The Effect of Physical Therapy on Time to Discharge After Lumbar Interbody Fusion
Macki M, Zakaria HM, Massie LW, Dakroub B, and Chang V. The Effect of Physical Therapy on Time to Discharge After Lumbar Interbody Fusion. Spine J 2019; 19(9):S47.
BACKGROUND CONTEXT: With a lesser degree of tissue destruction and lower postoperative opiate burden, patients undergoing minimally-invasive spine surgery are primed to benefit from early mobilization, which can further enhance recovery and hasten rehabilitation after surgery. PURPOSE: To determine the role of physical therapy on earlier postoperative discharge after minimally-invasive transforaminal lumbar interbody fusion (TLIF). STUDY DESIGN/SETTING: Cohort study. PATIENT SAMPLE: All patients undergoing one- and two-level minimally-invasive TLIF for degenerative lumbar diseases were operated on by the senior author from January 1, 2016 until August 31, 2018. Demographic data, comorbidities, preoperative patient-reported outcomes (PROs), intraoperative parameters, and postoperative measures were abstracted from a prospectively maintained database, ie, Michigan Spine Surgery Improvement Collaborative (MSSIC). Data on ambulation were collected from the physical therapy notes. OUTCOME MEASURES: The primary outcome measure is postoperative length of acute care stay. Length of stay was divided into (1) discharge on postoperative day 1 (POD 1 cohort), (2) discharge on postoperative day 2 (POD 2 cohort), and (3) discharge on ≥3 postoperative days (POD ≥3 cohorts) to maintain three equal-time cohorts. METHODS: An ordinal logistic regression model was fitted to the data to estimate the effect of discharge on postoperative day 1 vs postoperative day 2 vs postoperative ≥ day 3. Anesthesiology (ASA) classification was used as a surrogate marker of comorbidity burden. RESULTS: Of the 90 patients, the day of first ambulation with physical therapy increased from a mean of 14.4 ± 9.6 hours after surgery in the POD 1 cohort, 19.2 ± 7.2 hours in the POD 2 cohort, to 24.0 ± 12.0 hours in the POD ≥3 cohort (p=0.009). Furthermore, mean distance ambulated upon first interaction with physical therapy decreased from 162.8 ± 127.5 feet in the POD 1 group, 111.2 ± 83.6 feet in the POD 2 group, to 58.7 ± 59.3 feet in the POD ≥3 group (p<0.001). The three cohorts did not differ in baseline (preoperative) PROs: Oswestry Disability Index, EQ-5D, Numeric Rating Scale–Back Pain, and Numeric Rating Scale–Leg Pain. Following a multivariable ordinal logistical regression controlling for disposition to rehab over home (ORadj=6.07, p=0.029), the odds of longer length of stay decreased by 35% for every 50-feet ambulated (p=0.014). Preoperative Oswestry Disability Index failed to predict day of discharge (ORadj=1.01, p=0.146). CONCLUSIONS: Time to first ambulation with a therapist independently increases the odds of earlier discharge. Regardless of preoperative patient-reported outcomes, ambulation remains a stronger predictor of discharge. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.