Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Michael L. DiLuna

Abstract

Posterior Spinal Fusion (PSF) is a common surgical intervention for severe cases of adolescent idiopathic scoliosis (AIS). However, prolonged hospital stays due to delayed ambulation and extended transition from intravenous (IV) to oral analgesics are significant concerns. In this study, we investigate the risk factors for delayed ambulation and prolonged transition to oral analgesics, and their respective impacts on hospital length of stay (LOS). Additionally, we explore the impact of a multidisciplinary Quality Improvement (QI) spine conference initiative on perioperative outcomes for patients undergoing PSF for AIS.This retrospective cohort analysis was carried out on 126 adolescents who underwent elective PSF for AIS at Yale New Haven Hospital between 2013 and 2020. Patients were categorized based on days from surgery to ambulation: early (≤ 1 day), intermediate (2 days), or late (≥ 3 days); and by IV to oral opioid transition time: normal (≤ 2 days) vs prolonged (≥ 3 days). Variations in patient demographics, comorbidities, deformity characteristics, surgical variables, and postoperative outcomes were explored. Statistical analyses identified risk factors associated with delayed ambulation, prolonged IV to oral analgesic transition time, and extended LOS. In February 2020, a QI initiative that included monthly multidisciplinary spine conferences to discuss surgical planning and perioperative protocols was implemented. The 96 patients who received surgical treatment for AIS within three years surrounding the QI initiative implementation were divided based on whether they underwent surgery before or after the implementation of the QI initiative. Patient demographics, comorbidities, deformity characteristics, intraoperative variables, ambulation status, postoperative complications, LOS, and unplanned readmission rates were assessed. Of the 126 patients who met criteria for the time to ambulation analysis, 8.7% were early ambulators, 42.9% were intermediate ambulators, and 48.4% were late ambulators. Early ambulators were significantly older (Early: 15.4 ± 2.0 years vs Intermediate: 14.8 ± 1.7 years vs Late: 14.1 ± 1.9 years, p = 0.034) and had more severe major curves (Early: 57.0 ± 9.6 vs Intermediate: 57.8 ± 9.0 vs Late: 64.0 ± 12.1, p = 0.001). Hospital LOS increased with late ambulation (Early: 4.2 ± 1.5 days vs Intermediate: 4.7 ± 0.9 vs Late: 5.1 ± 1.2, p < 0.001). Rates of complications (p = 0.101) and readmissions (p > 0.99) were similar. On multivariate analysis, delayed time to ambulation was significantly associated with younger age (aOR: 0.78, CI: 0.62 – 0.98, p = 0.036), levels fused (aOR: 1.61, CI: 1.08 – 1.98, p = 0.014) and procedure time (aOR: 1.49, CI: 1.08 – 2.11, p = 0.017). Of the 126 patients who met criteria for the time to oral analgesics analysis, 30.2% experienced a prolonged transition from IV to oral analgesics. Patient demographics, comorbidities, and deformity characteristics were similar between the two cohorts. Patients in the prolonged transition cohort had significantly longer LOS (Normal: 4.7 ± 1.2 days vs Prolonged: 5.1 ± 0.8 days, p = 0.002). Complication (p = 0.237) and readmission rates were similar (p > 0.99). On multivariate analysis, longer procedure time was a predictor of prolonged transition time to PO pain medications (aOR: 1.49, CI: 1.09 – 2.09, p = 0.015). Independent predictors of extended LOS included the number of levels fused (aOR: 1.63, CI: 1.19 – 2.27, p = 0.003), procedure time (aOR: 1.73, CI: 1.19 – 2.59, p = 0.005), and days to PO pain regimen (aOR: 2.95, CI: 1.44 – 6.64, p = 0.005). Of the 96 patients who underwent surgery surrounding the time when the QI initiative was implemented, 45.8% underwent surgery before the QI initiative implementation and 54.2% underwent surgery afterwards. The Post-QI cohort had fewer levels fused (Pre-QI: 11.7 ± 1.7 levels vs Post-QI: 10.4 ± 2.6 levels, p = 0.009), less blood loss (Pre-QI: 1063.6 ± 631.5 mL vs Post-QI: 415.8 ± 189.9 mL, p < 0.001), fewer blood transfusions (Pre-QI: 25.0% vs Post-QI: 9.6%, p = 0.044), and shorter procedures (Pre-QI: 6.3 ± 1.1 hours vs Post-QI: 4.3 ± 1.0 hours, p < 0.001). Patients in the Post-QI cohort walked sooner after surgery (Pre-QI: 2.1 ± 0.9 days vs Post-QI: 1.3 ± 0.5 days, p < 0.001), had fewer complications (Pre-QI: 72.7% vs Post-QI: 34.6%, p < 0.001), and had shorter LOS by 1.3 days (Pre-QI: 4.5 ± 1.1 days vs Post-QI: 3.2 ± 0.8 days, p < 0.001). Our analyses suggest that multidisciplinary spine conferences effectively enhance perioperative care for AIS patients undergoing PSF, reducing surgical time, EBL, complications, and hospital LOS. Identifying specific risk factors for delayed ambulation and prolonged IV to PO transition times enables targeted interventions to further enhance patient care. The success of this QI initiative suggests the potential for broader application across other institutions to validate the generalizability of these findings.

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This is an Open Access Thesis.

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