- Chief of Neurosurgical Research and Education, Winthrop University Hospital, Mineola, NY 11501, USA
Nancy E. Epstein
Chief of Neurosurgical Research and Education, Winthrop University Hospital, Mineola, NY 11501, USA
DOI:10.4103/2152-7806.130674Copyright: © 2014 Epstein NE This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Epstein NE. A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures. Surg Neurol Int 16-Apr-2014;5:
How to cite this URL: Epstein NE. A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures. Surg Neurol Int 16-Apr-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/a-review-article-on-the-benefits-of-early-mobilization-following-spinal-surgery-and-other-medicalsurgical-procedures/
Background:The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients.
Methods:We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations.
Results:In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS.
Conclusions:A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.
Keywords: Decreased cost, early mobilization, length of stay, prehabilitation, reduced morbidity, rehabilitation, spinal surgery
A review of multiple studies’ early mobilization protocols, involving hospitalized medical/surgical patients, indicates getting out of bed “early” (e.g. out of bed the day of surgery [OOBDS] or the first postoperative day or soon thereafter (OOBFD)) reduces perioperative morbidities and length of stay (LOS) [
Reinventing the culture of postoperative care
Here we reassess the “culture” surrounding early mobilization of medical/surgical intensive care unit (ICU) patients and/or those who have recently undergone spinal surgery. To accomplish this goal, we reviewed multiple early mobilization protocols along with other factors within these protocols that contributed to a reduction in both morbidity and LOS. Early mobilization was variously defined, but optimally included getting patients OOBDS, the first postoperative day (OOBFD), or very soon thereafter. We paid particular attention to the “pros” of proactive maneuvers associated with early mobilization, and realized that we must educate our patients, our families, our nurses, and ourselves, to improve patients’ health and reduce LOS.
Role of prehabilitation, protein drinks, and earlier rehabilitation in improving outcomes and reducing LOS in spine surgery
Nielsen et al. assessed whether prehabilitation in addition to early rehabilitation would improve outcomes following spinal surgery.[
Benefits of early mobilization in spinal surgery
Early mobilization of spinal cord injury patients decreased morbidity and LOS
In Wang et al. retrospective analysis of patients who sustained acute spinal cord injuries, the interval between surgery and patient mobilization was correlated with postoperative complications and LOS.[
Early tracheostomy allows for early mobilization following acute spinal cord injuries, and decreases morbidity and LOS
Babu et al. observed that after spinal cord injury, patients often require not only anterior cervical spine fixation (ACSF), but also tracheostomies.[
Benefits of early mobilization in other medical/surgical subspecialties
Early mobilization (day of surgery) decreases LOS for total joint replacement surgery
Tayrose et al. noted that utilizing a protocol that required early mobilization following total joint replacement (TJR) enhanced postoperatively recovery, while reducing costs and LOS.[
Benefits of respiratory therapy and early physiotherapy for children undergoing lung resections
Kaminski et al. evaluated the benefits of early respiratory therapy (e.g., including mask positive expiratory pressure, expiratory rib cage compression, and coughing) and physiotherapy (e.g. arm lifting and walking in <4 postoperative hours/and continued for 3 times/day) in 52 children undergoing lung resections versus 71 controls (who did not receive these early therapies).[
Early ICU mobility therapy minimizes LOS for adults with respiratory failure
Utilizing a prospective cohort, Morris et al. instituted an active early mobility/PT (“Mobility Team”) protocol versus the “usual care” (control group) to treat patients with acute respiratory decompensation who required mechanical ventilation at the time of admission to a medical ICU.[
Impact of fast-track cardiac care including early extubation and early mobilization on mortality, morbidity, LOS, and cost
For adult cardiac patients undergoing surgery in the Zhu et al. study, the impact of fast-track cardiac care was specifically aimed at early extubation, and hence early mobilization, to reduce the LOS in ICUs, and total hospital LOS.[
