia is administered and patients are positioned supine.
A transverse right-sided cervical incision is used for exposure. An
intraoperative x-ray is used to verify correct level. Distraction pins are
placed in the vertebral bodies, and radical discectomy is performed with
use of an operative microscope, ensuring disc and posterior osteophyte
removal. The posterior longitudinal ligament is routinely excised at the
target disc space. Bony endplates are prepared with the curet or highspeed drill. Cadaveric cortical allograft is placed in the intervertebral
space, and a titanium plate is secured anteriorly. Postoperative care was
similar to that described for lumbar microdiscectomy with the exception
that the patients are monitored for airway issues for 4 hours in the
postoperative care unit. Neck circumference and ability to swallow clear
fluids are assessed. Monitoring is continued in the DSU for a minimum
of 6 hours. All patients are reviewed by the senior surgeon before discharge from the DSU and given clear instructions for contacting their
family physician or their surgeon. Postoperative instructions include
a follow-up appointment typically within 2 months of the operation,
pain management, and expectation of symptoms.
Awake craniotomy. A detailed surgical description of outpatient awake
craniotomy was previously reported.20 Patients arrive at the DSU at 6:00 AM
the morning of the surgery. All patients undergo magnetic resonance
imaging, and in all cases, the StealthStation image-guidance system
(Medtronic Surgical Navigation Technologies, Louisville, Colorado) is
used for neuronavigation.
The patients are positioned as desired (supine, decubitus, or sitting)
with great attention given to patient comfort. Draping is performed,
allowing the patients to see and speak freely. The Sugita headrest is
placed using local anesthetic over the pin sites, and after this neuronavigation is registered. Arterial lines, central lines, and urinary catheters
are rarely used. Nasal prongs are placed for oxygen. Monitoring includes
pulse oximetry, end-tidal capnography, noninvasive blood pressure
monitoring, and placement of electrocardiographic leads. Prophylactic
antibiotics and steroids are administered. Craniotomy is performed using
short-acting, well-timed sedation. Incisions are typically linear or curvilinear, and the bone flap is created with a single burr hole and sidecutting drill. Brain mapping is performed. Total or subtotal resection is
performed using standard microsurgical techniques. The dura is closed
primarily when possible; otherwise, duroplasty is placed over the dural
defect. The bone flap is placed and fixed. The galea and skin are closed in
the typical fashion. Full head dressing is kept on for 24 hours.
After completion of the operation, the patients are monitored in the
postoperative care unit for 2 hours and then transferred to the DSU and
observed for a minimum of 6 hours. A plain computed tomography (CT)
scan of the brain is performed 4 hours postoperatively. All patients are
examined by the senior surgeon who determines whether they are fit for
discharge. They must have normal findings on the postoperative CT and
demonstrate adequate pain control and wound hemostasis, stable neurological status, and the presence of a family member or close friend who
will monitor them overnight. Patients are given a prescription for
analgesics (typically acetaminophen with codeine) and clear written
instructions concerning pain control, expected and unexpected
NEUROSURGERY
symptoms, and future clinic visits. The patients are told explicitly to
return to the emergency department if they experience any clinical
deterioration, including seizures, decreased level of consciousness or
weakness. Follow-up appointments are 7 to 10 days later for formal
pathological review and scheduling of future appointments and
treatments.
Image-guided biopsy. A detailed surgical description was previously
reported.11 Patients arrive at the DSU on the morning of their procedure
at 6:00 AM. They undergo either frame-based localization using an
image-guided base ring or neuronavigation using the StealthStation
image-guidance system (Medtronic). A single burr hole or twist drill hole
is made using a local anesthetic and light neurolept anesthesia. Biopsy is
performed using a side-cutting Sedan needle. Typically, 1 core of tissue is
obtained and sent for immediate pathological assessment of frozen
section or smear. Postoperative care is identical to that for awake outpatient craniotomy.
