MINIMALLY INVASIVE TUBULAR DECOMPRESSION OF THE SPINE: ANALYSIS OF HOSPITAL STAY AND COSTS

DESCOMPRESSÃO TUBULAR MINIMAMENTE INVASIVA DA COLUNA VERTEBRAL: ANÁLISE DE PERMANÊNCIA HOSPITALAR E CUSTOS

DESCOMPRESIÓN TUBULAR MÍNIMAMENTE INVASIVA DE LA COLUMNA VERTEBRAL: ANÁLISIS DE ESTANCIA HOSPITALARIA Y COSTES

ABSTRACT

Introduction:

Minimally invasive tubular surgeries are an option for neural decompression in the spine. Despite its advantages described in the literature, controversy persists regarding its safety in reducing the length of hospital stay.

Objective:

To evaluate the readmission rate and hospital costs of patients discharged within 24 hours after minimally invasive tubular decompression.

Methods:

Retrospective comparative analysis of patients undergoing tubular decompression of the spine between 2017 and 2023 who had no perioperative complications. One group was made up of patients who were discharged from hospital within 24 hours after the end of the surgery, and the other was made up of patients who were discharged after this period. Data regarding costs and readmissions/reoperations within 180 days after hospital discharge were compared.

Results:

The sample consisted of 179 patients, 167 of whom were discharged early. There were 18 cases of readmission/reoperation within 180 days, and all were cases from the group that received early discharge. The main reason for readmission was recurrence (61.1%). Total hospital costs were higher in the “non-early” group, with an average of R$30,756.00, representing a 40.39% higher percentage expense when compared to the “early discharge” group.

Conclusion:

Microsurgical tubular decompression of the spine is a technique that enables safe early discharge and does not increase the risk of readmission within 180 days. Patients who were discharged early had lower hospital costs related to hospitalization. Level of evidence III; Retrospective Comparative Study.

Keywords:
Decompression; Spine; Hospital Costs; Length of Stay; Patient Discharge; Patient Readmission

RESUMO:

Introdução:

Cirurgias tubulares minimamente invasivas são opção para descompressão neural na coluna. Apesar de suas vantagens descritas na literatura, persiste uma controvérsia quanto à segurança em reduzir o tempo de internação hospitalar.

Objetivo:

Avaliar a taxa de readmissão e os custos hospitalares de pacientes que receberam alta hospitalar em até 24 horas após descompressão tubular minimamente invasiva.

Métodos:

Análise retrospectiva comparativa de pacientes submetidos a descompressão tubular na coluna vertebral, entre 2017 e 2023, que não apresentaram intercorrências perioperatórias. Um grupo foi composto por pacientes que receberam alta hospitalar em até 24 horas após término da cirurgia, e o outro por pacientes que receberam alta após esse período. Foram comparados dados referentes a custos e readmissões/reoperações em até 180 dias após a alta hospitalar.

Resultados:

A amostra foi composta por 179 pacientes, sendo que 167 receberam alta precoce. Houve 18 casos de readmissão/reoperação em até 180 dias e todos foram casos do grupo que recebeu alta precoce. O principal motivo de readmissão foi recidiva (61,1%). Os custos hospitalares totais foram maiores no grupo “não precoce”, com média de R$ 30.756,00, que representou gasto percentual 40,39% maior, quando comparado com o grupo “alta precoce”.

Conclusão:

Descompressão tubular microcirúrgica da coluna vertebral é uma técnica que viabiliza a alta precoce segura e que não aumenta o risco de reinternação em até 180 dias. Pacientes que receberam alta precoce tiveram menores custos hospitalares referentes à internação.

Nível de evidência III; Estudo Retrospectivo Comparativo.

Descritores:
Descompressão; Coluna Vertebral; Custos Hospitalares; Tempo de Internação; Alta Hospitalar; Readmissão do Paciente

RESUMEN:

Introducción:

Las cirugías tubulares mínimamente invasivas son una opción para la descompresión neural en la columna. A pesar de sus ventajas descriptas en la literatura, persiste la controversia sobre su seguridad para reducir la estancia hospitalaria.

Objetivo:

Evaluar la tasa de reingreso y los costos hospitalarios de los pacientes dados de alta dentro de las 24 horas posteriores a la descompresión tubular mínimamente invasiva.

Métodos:

Análisis comparativo retrospectivo de pacientes sometidos a descompresión tubular de columna, entre 2017 y 2023, que no tuvieron complicaciones perioperatorias. Un grupo lo formaron los pacientes que fueron dados de alta del hospital dentro de las 24 horas posteriores a la finalización de la cirugía y, el otro, los pacientes que fueron dados de alta después de este período. Se compararon los datos sobre costos y reingresos/reoperaciones dentro de los 180 días posteriores al alta hospitalaria.

