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Outpatient Disc Surgery
by Bruce R. Cook, M.D., F.A.C.S., Division of Neurological Surgery
Hospital length of stay following a surgical procedure is determined primarily by a patient's need for nursing services for pain management. The need for parenteral narcotics and treatment for the side effects they cause has lengthened hospital stays for some patients. In recognition of these facts, the surgeons and pain management specialists of New England Neurological Associates have developed a protocol for the management of patients which assures a smooth post-operative course, with freedom from post-op pain and the possibility of early discharge from the hospital. Utilizing this approach, eight out of ten laminectomy patients are able to leave the hospital on the day of their operation. Our model covers several aspects of patient care.
Patient Education About Pain
First, the patient is educated by the surgeon in an office visit prior to surgery. He or she is told that they will have little or no pain after the operation and will get up within an hour of the surgery's completion. Patients are told that they will be allowed to go home later that day if they are comfortable, able to ambulate independently, and void. They are given information about the care and instructions they will receive before leaving the hospital. They are informed that 80% of patients are eager to leave by evening, whereas 20% stay overnight for various reasons.
Preempting Pain
Second, the anticipated pain of an operation is treated in a preemptive fashion. Before the incision is made, the area is infiltrated with long-acting local anesthetics. During surgery, high dose anti-inflammatory medicines are given intravenously and then continued by oral route after surgery. At the completion of surgery, the spinal muscles are infiltrated with long-acting local anesthetics mixed with a slow release steroid preparation. A single dose of intravenous anti-emetic is given before emergence from anesthesia. Use of these medications, along with a microscopic surgical technique, allows patients to awaken without pain.
Post-operative Protocol
Third, a nursing protocol is in place which provides a detailed plan for the patient's post-operative course on an hour by hour basis. As soon as the patient awakens from anesthesia, mobilization begins with gentle exercise. Upon leaving the recovery room, the patient meets with the physical therapist to learn body mechanics and exercises. Ambulation and stair climbing are begun. Nurses begin instruction in diet and activity to be followed at home. Wound care is taught to the family and patient. Post-operative patients are eligible for early discharge when they are comfortable on oral medications, able to drink sufficient liquids, ambulatory, and able to void. Discharge typically occurs six to eight hours after completion of surgery.
Follow-Up
Fourth, there is a follow-up phone call to each patient on the morning after the discharge. The nurses who treated the patient in the hospital phone with a list of questions and fill out a form with the responses. The completed form is then faxed to the surgeon, who makes a call to the patient if there is any significant problem.
Conclusion
This protocol has been in place for the past year, and has had an enthusiastic response from patients. Properly prepared patients are happy to leave the hospital shortly after surgery if this is presented as an opportunity rather than as a requirement. When patients return to the office in follow-up, most report a rapid recovery and minimal use of oral narcotic medication. There has been no increase in complications and no problem associated with early discharge. In fact, the early mobilization and freedom from pain has allowed an early return to work and full activity for many patients.
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