RESULTS
From August 1996 to December 2009, 1003 outpatient
procedures were performed by the 2 senior authors (E.M.,
n = 332; M.B., n = 671). There were 602 spinal decompressions
(60%), 152 image-guided biopsies (15%), and 249 craniotomies
for supratentorial tumors (25%) (Figure 1). Overall, there was
a 96% success rate with a 4% conversion rate and 0.6% readmission rate (Table 2). No patients experienced an adverse event
as a result of early discharge. In 2009, 36% of the entire surgical
practice, including emergency procedures, was performed on an
outpatient basis.
Spinal Decompression
During the 158-month study period, 1131 patients underwent
elective spinal surgery. This includes all single- and multilevel
cervical, thoracic, and lumbar procedures that were performed by
FIGURE 1. Distribution of procedures. Pie chart representing anatomic site and
histopathological diagnosis as percentage of total cases. Craniotomies are shown in
red, spinal decompressions are shown in blue, and biopsies are shown in green.
GBM, glioblastoma multiforme; LGG, low-grade glioma; met, metastasis.
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PURZNER ET AL
TABLE 2. Number of Patients Successfully Discharged From the
Day Surgery Unit Admitted From the Day Surgery Unit the Evening
of the Operation and Discharged From the Day Surgery Unit and
Later Readmitteda
No. of Cases
(% Total
Cases)
Spine
Biopsy
Craniotomy
Total
a
602 (60.0)
152 (15.2)
249 (24.8)
1003
Successfully Admitted Discharged
Discharged
From
and
From DSU
the DSU Readmitted
585
143
231
959
(97.2)
(94.1)
(92.8)
(95.6)
16
7
13
37
(2.7)
(4.6)
(5.2)
(3.7)
1
2
5
7
(0.2)
(1.3)
(2.0)
(0.7)
DSU, day surgery unit.
the 2 senior authors except those involving a tumor and those that
were performed on an emergency basis. Of 1131 patients, 602
(53%) were prospectively selected to undergo the procedure as an
outpatient (Figure 2): 62 procedures (10%) were cervical, 11
(2%) were thoracic, and 529 (88%) were lumbar (Figure 1).
These included unilateral, 1-level, first-time operations as well as
multilevel and redo operations. Seventy-two procedures (12.0%)
were multilevel.
Of the 602 patients in the study, 586 patients (97.3%) were
successfully discharged from the DSU (Table 2). Fifteen patients
(2.5%) were admitted from the DSU on the evening of the surgery:
5 patients were admitted for observation of a dural tear; 2 were
admitted for nausea and vomiting; 3 were admitted for anesthesiarelated respiratory problems including laryngospasm requiring
reintubation, stridor, and sleep apnea; 1 was admitted for urinary
retention; 1 was admitted for pain at the incision site; and 1 was
admitted for left-sided numbness (Tables 3 and 4). One patient
was admitted by patient preference. Average length of stay was 2.8
days for all converted patients, and 0.08 days for all patients. Of the
15 patients requiring admission from the DSU, all symptoms had
completely resolved by the first postoperative visit (between 4 and
6 weeks) except for 1 patient who continued to have left-sided
numbness. One patient (0.2%) who underwent an L4-5 microdiscectomy was discharged and readmitted the next day with respiratory failure. After extensive workup, the likely diagnosis was
TABLE 3. Characterization of Complications Requiring Admission
to Hospital: Complications in Patients Who Were Admitted From
the Day Surgery Unit the Same Day as the Procedure in Spinal,
Biopsy, and Craniotomy Cases
No.
Spine
Nausea and vomiting
Laryngospasm and reintubation
Urinary retention
Left hemibody numbness
Anesthesia related
Patient elected to stay
Pain at incision
Dural tear
Biopsy
Headache
Worsened neurological status
Intravenous antibiotics for abscess
Intracerebral hemorrhage
Craniotomy
Nausea/vomiting
Worsened neurological status
Intraoperative event
(air embolus, myocardial infarction, seizure)
Intracranial hemorrhage
Vasovagal attack
Patient preference
2
1
1
1
2
1
1
7
1
1
1
7
2
5
3
2
1
1
congestive heart failure precipitated by anesthesia in a patient with
compromised cardiac status.