Resultados:

La muestra estuvo compuesta por 179 pacientes, 167 tuvieron alta temprana. Hubo 18 casos de reingreso/reoperación dentro de los 180 días y todos fueron casos del grupo que recibió el alta temprana. El principal motivo de reingreso fue la recurrencia (61,1%). Los costos hospitalarios totales fueron mayores en el grupo “no temprano”, con un promedio de R$ 30.756,00, lo que representó un gasto porcentual 40,39% mayor cuando comparado al grupo “alta temprana”.

Conclusión:

La descompresión tubular microquirúrgica de la columna vertebral es una técnica que permite el alta temprana segura y no aumenta el riesgo de reingreso dentro de los 180 días. Los pacientes que fueron dados de alta tempranamente tuvieron menores costos hospitalarios relacionados con la hospitalización. Nivel de evidencia III; Estudio Comparativo Retrospectivo.

Descriptores:
Descompresión; Columna Vertebral; Costos de Hospital; Tiempo de Internación; Alta Hospitalaria; Readmisión del Paciente

INTRODUCTION

In 1934, Mixter and Barr described the first surgery to remove an intervertebral disc fragment,¹ to relieve direct pressure on neural structures. In the 1970s of the 20th century, Caspar introduced the use of the microscope, a relevant factor for obtaining better clinical outcomes due to the possibility of magnification and better surgical field illumination.²,³ The use of tubular retractors for lumbar decompression was popularized by Foley et al., which led to smaller incisions and dissections.⁴

In recent decades, several studies have evaluated the efficacy and safety of tubular surgeries for neural decompression in the spine, with short- and medium-term clinical results superior to open surgeries.⁵,⁶,⁷ Other advantages of tubular surgeries were lower consumption of postoperative analgesics and early postoperative ambulation.³ Furthermore, the overall complication rate in minimally invasive surgeries was 20% lower than in open surgeries.⁷

With the exponential increase in medical costs related to hospitalizations, mainly linked to associated surgeries, the analysis of hospital stay duration after spinal surgeries has gained relevance in recent years.⁸,⁹,¹⁰ Likewise, refining surgical techniques and postoperative discharge protocols.⁶,⁹,¹⁰ The main concern about performing outpatient surgeries is related to their safety and the potential need for unplanned readmissions.

In this way, controversy persists over the rate of readmissions, reoperations, and hospital costs resulting from early medical discharge after spinal surgeries.

METHODS

A comparative retrospective analysis was performed on patients who underwent tubular micro-surgical neural decompression in the spine between 2017 and 2023. The analyses were carried out using an institutional database. A single senior surgeon performed all surgical procedures. The data was anonymized, so it was impossible to identify any individual in the sample, which exempted the need for the application of the Free and Informed Consent Term. The Institutional Research Ethics Committee approved the study, protocol CAAE 67102322.3.0000.0071.

All patients had symptoms of neural compression (cervicobrachialgia, cruralgia, sciatica, or neurogenic claudication) confirmed by cervical or lumbosacral magnetic resonance imaging and underwent microdiscectomy and/or tubular decompression of the lateral recess and/or foraminotomy procedures. The surgeries were performed with microscopy (Zeiss, Pentero) and a system of tubular retractors with a diameter of 14 to 18mm (Medtronic, Metrx). (Figure 1)

Figure 1
Lumbar decompression with tubular retractors: A - coronal view diagram of the tubular retractor system (Medtronic, Metrx); B - Intraoperative image using the tubular retractor for lumbar microdiscectomy procedure.

Adult patients over 18 years of age with symptoms of neural compression in any segment of the spine who had failed conservative treatment for at least six weeks and with at least one year of postoperative follow-up were included. Urgent cases with myelopathy or radicular compression with strength less than or equal to three were considered urgent and immediately referred for surgery.

Patients who presented intraoperative complications, such as incidental durotomy, as well as perioperative clinical complications that made early discharge unfeasible, such as deep vein thrombosis, pneumonia, and paralytic ileus, were excluded. Patients who underwent open or endoscopic procedures and those who underwent arthrodesis were also excluded.

Two groups were formed for comparison: one composed of patients who were discharged from the hospital within 24 hours of the end of the surgical procedure (“Early Discharge” Group) and another composed of patients who were discharged from the hospital after 24 hours (“Non-Early Discharge” Group).

Data regarding readmissions and/or reoperations within 180 days after hospital discharge were compared. Furthermore, the total average cost and percentage between the two groups were also compared. The data obtained were subjected to statistical analysis and compared.

