No Consensus on Drains and ACDF Among Twitter Docs

Do you use a drain in a multi-level ACDF? The Twittersphere weighs in on a surprisingly divisive question.

Peer Reviewed

You might not think of Twitter as the place to throw down with controversial conversations about the preferred placement of multi-level anterior cervical discectomy and fusion (ACDF) drains, but it certainly can be. 

Doctor on Twitter talking about drains and ACDFTwitter can help clinicians step out of their practice bubble, says Ali A. Baaj, MD.

Ali A. Baaj, MD, Chief of Spine Surgery, University of Arizona – Banner Health in Phoenix Arizona, recently tweeted out a question to his colleagues pondering who among them uses drains with routine 1-2 level ACDF surgery. And the results? Well, they were surprising. 

We turned to Dr. Baaj, a SpineUniverse editorial board member, to get more of his thoughts on the ensuring Twitter debate and try to settle the question once and for all: to drain or not to drain? 

Turning to Twitter

So what exactly was Dr. Baaj’s tweet heard `round the world? “Drains with routine 1-2 level ACDF: Who’s using them?” he asked.

He was referencing the placement of subfascial drains, which as the Journal of Spine Surgery (Hong Kong) explains, are routinely used after multi-level anterior cervical discectomy and fusion (ACDF) procedures despite little evidence to support their use. Proponents of using the drain cite benefits such as a reduction in post-op hematomas and infections at the surgical site, while opponents say it’s an unnecessary intervention that cause additional trauma without any benefit. 

Because of the dissonance between drain use and the level of evidence to support that use, Dr. Baaj turned to the Twittersphere to hear what other surgeons. “I really wanted to know what colleagues around the world do,” Dr. Baaj tells SpineUniverse about what prompted him to post his tweet. “I know it’s a controversial subject and I was interested in seeing how surgeons would respond.

He posed his question directly to some fellow surgeons in the field, tagging prominent leaders such as A.T. Mameghani, MD,  (@atmghn), a spine surgeon who received the AOSpine Global Spine Diploma in 2020, and Katrin Rabiei, MD, PhD, (@drkatrin_rabiei), neurosurgeon and SoMe editor of Acta Neurochirurgica journal. 

Dr. Mamaghani, after rather playfully noting that Dr. Baaj has a habit of asking “the most divisive questions,” explained that his stance is that it’s important to have one standard in postop care on the ward for anterior cervical. “So, one standard for ACDF, ACCF, degen/trauma/tumor,” he added. “Thus, a drain is my standard. But I am willing to leave.”

Dr. Rabiei, on the other hand, held the opposing stance. “I'm from the school: never ever!” she replied. “I would be asked to leave neurosurgery if I put a drain in!” 

Many other surgeons tuned into Twitter to chime in with their responses as well, which ran the gamut from strict drain placement to individualized decisions based on each patient to temporary drains observed and then removed prior to discharge to drains for level 2 or more, but never for level 1. 

All in all, the unofficial poll that Dr. Baaj ran revealed the findings that out of 169 votes, 53.8% of those who answered almost never place drains, while 46.2% almost always do. It was a closer race than many might have expected, but it still revealed a wide range in opinions among even surgeons who perform the same procedure in their own practices. 

To Drain or Not to Drain? 

To drain or not to drain is the question and if you’re wondering what Dr. Baaj’s personal opinion is, he’s officially on team no drains. “I do not typically place drains in ACDF surgery,” he says. “I will consider placing a drain for anterior corpectomy for a trauma or tumor diagnosis, but not in basic degenerative conditions.”

His personal opinion aside, however, Dr. Baaj does point out that there is no official “right” or “wrong” when it comes to placing drains after ACDF surgery. Instead, he explains that a surgeon’s decision to use drains is likely based on their training and any influential personal anecdotal experience. 

“There is no robust evidence in the literature that I’m aware of on this topic,” he notes. “Some believe it can decrease the risk of hematoma formation, whereas others feel it cannot safeguard against symptomatic bleeding.”

Bursting the Bubble

Along with revealing an interesting and wide range of beliefs about drains with ACDF surgery, Dr. Baaj’s post highlights an interesting truth: social media isn’t just for memes or sharing conspiracy theories that your uncle posted on Facebook. Instead, social media can be used in the professional space as both a means of sharing information, as well as engaging with and gathering input from other professionals in the field. In fact, Dr. Baaj says he enjoys using social media specifically for those reasons. 

“It’s a fast and cost-effective way to see how others think and feel about a certain topic,” he notes. “Many of my posts–and especially the polls I present–are in fact a mechanism for me to learn about my practice and how I can learn from others and improve.”

His unofficial drain poll was the perfect example of how surgeons can learn from each other online. For instance, Richard B. Rogers, MD, a neurosurgeon with Goodman Campbell Brain & Spine remarked in a tweet that he was “really surprised” at the results the poll and ensuing comments had revealed. 

But that, says Dr. Baaj, was the point all along. 

“These types of polls show us that we often work ‘in a bubble,’” he observes. “We think we’re like most other surgeons in terms of practice style and management but there’s in fact wide variation depending on training, practice type and even geography.” 

And while many of us may have viewed social media as a divisive source of frustration during the past year–perhaps that is just one example of how it might actually be a tool to help us see our differences in order to learn and grow.  

Updated on: 05/06/21
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