Image-Guided Biopsy
During the study period, 244 patients underwent elective
image-guided biopsy. Of these, 152 (62%) were prospectively
selected to undergo the procedure as outpatients (Figure 2). The
breakdown of histopathology is included in Figure 1. Of the 152
patients in the study, 143 patients (94.1%) were successfully
TABLE 4. Complications Requiring Readmission in Patients
Discharged From the Day Surgery Unit
No.
FIGURE 2. Percentage of total craniotomies, biopsies, and spinal decompressions
over the study period that were prospectively selected to be performed as outpatient
procedures.
122 | VOLUME 69 | NUMBER 1 | JULY 2011
Spine
Congestive heart failure
Biopsy
Worsened neurological deficit
Intracranial hemorrhage
Craniotomy
Headache/drowsiness
Seizure
Nausea
Intracranial hemorrhage
1
1
1
1
2
1
1
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OUTPATIENT BRAIN TUMOR, SPINAL SURGERY
discharged from the DSU (Table 2); 7 patients (4.6%) were admitted from the DSU on the evening of the surgery, 1 patient was
admitted for postoperative headache, 1 patient was admitted for
worsened neurological status, 1 was admitted for intravenous
antibiotics when biopsy revealed an abscess, and 4 patients were
admitted for intracerebral hemorrhage (ICH) (Tables 3 and 4). No
patients were admitted by preference. Of the 4 patients admitted
for ICH, 1 had a worsened neurological deficit caused by brisk
intraoperative bleeding after a needle biopsy of a deep dominant
temporal glioblastoma, and 1 patient died of a massive subarachnoid hemorrhage after an uncomplicated biopsy of a glioblastoma multiforme. The other 2 patients had a small ICH with
mild worsening of symptoms. The average length of stay was 3 days
for all converted patients and 0.18 days for all patients. Two
patients (1.4%) were discharged and readmitted the next day. One
patient was readmitted the next morning with ICH presenting
with headache. This patient was observed overnight and then
discharged the next day stable and without a deficit. The second
patient returned the evening of the procedure with minimal
worsening of his deficits. He improved on Decadron (dexamethasone) and was discharged 5 days later at baseline function.
Craniotomy for Intra-Axial Tumor Resection
During the study period, 989 patients underwent elective
craniotomy for intra-axial, supratentorial tumors. Of 989 patients, 249 (25%) were prospectively selected to undergo the
procedure as an outpatient (Figure 2) on the basis of the inclusion
criteria (Table 1). A total of 628 awake craniotomies were performed. Of these, 228 (36%) were performed as outpatient
procedures. Size and location of tumor were not necessarily
reasons for exclusion, and cases included large, dominant lobe
tumors and redo resections (Figure 3).
Of 249 patients in this study, 231 patients (92.4%) were
successfully discharged from the DSU (Table 2). Thirteen patients (5.2%) were admitted from the DSU on the evening of the
surgery; 2 patients were admitted for nausea and vomiting, 5 were
admitted for worsened neurological deficit, 1 was admitted for
intraoperative air embolus, 1 was admitted for an intraoperative
myocardial infarction requiring intubation and transfer to the
intensive care unit, 1 was admitted for an intraoperative seizure
with conversion to general anesthetic, 2 were converted for ICH
(1 resulting in hemiplegia, 1 resulting in no neurological deterioration), 1 was admitted for a vasovagal attack, and 1 was
admitted by patient preference (Tables 3 and 4). Of these 13
patients, all symptoms had resolved by the first postoperative
visit. Average length of stay was 6.21 days for all patients converted to inpatient status and 0.47 days for all patients. Five
patients were discharged and readmitted at a later date. One
patient was readmitted later in the evening because of headache,
drowsiness, and slight dysphasia. CT findings were unremarkable, and he was discharged 2 days later in his preoperative state.