The data was recorded in a Microsoft Excel® spreadsheet for MAC and later imported into the Jamovi® Application, which uses R language for data analysis. In the descriptive statistical analysis, continuous data were described by the mean + standard deviation (sd) and categorical data by their absolute number of occurrences and their proportion within the categories of each variable. In inferential statistical analysis, continuous data were tested for their distribution using the Shapiro-Wilk test, and if the distribution was symmetric, the t-student test was used to compare groups; otherwise, the Mann-Whitney test was used. The chi-square test was performed to analyze the association between categorical data. Values equal to or less than 0.05 for type I errors were interpreted as statistically significant.

RESULTS

The sample consisted of 179 patients, with a mean age of 52.3+14.1 years, of which 56.4% were female. Of the sample, 167 patients were discharged early, and 12 patients were hospitalized for more than 24 hours, not considered for early discharge, as shown in Table 1. In both groups, there was a large majority of women compared to men. Age, weight, height, and BMI were similar in both groups.

Table 1
Sample group (early discharge x no early discharge).

Early discharge	N	Total	Proportion	P
Yes	167	179	0.933	<.001
No	12	179	0.067	<.001

Hypertension patients represented 16.2% of the cohort, and all belonged to the group that was discharged early. Diabetes mellitus was present in 9.5% of the patients and was similar in both groups. Smoking was reported by 6.1% of patients, which is higher in the group that did not receive early discharge (16.7%) than the group that received early discharge (5.4%). Cardiopathies were found in 3 patients, with 2 in the early discharge group.

Among the diagnoses, the most common was a herniated disc, 84.3%, and another 4.7% with a herniated disc associated with another spinal disease. The majority (88%) had no history of previous spinal surgery. The lumbar region was the most frequent region, with 96.1% of the cases, and proportionally, the cohort of patients who were discharged early had more cases in the lumbar region, 97.5%, compared to the group that was not discharged early, as in this group 25% of the cases were of tubular decompression in the cervical region. In the lumbar region, the most frequent level was L4-L5, which represented 44.5% of the cases, followed by the L5-S1 (or L5-S2 or L5-VT) level with 34.5%. Eighty-seven percent of the cases had one level involved, and only 12.7% had two or more levels involved. Twenty-five percent of the patients had some comorbidity, and the majority, 93.3%, were in the group that was discharged early. The sample description is represented in Tables 2, 3, and 4 below.

Table 2
Sex and comorbidity descriptors.

Early discharge	N	Female	Male	SAH	DM	Cardiopathy	Smoking
Yes	167	66 (39.5%)	101 (60.5%)	29 (17.4%)	16 (9.6%)	2 (1.2%)	9 (5.4%)
NO	12	7 (58.3%)	5 (41.7%)	0 (0.0%)	1 (8.3%)	1 (8.3%)	2 (16.7%)

Table 3
Weight, height, and BMI descriptors.

Early discharge	N	Weight	Height	BMI	Age
Yes	167	79.85 (±14.58)	1.72 (±0.10)	26.91 (±3.93)	51.9 (±13.8)
NO	12	78.55 (±13.61)	1.70 (±0.10)	27.09 (±4.64)	56.9 (±18.0)

Table 4
Region descriptors and level operated on the spine.

	Early discharge
Cervical/lumbar	Yes	No	Total
Cervical	4	3	7
% in line	57.1 %	42.9 %	100.0%
% in column	2.4%	25.0%	3.9 %
Lumbar	163	9	172
% in line	94.8 %	5.2 %	100.0%
% in column	97.6 %	75.0 %	96.1 %
Total	167	12	179
% in line	93.3 %	6.7 %	100.0%
% in column	100.0%	100.0%	100.0%
Level addressed	Yes	No	Total
c5-C6	0	1	1
C5-C7	1	0	1
C6-C7	3	2	5
L2-L3	2	0	2
L2-L3/L5-S1	1	0	1
L3-L4	4	3	7
L3-L5	6	2	8
L3-S1	4	0	4
L4-L5	75	3	78
L4-L5	2	0	2
L4-L6	1	0	1
L4-S1	4	0	4
L4-VT	1	0	1
L4-VT	1	0	1
L5-S1	58	1	59
L5-S2	1	0	1
L5-VT	3	0	3
TOTAL	167	12	179

Readmission within 30 days occurred in 5 cases (2.9%) in the group that was discharged early. Eighteen cases required readmission/reoperation up to 180 days, all of which were from the early discharge group, representing 10.1% of this cohort. There were no cases in the group that did not receive early discharge. Due to the small number of cases in this group, the difference was not statistically significant.

