Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key?

Current trends in the surgical treatment of patients with adolescent idiopathic scoliosis (AIS) involve the use of high dependency unit (HDU) in the postoperative period. The British Scoliosis Society also recommends the availability of HDU support in the postoperative period for these patients. However, this practice may lead to unexpected theatre cancellations due to lack of availability of HDU bed on the day of surgery. We also hypothesize that this practice may eventually lead to longer inpatient stay for the patients. All AIS patients at our unit are managed on a paediatric ward postoperatively, without HDU support. The primary aim of the study therefore is to evaluate whether operating on AIS patients without HDU support is well tolerated practice. Secondary aims were to evaluate patient related outcomes, including length of stay (LOS), and postoperative analgesia requirements. Adolescents aged 12-17 years with idiopathic scoliosis deformity who were treated with posterior instrumented scoliosis (PIS) correction were included in this prospective cohort study. The study period was between 12 November 2012 and 6 August 2018. Twenty-two patients were included in the HDU group and 33 patients in the non-HDU group. These were two matched cohort groups. Data were collected on complication rates, LOS, analgesic requirements, time to bowel opening, and attainment of physiotherapy goals in the immediate postoperative period. Statistical analysis was performed using statistical software R (3.4.3). There were no complications in the non-HDU group and one pneumothorax in the HDU group. There was a significant reduction in the LOS from 7.4 days (SD ±2.3, CI 0.012) days, to 5.8 (SD ±1.4, CI 0.01) days in the non-HDU group (P = 0.0001). There was no significant difference statistically or clinically in opiate usage between the HDU group, 115 mg (SD ±60.7, CI 0.8) and the non-HDU group 116 mg (SD ±55.8, CI 0.6) (P = 0.609). However, there was an improvement in pain scores in the non-HDU group where oral analgesics only were used (P = 0.002). A cost saving of £2038.80 per AIS case was made in the non-HDU group. AIS surgery can be performed safely without the need for HDU support in healthy adolescents. An oral analgesia-based enhanced recovery regime compares favourably to patient-controlled analgesia (PCA) and indicates these patients can be managed safely with strong multidisciplinary support on a paediatric ward.