Surgeon Surveys Provide Framework for Enhancing Perioperative Spine Care
Although spine surgery has been shown to improve functional and pain outcomes for many patients with spine-related symptoms, there is still a significant population of patients for whom surgery does not achieve the desired outcomes. Recent efforts have centered on perioperative interventions outside the operating room that might foster better outcomes more cost-effectively.
To identify potential factors related to preoperative and postoperative care that could yield improved outcomes, Michael L. Reed, DPT, OCS, from the Hospital for Special Surgery in Jupiter, Florida, who is a member of the North American Spine Society (NASS) Section on Allied Health, reviewed the results of 3 surveys assessing surgeons’ views on issues related to perioperative care.1
Along with colleagues, Reed conducted two of the surveys, querying attendees at annual meetings (1998 and 2008) of the NASS,2.3 and McGregor et al conducted the third, in 2002, querying surgeon members of the British Association of Spinal Surgeons and the Society for Back Pain Research in the United Kingdom.4
Variation Among Respondents
The 1998 NASS survey asked the respondents about multiple factors related to perioperative care that could affect outcomes after spinal surgery. Of the 215 respondents, 90% stressed the value of preoperative education, with 60% indicating that it was “always” important and 30% indicating that it was “often” important. The educational methods preferred by respondents were one-on-one teaching (91%), booklets (38%), videos (27%), group education (14%), and computer-assisted training (7%).
A similar 87% of overall respondents stressed the “importance of fitness and the integrity of the supportive musculature,” with 39% and 48%, respectively, indicating that these factors are “always” or “often” important to surgical outcomes. However, 23% fewer respondents (64%) indicated that they “encouraged patient conditioning,” with 30% indicating that they “always” encourage it and 34% indicating that they “often” do.
Regarding the use of outpatient rehabilitation services after spine surgery, 26% of respondents “always recommended” it and 34% “often encouraged” it, with spinal stabilization training (75%) and general exercise (75%) considered the most appropriate rehabilitation interventions.
The 51 surgeons responding to the 2002 UK study varied with respect to care approaches after discharge. Overall, 79% reported that they had “a routine postoperative management regimen,” but only 35% gave their patients written postoperative instructions. Although 73% of the respondents discouraged bed rest during the postoperative period, 8% of surgeons encouraged extra bed rest up to the third postoperative week. There were significant differences among the respondents with respect to lifting, with 45% restricting lifting until the end of postoperative week 12, 20% until the end of week 6 and some surgeons not restricting lifting at all.
Recommendations regarding returning to work also varied, from 10 weeks off work for manual workers compared with five weeks off for those with sedentary jobs.
Recommendations for when to return to sports activity ranged from 4 to 28 weeks. As in the NASS 1998 study, outpatient rehabilitation was not consistently recommended. More than half (55%) of the UK respondents did not refer their patients for outpatient rehabilitation.
The third study, which included responses from 193 surgeons during the NASS 2008 annual meeting, 48.5% reported they refer half of their patients to rehabilitation services before surgery “because of prior inadequate care or no history of intervention.” Only 42% responded that there was data supporting such a practice, whereas over 57% reported that payors require preoperative rehabilitation before surgery.
Nearly 65% of the NASS 2008 respondents referred their patients for postoperative rehabilitation, although only 45% reported that they believed evidence supports this practice. The types of activities the surgeons recommended most for both preoperative and postoperative rehabilitation included core strengthening, back strengthening, and stretching.
The three surveys indicate that surgeons value preoperative education as a way to improve postsurgical outcomes, considering individualized training to be the most effective approach. Reed noted that such education and preoperative conditioning might facilitate patient recovery after surgery. And although the surgeons surveyed had mixed views on the value of postoperative rehabilitation, Reed cited studies indicating that early postoperative training also may contribute to improved outcomes.5-7 Concluding that there is much confusion in this area, he said these findings offer a “framework” on which to base future research.