Nine patients underwent reoperation at the same site as the primary surgery within the first ninety days after the operation, all of whom were in the early discharge group. Regarding patients who underwent reoperation within six months after hospital discharge, 11 patients required reoperation, all of whom were from the early discharge group. Due to the small number of cases in the group that did not receive early discharge, the difference was not statistically significant.

As shown in Table 5, of the 18 cases that underwent readmission and reoperation, the majority, 61.1%, were due to hernia recurrence at the same previously addressed level, and 11.1% were due to a new hernia at another anatomical level. A 5.6% of the readmission/reoperation was due to contralateral recurrence, that is, recurrence of the hernia at the same previously addressed level but with symptoms and location of the hernia on the opposite side to the previously operated one. Twenty-two percent were subjected to readmission and reoperation due to the need for surgical revision, that is, due to suspected local hematoma, perineural fibrosis, or the presence of residual herniated fragment, in patients who left the surgical procedure with partial improvement of the clinical condition and maintained the complaint even after hospital discharge without significant improvement.

Table 5
Reasons for Readmission/Reoperation.

	Early Discharge
Reason		Yes	No	Total
new hernia at adjacent level	Observed	2	0	2
	% in line	100.0%	0.0%	100.0%
	% in column	11.1%	NaN	11.1%
Contralateral recurrence	Observed	1	0	1
	% in line	100.0%	0.0%	100.0%
	% in column	5.6%	NaN	5.6%
Hernial recurrence	Observed	11	0	11
	% in line	100.0%	0.0%	100.0%
	% in column	61.1%	NaN	61.1%
Review	Observed	4	0	4
	% in line	100.0%	0.0%	100.0%
	% in column	22.2%	NaN	22.2%
Total	Observed	18	0	18
	% in line	100.0%	0.0%	100.0%
	% in column	100.0%	100.0%	100.0%

Total hospital costs (excluding medical fees) were compared in both cohorts, with higher values observed in the group that did not receive an early discharge (average value of R$30,756.00), while in the early discharge group, the average value was R$21,885.00, as shown in Table 6. The values were adjusted to 2024 using a 5% correction per year.

Table 6
Values in Brazilian Reais. The values were adjusted to 2024 using a 5% correction per year.

	95% Confidence interva
	Early discharge	Ν	Average	Lower limit	Upper limit	Standard deviation	Minimum	Maximum
Total adjusted cost	Yes	167	21885	20909	22861	6386	9986	51805
	No	12	30756	25492	36021	8285	22568	47087

Furthermore, as the cost distribution was not asymmetric, Table 7 below shows the median, p25, and 75 values and the minimum and maximum values of the costs.

Table 7
Distribution of hospital cost.

			Percentiles
	Early discharge	Ν	25th	50th	75th
Total adjusted cost	Yes	167	18011	20261	24390
	No	12	24089	26720	36788

Finally, as evidenced in Table 8, the percentage difference in costs between the two groups was also evaluated, and it can be inferred that early discharge resulted in a 28.77% saving or that the group that did not receive early discharge represented a 40% higher expenditure compared to the group that received early discharge.

Table 8
Percentage difference in hospital costs between groups.

Results costs		95% CI
Lower		Upper
Difference	R$ 8,849.00	R$ 5,036.80	R$ 12,661.20
Economy	28.77%	16.38%	41.17%
Extra expense	40.39%	30.28%	52.79%

DISCUSSION

With the exponential increase in healthcare costs, especially due to prolonged medical hospitalizations after surgeries, there is a growing interest in early and safe hospital discharge.⁸,⁹,¹⁰,¹¹

No definitions were found in the current medical literature regarding early or late discharge for spine surgery. Thus, the present authors arbitrarily defined the 24-hour cutoff as a hospital day to divide the studied sample, thus creating “early discharge” and “non-early discharge” groups.

Some authors describe the need for shorter hospital stays for less invasive techniques for spine surgeries.¹⁰,¹²,¹³,¹⁴ Khan-Makoid et al., for example, through a retrospective study involving 223 patients undergoing procedures on the thoracic and thoracolumbar spine via anterolateral approach, showed that patients undergoing minimally invasive exposures with retractors had shorter hospital stays with lower rates of cardiopulmonary complications compared to those undergoing standard exposures.¹²

Similarly, Kumar et al. and Li et al. showed shorter hospital stays for percutaneous fixation with minimally invasive microsurgical separation surgery for metastatic tumors,¹³ and minimally invasive percutaneous endoscopic treatment for symptomatic lumbar disc herniation,¹⁴ respectively, compared to conventional open treatment.

