Outpatient Disc Surgery by Bruce R. Cook, M.D., F.A.C.S.
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 some hospital
stays. 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 are.
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. Information is given about the care and instruction they
will receive before discharge. They are informed that 80% of patients are eager to
leave by evening, whereas 20% stay overnight for various reasons.
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.
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.
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.
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.
Disclaimer: The information and references contained
herein are intended solely for the information.
It should not be used for treatment purposes, but rather for
discussion with the patient's own physician.
220 Sutton Street, North Andover, MA 01845
Phone (978) 687-2321 Fax (978) 685-7265