One patient was readmitted next day with a seizure. He was
found to have a low Dilantin (phenytoin) level. The Dilantin
NEUROSURGERY
(phenytoin) dose was corrected, and he was discharged seizure
free 2 days later. One patient was readmitted to a local hospital 18
hours later because of a seizure. One patient was readmitted 12
hours later because of nausea. These patients demonstrated
normal CT findings and were discharged 2 days later. One patient was readmitted the next morning with confusion and
drowsiness. He was found to have an ICH, which was treated
conservatively. Unfortunately, he went on to have an ischemic
event 8 days later, followed by a pulmonary embolism and STsegment elevation myocardial infarction. One month postoperatively, a second, large ICH developed, resulting in death.
DISCUSSION
Outpatient neurosurgical procedures have been performed for
more than a decade in our center. Early reports demonstrated the
safety and efficiency of outpatient awake craniotomy,10,20,21 biopsy,11,20 and spinal decompression in both the cervical and
lumbar spine.6,18,22 To date, there has been no reported case of
a patient having a negative outcome as a result of early discharge.
Success rates range from 89% to 98% in prospectively selected
patients and rates of readmission are comparable to those expected
after a conventional, prolonged hospital stay.21 Qualitative studies
on patients’ perception of outpatient craniotomy have shown high
patient satisfaction.23 This may also be inferred from the results of
the current study, in which only 2 of 1003 patients (0.2%) were
admitted to hospital because of preference. This suggests that in
those patients who did not require conversion to inpatient status
for medical reasons, more than 99% were sufficiently satisfied with
their postoperative state that they were comfortable leaving the
hospital. In fact, to many, the possibility of being discharged the
same day as their operation made the disease and its management
seem less serious.23 Particularly in the case of patients with highgrade gliomas or brain metastases, helping to alleviate the psychological impact of their diagnosis and management while
minimizing the total hospital stay associated with each intervention
is important for overall quality of life.
Shortened hospital stays will likely result in a reduction of
nosocomial infections, thromboembolism, and medical error.
Adverse events occur in approximately 7.5% of all hospital admissions, 21% of which result in death,24 and so it is important to
not consider inpatient admissions as a benign alternative to
outpatient procedures. For example, the rate of thromboembolic
complications in inpatients after craniotomy ranged from 0%
to 19%,25 while averaging 2.1%26 in patients after spine surgery.
In both groups, patients were given low molecular weight or
unfractionated heparin. No thromboembolic complications were
observed in patients after the day surgery protocol. However, to
demonstrate a true decrease in nosocomial complications, similar
patients undergoing either day or inpatient surgery must be directly compared. The privacy of home on the first postoperative
day allows for overnight observation and assistance by family
members and friends without the disturbances by other inpatients. In previous qualitative studies, approximately half of
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PURZNER ET AL
FIGURE 3. Pre- and postoperative images obtained in a patient undergoing outpatient craniotomy for tumor resection.
A, preoperative axial gadolinium-enhanced T1-weighted magnetic resonance images showing a large recurrent glioblastoma
multiforme. B, Unenhanced axial computed tomography images 4 hours after surgery demonstrating aggressive resection. The
patient was successfully discharged 6 hours postoperatively.
patients believed that they would recover more quickly and more
comfortably at home.23
In health care systems with finite resources, there is a constant
pressure to create a more efficient and cost-effective system. It has
been estimated that the cost of 1 night in a surgical ward bed is
$1200. The average length of stay for elective inpatient lumbar
microdiscectomy is 1.6 days.18 In this study, 585 patients in the
spine group were successfully discharged from the DSU, thereby
saving a total of 936 days and $1 123 200.00 by bed alone. By
similar analysis, the average length of stay for biopsy and craniotomy in high-volume centers is 2.527,28 and 6.829 days, respectively. In this study, 143 patients in the biopsy group and
231 patients in the craniotomy group were successfully discharged, saving a total of 1928.3 days and $2 313 960.00.