A meta-analysis of 4 controlled and randomized studies evaluating a total of 523 patients showed that tubular microdiscectomy was superior in functional outcomes, with a greater improvement in the Oswestry Disability Index when compared to conventional microdiscectomy. However, there was no statistically significant difference in intraoperative complications, blood loss, and hospital stay.¹⁵

Linhares et al. evaluated the cost-effectiveness of outpatient lumbar discectomy through a cost analysis of 20 patients undergoing lumbar microdiscectomy with same-day discharge and 20 patients undergoing lumbar microdiscectomy with hospital admission, concluding that the outpatient lumbar microdiscectomy regime, i.e., with same-day discharge, had a lower average hospitalization cost, averaging 630.14 euros, compared to an average of 1477.66 euros for the hospital admission regime, which had an average hospital stay of 2.5 days.¹⁶

These results are in agreement with what we found since the early hospital discharge regime shows a percentage saving of approximately 28.77% when compared to the non-early discharge regime, so, as presented by Linhares et al., the average cost for the same-day discharge regime, in less than 24 hours after the lumbar microdiscectomy procedure, shows a significant reduction in costs with clinical results similar to the hospital stay regime that lasted an average of 2.5 days, that is, more than 24 hours after the surgical procedure.¹⁶

Segura-Trepichio et al., in turn, compared 67 patients, evaluating the length of hospital stay, costs, and readmission and reoperation rates in lumbar disc herniation surgery using standard posterior lumbar interbody fusion (PLIF) versus a new technique of dynamic interspinous stabilization with microdiscectomy. Although it does not specifically focus on discharge protocols and compares arthrodesis procedures with a form of interspinous stabilization and lumbar microdiscectomy, we can see that the latter group had an average hospital stay of 2.16 days, with lower hospital costs averaging 1066.22 euros per admission, while not showing significant differences in readmission and reoperation rates within 90 days.¹⁷

Similarly, probably due to the limited number of 12 patients who did not receive early discharge in our study, we did not find a significant statistical difference in readmission and reoperation rates within 180 days between the two groups analyzed. However, similar findings regarding lower hospitalization costs in patients undergoing microdiscectomy and subject to shorter hospital stays were maintained.

Other studies aiming to compare endoscopic discectomy techniques with lumbar microdiscectomy show shorter hospital stays with the endoscopic approach.¹⁸,¹⁹ However, after a prospective analysis of 440 patients with failed conservative treatment for lumbosciatica, who were divided into two groups of 220 patients, each undergoing foraminal endoscopic discectomy or lumbar microdiscectomy, no significant cost difference was evidenced between the two groups, with an average hospital stay of 2 days and five days, respectively.¹⁸

It is worth noting that, despite lower hospital costs, we found in our study a 10.1% rate of readmission/reoperation within 180 days, with 18 out of 167 patients who were discharged early being readmitted and reoperated. Furthermore, the main cause of reoperation/ readmission of the 18 patients who underwent tubular decompression in our study was hernia recurrence, accounting for up to 61.1% of this group.

In this way, we understand that the reoperation and read-mission rate within six months, or even within one year, is not directly related to the length of hospital stay or variations in minimally invasive surgical decompression techniques but rather to the degenerative disc disease itself. The analysis of larger and symmetrical cohorts, like the study by Gadjradj et al.,²⁰ comparing early discharge with stays longer than 24 hours in similar groups undergoing tubular decompression, could provide a better substrate for evaluating the true relationship between the readmission/reoperation rate and early or non-early discharge outcomes in this patient population.

Despite this, we found a readmission rate within 30 days similar to that described in the literature. According to Hoggett et al., in a retrospective study of 134 patients who underwent lumbar microdiscectomy and were discharged on the same day, a read-mission rate of 3% was found within 30 days, showing in agreement with our findings that the possibility of discharge in less than 24 hours from the tubular decompression procedure can be safe and effective.²¹

It is worth noting that the present study had limitations due to a small sample group of patients who did not receive early discharge and all surgeries being performed by only one surgeon. In this way, the reduced sample group is explained by the fact that early discharge for tubular micro-surgical decompression surgeries in the spine is standard in our practice in patients who do not present perioperative complications.

CONCLUSIONS

Micro-surgical tubular decompression of the spine is a technique that enables safe early discharge and does not increase the risk of readmission within up to 180 days. Patients who were discharged early had lower hospital costs related to hospitalization.

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Publication Dates

• Publication in this collection
  13 Sept 2024
• Date of issue
  2024

History

• Received
  28 Mar 2024
• Accepted
  24 June 2024