Benefits of early mobilization of intensive care unit patients on mechanical circulatory support following cardiac surgery
Freeman et al. previously observed that following cardiac surgery, if ICU patients on mechanical circulatory support were kept in bed, it increased their risk of venous thromboembolism (DVT)/pulmonary emboli (PE), poorer/reduced pulmonary function that increased risk of PN, longer LOS, further deconditioning, and a greater need for postoperative rehabilitation.[
Better recovery following bariatric surgery utilizing early mobilization
Awad et al. noted few protocols like the “Enhanced Recovery After Bariatric Surgery (ERABS)” were utilized in patients undergoing bariatric surgery.[
Physician accountability in reducing costs and/or LOS
Increasing surgeons’ awareness of costs of implanted vs. explanted (“wasted”) instrumentation for single-level anterior diskectomy and fusion
Epstein, Schwall, and Hood evaluated the costs of devices (plates, screws, spacers) implanted versus explanted (wasted or removed prior to closure) during 87 single-level anterior cervical diskectomy and fusion surgical procedures (ACDF) performed over one year at a single institution.[
Surgeon education reduces the cost/frequency of explantation for single level ACDF at one institution
Epstein, Schwall, and Hood then demonstrated how making surgeons aware of waste/explantation (the cost of implanting devices but removing them prior to closure) occurring during single-level ACDF would substantially reduce costs.[
Reduction of unnecessary LOS while improving care by making physicians accountable
Caminiti et al. observed that more than 20% of hospital LOS is inappropriate, wastes resources, and increases iatrogenic risk.[
Major factors impacting hospital costs for spinal surgery
Hospital costs attributed to extent of neuromuscular scoliosis surgery.
Diefenbach et al. evaluated whether the hospital, operating room, and hospital bed/stay costs of performing “neuromuscular scoliosis” (NMS) surgery in 74 patients could be reduced.[
Endocrine abnormalities (Diabetes, Hypothyroidism) Increase LOS for Patients Undergoing Spinal Surgery
Walid and Zaytseva noted that prior studies correlated increased LOS for spine surgery with diabetes, but that these studies did not include assessment of attendant hypothyroidism.[
Complications (based on comorbidities) and optimal selection of patients impacts LOS for patients undergoing spine surgery
Can the frequency of complications following spine surgery, which lengthen LOS, be predicted?
Bekelis et al. modeled the frequency of complications following spinal surgery using the National Surgical Quality Improvement Program (NSQIP) between 2005 and 2010.[
Obese class III spinal patients increase complications and LOS for spinal surgery
Buerba et al. identified 10,387 patients undergoing spinal surgery from the American College of Surgeons (ACS)-NSQIP database (2005-2010) who were considered “class III obese” ((≥40 kg/m2: 6.9%).[
Timing of cervical surgical admission significantly impacts LOS
Outcomes of cervical trauma surgery based on weekday vs. weekend admissions
In Nandyala et al. retrospective study based on a 34,122 Nationwide Inpatient Sample (2002-2011), the outcomes of cervical trauma surgery (anterior cervical fusions (ACF 11.5%,), posterior cervical fusion (PCF 19.9%), or combined fusions (anterior posterior cervical fusion (APCF) 17.2%)) were analyzed for patients admitted/operated on during the week versus over a weekend.[
Reduction of LOS and costs in other surgical specialties
Prophylactic gastrostomy for Head and Neck cancer
When Hughes et al. evaluated patients with head/neck cancer undergoing chemotherapy/radiation, they considered the benefits of prophylactic gastrostomy to maintain nutritional status, and potentially improve patient outcomes.[
Prophylactic gastrostomies were performed in 165 patients undergoing radical chemoradiation for head/neck cancers; this resulted in fewer complications, fewer admissions/readmissions, and shorter LOS versus those not receiving gastrostomies. The authors concluded that preventive placement of gastrostomy tubes for this patient population significantly decreased hospital admissions/readmission rates and LOS, thereby reducing hospital costs, and increasing bed availability (increasing income).
Increased morbidity/mortality and LOS attributed to sepsis: a reason to curtail unnecessary hospitalization
The de Kraker et al. study involving 31 countries participating in the European Antimicrobial Resistance Surveillance System (EARSS), assessed the unnecessary deaths and hospital costs due to sepsis attributed to prolonged LOS.[
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