Therefore, the total savings by reduced hospitalization nights,
realized by 2 surgeons’ practice over the period of this study, is
approximately $3 437 160.00. Although this figure provides
a rough estimate of cost savings, a more complete financial
analysis, addressing the institutional, regional, and international
variations in operative and perioperative care is required. This
would include additional costs such as allied health (physiotherapists, occupational therapists), supplemental consultation
fees, costs of unexpected readmission, medicolegal costs, and costs
of outpatient complications. More formal conclusions regarding
cost savings of day neurosurgery will require future study. The
benefit of outpatient surgery extends beyond the cost savings to
the health care system. Operations require a great deal of
124 | VOLUME 69 | NUMBER 1 | JULY 2011
forethought and planning on the part of the patient. Occupational and logistical arrangements must be made in advance by
patients and their family members to assist with postoperative
recovery. Therefore, case cancellation results in significant
emotional and financial consequence to the patient. Outpatient
surgery does not require an overnight bed, thereby operating
room cancellation rates are reduced. This benefits the patient,
surgeon, and flow of the health care system as a whole.
Nonetheless, outpatient neurosurgery is slow to be adopted by
practicing neurosurgeons. In a survey of the members of the
American Association of Neurological Surgeons and the Congress
of Neurological Surgeons, only 6% performed outpatient imageguided biopsy, although the majority agreed that discharge home
on the same day of surgery is safe and reasonable.30 This likely
reflects the continued perception that delayed neurological deterioration occurs at a high enough frequency that close observation for longer than 6 hours is warranted. Indeed, delayed
recognition and management of postoperative complications can
result in devastating outcomes. Patients undergoing imageguided biopsy and craniotomy are at risk of perilesional edema,
seizures, and ICH. Patients undergoing spinal decompression are
at risk of postoperative urinary retention, anterior neck hematomas resulting in potentially fatal airway compromise, and the
rare but serious occurrence of vascular injury. To justify outpatient surgery, it must first be shown that patients discharged
6 hours postoperatively are at no higher risk of long-term morbidity and mortality than patients kept overnight.
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OUTPATIENT BRAIN TUMOR, SPINAL SURGERY
Image-guided brain biopsy is associated with morbidity
and mortality rates of 1.2% to 6.3%,3,5,11,31,32 and neurological
deterioration may develop after a craniotomy 2.9% to 19.7% of
patients.4,33 In a study of 2305 elective craniotomies or biopsies,
postoperative ICH developed in 50 patients. ICH developed in
44 of the 50 patients within 6 hours, and after 24 hours in the
remaining 6 patients (6 of 50 ICH).34 In another series of 300
biopsies, clinically significant hematomas developed 3 patients
after 4 hours. None of these presented in a catastrophic manner.
Similarly, in a study of 269 patients undergoing biopsies, postoperative ICH occurred in 8 patients, 1 of which resulted in
death. All complications occurred within 6 hours, and any sustained deficit demonstrated a clot on postoperative CT scans.35 A
pilot study for outpatient craniotomy was reported in 2001.10
This study demonstrated the safety of outpatient craniotomy with
a success rate of 89%. with no patients experiencing adverse
outcomes as a result of early discharge. In 2002, a study of 102
patients undergoing stereotactic biopsy demonstrated the safety
of outpatient biopsy with a success rate of 98%. No patients who
were clinically well and had normal CT findings experienced
delayed deterioration. Another recent small study on outpatient
craniotomy and biopsy was reported in 2008, again supporting
the safety of outpatient surgery with no patients experiencing an
adverse event as a result of outpatient surgery.21 The current
study is the largest series reported, with 401 patients undergoing
craniotomy or biopsy. The safety of outpatient craniotomy and
biopsy is supported by the current study, and the success rate
parallels those previously reported. Ninety-three percent of patients prospectively selected for outpatient craniotomy and 94%
of patients undergoing biopsy were discharged the same day.
