Rapid-Recovery Protocol Shows Promise in Trimming LOS After Scoliosis Surgery

How great would it be to tell adolescent patients with scoliosis they’ll likely be able to go home three or four days after surgical repair instead of the typical six or seven days? If initial results with a new rapid-recovery protocol hold up during further evaluation, that may be the reality for more and more young patients undergoing fusion for idiopathic scoliosis.

The protocol was introduced at Cleveland Clinic Children’s last year under the direction of Ryan Goodwin, MD, Director of the Center for Pediatric Orthopaedics and Spine Deformity. He heard about it from colleagues at Children’s Healthcare of Atlanta, where it originated, and thought it could offer real value for many of the approximately 150 patients who undergo scoliosis repair surgeries at Cleveland Clinic Children’s each year. So Dr. Goodwin’s team made a few adaptations to the protocol and have since been using it in many of their adolescent patients.

The protocol at a glance

The protocol, intended for use in otherwise healthy patients undergoing surgical fusion to repair idiopathic scoliosis, aims to reduce postoperative length of stay (LOS) by adjusting the patient’s pain medication regimen to promote earlier and more aggressive mobility.

In contrast to traditional practice, in which patients awaken from surgery on an abundance of pain medications that are typically continued regardless of their effects on ambulation, the rapid-recovery protocol takes a more proactive approach to pain control with the aim of earlier mobility. Essentials of the protocol include:

• Initiation of gabapentin in the preoperative holding area, with continuation throughout the hospital stay
• Administration of narcotics and nonnarcotic anti-inflammatory medications by anesthesiologists during the procedure
• Intraoperative placement of two epidural catheters that are removed on postoperative day 2
• Aggressive use of local anesthetics at the time of surgery
• Scheduled introduction of early patient mobilization and ambulation

Dr. Goodwin notes that the placement of epidurals and use of liposomal bupivacaine are Cleveland Clinic’s modifications of the original Atlanta protocol.

“It’s essentially a pre-emptive approach to pain control, with a lot of intervention up front, to help get patients up and moving earlier,” he says. “I think that’s the reason it seems to work so well.”

Preliminary results hint at near-halving of LOS

He’s referring to results from a pilot study of approximately 20 of the first patients treated under the protocol at Cleveland Clinic Children’s. These patients’ average LOS has been three to four days — vs. an average six- to seven-day historical LOS.

Dr. Goodwin says these results are similar to what the Atlanta hospital has achieved.

Next steps: Data presentation and a likely prospective trial

He notes that Cleveland Clinic Children’s plans to present and publish data on its experience with the protocol in the coming months — once results are analyzed for at least 50 patients.

If the effects on pain scores, LOS, overall outcomes and cost continue to be favorable in that analysis, a prospective study will likely follow.

A natural for scoliosis

Dr. Goodwin says that a rapid-recovery protocol makes particular sense for scoliosis because it’s the most reproducible procedure performed in pediatric orthopaedics and it’s common enough that value-based efficiencies could significantly impact healthcare resource use.

“Plus,” he adds, “patients are better off when they get back to their home environment sooner.”