Seven patients (4.6%) undergoing a biopsy were admitted from
the DSU, and 2 patients (1.4%) were readmitted later for mild
worsening of deficits and a small ICH that was observed overnight. In both patients, symptoms had resolved by discharge. In
the craniotomy group, 13 patients (3.6%) were admitted from
the DSU, and 5 patients (1.3%) were readmitted at a later date as
a result of 3 clinically silent hemorrhages that were identified in
the DSU and were all treated conservatively. In this study, 5
patients (0.8%) were readmitted at a later date. These overall
readmission rates do not appear to be higher than what would be
expected for patients staying overnight in the hospital.
Spine surgery has a longer tradition of being performed on an
outpatient basis. Since the first outpatient lumbar microdiscectomy was performed in 1985, its success and safety have
been supported by multiple studies.12-16 The largest trial was of
1377 microlumbar discectomy patients with a mean follow-up of
4.4 years, reported in 2006.22 Of all microlumbar discectomies
performed during the study period, 96% were performed on an
outpatient basis with a success rate of 98.3%. Of all patients,
0.44% of patients required readmission to the hospital at a later
date as a result of urinary retention or dural tear. In a later
questionnaire, 82% of patients said their outcome was good to
excellent, and 82% of patients said they would undergo the
procedure again as an outpatient. In 2009, a retrospective case
NEUROSURGERY
series was performed comparing inpatient and outpatient singlelevel ACDF with plating.6 Sixty-four patients underwent ACDF
with plating as inpatients, and 45 patients had the procedure
performed as an outpatient. It was found that outpatient ACDF
with plating was safe and not associated with a significant difference in outcome compared with inpatients. All 4 complications that occurred during the study period were in the inpatient
group, including 1 delayed hematoma occurring 1 week postoperatively that required drainage. A similar study reported in
1996 compared 50 outpatient ACDFs with 53 inpatient ACDFs
and found no compromise in safety and efficacy when performed
as outpatient procedure and estimated that the overall health care
costs savings to the United States that would result from a conversion from inpatient to outpatient ACDF could exceed $100
million annually. A qualitative study investigating patient satisfaction of outpatient ACDF reported 96% of patients were
satisfied or very satisfied with their outcomes, and 78% of patients would have their procedure performed again as an outpatient. This current study parallels earlier studies and supports
the safety of outpatient spinal surgery. During the current study,
602 spinal operations were performed, including 62 cervical, 11
thoracic, and 529 lumbar decompressions. The success rate was
97%, with 15 patients requiring admission from the DSU (14
lumbar and 1 cervical) and 1 patient readmitted the next day with
congestive heart failure.
Outpatient craniotomy, biopsy, and spinal decompression
have been shown to be safe and effective in appropriately selected
patients. However, to be properly instituted, it requires rigorous
adherence to well-established protocols, thorough patient education, and a well-versed team of anesthetists, surgeons, and
nurses. A delay in recognizing clinical deterioration can result in
devastating outcomes. Before discharge, the health care team
must be cognizant of the early signs and symptoms of rare but
serious complications. These include vascular injury after microlumbar discectomy, postoperative anterior neck hematomas or
airway compromise after ACDF, and ICH or perilesional edema
after craniotomy. The patient and family must have a good
understanding of expected and unexpected symptoms and a low
threshold for returning to the emergency department.
There are numerous barriers to developing widespread use of
outpatient neurosurgery. A substantial concern is the medicolegal
risk of beginning a day neurosurgical program. There is concern
that patients in whom a late complication develops while at home
will have delayed treatment and a worse outcome. Our study,
along with existing data, demonstrates that these late complications are rare, and in our 1003 patients, none had substantial
morbidity from delayed treatment. As the cumulative experience
with day surgery increases, we hope that legal policy will be
accepting of alternative models of patient care.
Significant regional and institutional variability exists in the
timing and methods of scheduling surgery, particularly with
craniotomy for tumor resection. This will obviously affect the
number of patients to whom outpatient surgery can be offered in
other centers. However, a day surgery program can complement
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PURZNER ET AL
existing elective and emergency practices by providing another
pathway for patient care. It is up to the discretion of the individual surgeon and his or her center to what degree outpatient
surgery is a feasible option for their patients, given their specific
socioeconomic and medicolegal environments. Cases should be
considered on an individual basis, and outpatient procedures
should be presented as a well-informed option. Although outpatient neurosurgery is not likely appropriate for all surgeons and
centers, with rigorous adherence to patient safety, a select group
can benefit from this alternative pathway. Successful use of DSUs
in neurosurgery will rely on the comfort level of the surgeons to
advocate by educating not only patients but society. We hope
that our efforts will serve to this end.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
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COMMENTS
P
urzner et al present a retrospective update of their prospective series
of now 1003 cranial and spine patients operated on in the outpatient
setting. Although their results at earlier series size have been well published already, this is probably the largest series of outpatients currently
under study, and thus this recent update is an important landmark for
patient safety, socioeconomic, health regulation, and medical liability
interest. They are to be congratulated for the excellence of their
interdisciplinary pathway design and institutional interdisciplinary
cooperation, as well as the excellence of their surgical results.
This is a retrospective study involving only 2 surgeons in a unique
nationalized public health service environment without a U.S. model
tort liability system in play. It should also be noted that this study is
really 3 studies combined, namely outpatient spine surgery, outpatient
stereotactic brain biopsy, and outpatient craniotomy.
www.neurosurgery-online.com
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OUTPATIENT BRAIN TUMOR, SPINAL SURGERY
We need to recognize that this is a highly selected group of patients. For
example, for the craniotomy subgroup, all cases would need to be first case
starts of the day and completed by 1:00 PM. This requires all patients be
clinically stable and electively scheduled in advance. In the United States
(whether for social/family anxiety reasons, medicolegal liability concerns, or
financial incentive/case capture reasons), these cases are more often designated urgent ‘‘add ons’’ and may even already be inpatient if newly
diagnosed in the emergency department. Depending on local operating
room block time and scheduling concerns, ensuring that these cases are first
case starts and completed by 1:00 PM may be much more problematic in
those settings, even though they are not really medical emergencies.
Second, there are significant medicolegal barriers to generalization and
implementation of this approach outside of Canada, particularly in the
United States. Potential medicolegal liability concerns regarding delay in
intervention waiting for an elective first case operating room slot are 1
concern already mentioned. However, there are others as well. It is uncommon for anesthesiologists in the United States to proceed with craniotomy without an A-line for perceived patient care concerns (whether
valid or not), but also for medicolegal liability concerns. Indeed, many
anesthesiologists in the United States would feel medicolegally exposed
proceeding without a central line as well. It should also be noted that
almost all craniotomy case in this series were awake craniotomies, which are
generally only performed for special tumor location circumstances in the
United States. Finally, although studies like this provide important data to
help defend the practice of outpatient neurosurgery, many surgeons in the
United States will still likely feel exposed to potential practice-ending
liability for being sued for a delayed complication requiring readmission
based on the argument that the patient would have had a better outcome if
he or she were an inpatient and the complication recognized sooner with
earlier corrective and/or supportive intervention.
Third, the economic analysis used in the study is less than optimal.
Multiplying through the reduction in hospital days by the cost for each
hospital day is not ‘‘cost-effective analysis’’ and leaves out many relevant
factors. Cost of unexpected readmission, differential cost of managing
complications that might have cost less (been less severe, more recoverable, or recoverable with less costly or permanent disability) if the
complication were recognized earlier with inpatient monitoring as well as
potential additional medicolegal costs all need to be taken into account.
Additional factors include costs of additional tests or professional consultations pre- or postoperatively that would not have been ordered if the
patient was not being considered for outpatient surgery. For example,
each craniotomy underwent a computed tomography scan within 4
hours before DC decision. In the United States, at academic centers with
brain tumor programs, current standard of care clinically and requirement for clinical trial inclusion are brain magnetic resonance imaging (MRI) within 48 to 72 hours. In Canada, is MRI being done as an
outpatient in addition to the day surgery unit (DSU) within 4 hours of
computed tomography (CT) (cost of 2 neuroimages instead of 1)? Or if
generalized and implemented in the United States, would patients need
MRI within 4 hours to avoid having both postoperative CT and MRI?
Finally, in the United States, CMS is tracking strongly toward eliminating
hospital reimbursement for an expanding group of ‘‘never events.’’ What
would happen to the ‘‘cost-effectiveness’’ analysis if unexpected inpatient
admission from the DSU unit, and/or unexpected admission to hospital
within 1 week of surgery were not reimbursed under these regulatory
policies? Even given the failure to address or account for these additional
potential costs, the estimated savings concluded in this study of only
$245,511 per year ($3,437,160 over 14 years) seems very modest given the
potential additional costs outlined here.
NEUROSURGERY
There are also problems with generalizing data and conclusions from the
practice of 1 spine surgeon and 1 cranial tumor surgeon to the larger arena.
Ultimately, this needs to be studied in a prospective manner with a service
containing many more neurosurgeons in collaboration with appropriate
public health/health administrator/business management personnel.
Although outpatient stereotactic biopsy and/or tumor craniotomy is
a potentially safe and desirable goal, much more study on a prospective
basis with expanded surgeon participation and more sophisticated costeffectiveness analysis is necessary. Ultimately, at least in the United States,
significant public health policy and medical liability reform changes will be
necessary before it becomes a generalizable and practical reality.
Mark E. Linksey
Irvine, California
T
he authors should be congratulated on this thought-provoking and
well-written article. IT delineates the outpatient management of
more than 1000 spinal and cranial surgical cases. The study demonstrates
a very low complication rate for carefully selected cases in a busy academic practice in Canada. There are clear implications for cost savings.
The study is a retrospective analysis, and thus the conclusions are not
as strong as a prospectively conducted study. However, the argument for
same-day discharge for this patient population is very well reasoned.
Same-day spinal surgery is frequently performed in the United States;
outpatient management of cranial cases (both biopsies and craniotomies)
is much less common. The algorithms for management of cranial cases
are thoughtful and have been instrumental in outstanding results.
However, the article would be further strengthened if comparative data
for an inpatient cohort were available for complication rates (and reductions in treatment costs), including wound infections, deep venous
thrombosis, urinary tract infections, and urinary retention. There were very
few patients readmitted for delayed hemorrhage or edema after intracranial
procedures. However, these few seemed to be outliers beyond the ‘‘6-hour’’
rule. From a philosophical standpoint, it would be engaging to hear the
authors’ viewpoint if just one of these had resulted in a mortality. How
might this have affected their practice? There are medicolegal differences
between the U.S. and Canadian healthcare systems, and it is difficult to
fully anticipate the consequences of a poor outcome.
There are significant clarifications required for the cost-savings analysis
that was performed for this study. It would seem that a 6- to 8-hour stay is
not ‘‘free’’ after surgery. Are the actual cost savings a net between a prolonged postoperative care unit/DSU stay and an overnight stay in a hospital
bed? Is early postoperative MRI for appropriate craniotomies simply being
‘‘cost-shifted’’ to the outpatient arena and counted as cost savings? Were
the costs of readmissions clearly delineated?
There is little doubt that are cost savings with this approach, although
the net savings (approximately $250K per year and $3.5 million over
nearly 15 years) seem to be modest and likely comparable to costs of trial
preparation and/or loss of recoverable expenses for any perception of
harm that could be assigned to early discharge after craniotomies or
a delayed hemorrhage after a biopsy. The acceptance of this outpatient
management practice in the United States, particularly for cranial cases,
would require a sea-change within the health care environment that
would include federal and private payers, hospitals, surgeons, and, quite
likely, tort reform. A carefully performed prospective pilot study would
be required to enact such changes, but the authors have provided an
excellent foundation for such a study.
Mark E. Shaffrey
Charlottesville, Virginia
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