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- J Orthop
- v.37; 2023 Mar
- PMC9883175
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J Orthop. 2023 Mar; 37: 1–4.
Published online 2023 Jan 23. doi:10.1016/j.jor.2023.01.008
PMCID: PMC9883175
PMID: 36718421
Philipp Egenolf,a,∗ Maximilian Lenz,a Klaus John Schnake,b,c Arne Harland,a Stavros Oikonomidis,a Peer Eysel,a and Max Joseph Scheyerera
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Abstract
Study design
prospective, observational.
Background
Wound drainage's indwelling duration and general use are the centre of ongoing discussion. The aim of our prospective observational study was to evaluate the total drainage volume postoperatively and its course after lumbar interbody fusion surgeries to define an ideal point in time for drainage removal.
Methods
We included all patients who underwent monosegmental lumbar interbody fusion via transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). After application of the exclusion criteria, 27 patients were included in our study. Drainage volume was measured three times a day and at the time of drain removal.
Results
The PLIF group reached higher total drainage volume (337.14ml) than the TLIF group (215.5ml) (p=0.047. Drainage volume's plateau was reached after 33.0h (±1.8h) in the TLIF group and 25.3h (±1.7h) in the PLIF group following surgery.
Conclusions
Our study shows, that drainage volume did not increase significantly after the evening of the first postoperative day at latest. This was on average 33.0h after surgery. Therefore, extraction of the drainage tube hereafter can be assumed to be safe.
Keywords: Spinal fusion, Drainage, Spinal epidural hematoma
Highlights
•
PLIF has a higher postoperative drainage volume than TLIF.
•
Drainage volume does not increase after 33.0h following lumbar interbody fusion.
•
Established drainage indwelling times can potentially be reduced.
1. Introduction
Spinal surgery is a fundamental and increasing part of orthopaedic and neurosurgical treatment for various indications.1 Having one thing in common with every other specialty, complications can also happen in spine surgery. Most grave complications include surgical site infections (SSIs) and spinal epidural haematomas (SEHs).2, 3, 4 SEH can lead to spinal cord and nerve root compression, resulting in motoric and sensory loss as well as incontinence. SSI might result in extensive revision surgery, infectious embolization or sepsis.
In the assumption to prevent postoperative SEHs and seromas by allowing for a bypass instead of a local collection, closed wound drainage is commonly and regularly performed.5 However, a systematic review of the literature shows that evidence supporting the capability of drainage and therefore superiority of preventing SEHs is lacking.6 Most studies did not find an advantage of a drain over its absence.7, 8, 9 Wound healing has mainly not shown to be affected by a drain.10 However, the results are inconsistent.11
The second main indication for a drain is the thesis that local fluid collection is assumed to increase infection rates by preserving a breeding ground for bacteria. Interestingly, the majority of studies do not show significant differences between patients with and without a drain in regards to SSIs.11, 12, 13, 14 Some studies went even further by correlating drainage time with elevated risk of SSIs and duration of hospital stay.15,16
Since many surgeons continue using drains,17 the controversy described here leads to the primary objective of reducing drainage time. Therefore, it is necessary to identify the point in time at which drainage volume does not further increase significantly. Yet, no studies evaluated the course of drainage volume in spinal lumbar surgery.
The aim of this study was to describe the development of drainage volume after dorsal lumbar interbody fusion and determine the ideal drainage duration until removal.
2. Material and methods
2.1. Study design
In this observational study, we prospectively included all patients who underwent posterior monosegmental lumbar interbody fusion within a 1-year period. Inclusion criteria were one-level lumbar fusion via TLIF or PLIF and, due to measurement protocols, the presence of the patients on the orthopaedic ward during in situ drainage. Exclusion criteria were accidental extraction of the drainage before admission to the ward, pathological platelet count (<150.000/μL), tumour and infectious disease in the operated segment and postoperative SEH, assuming a potential malfunction of the drain. Previous minor operations like a decompression were no exclusion criteria.
The type of anticoagulant medication and thrombocyte count were also documented. All patients received at least prophylactic anticoagulant drugs in the form of subcutaneous low-molecular-weight heparin (LMWH) postoperatively once daily as the clinic standard. Patients in need of therapeutic anticoagulant drugs were, if possible, temporarily changed to an equivalent LMWH dosage, forming a subgroup (n=5). Therapeutic LMWH anticoagulation was paused 12h before surgery and reinstated 6h after surgery. All other patients did not receive anticoagulation before surgery.
2.2. Measurement protocol
All patients admitted to prospectively collecting their data for this study. One 12 Charrière (Ch) Redon tube was implemented at the end of surgery, guaranteeing submuscular placement. Vacuum of the drainage cavity was released to atmospheric pressure. The receptable was kept at the patient's bed (max. 10cm below wound level) and at his/her belt during mobilisation. Postoperative mobilisation protocol aimed to achieve sitting in the evening of the operation's day and mobilisation to a standing position and walking in the morning of the first postoperative day.
After surgery, the first measurement of DV was performed at readmission to the orthopaedic ward. From then on until removal, DV was documented three times a day. Measurement protocols were adjusted to fit the nursing schedule and therefore be implemented in the daily practice of nurses, resulting in the following times of measurement.
-
morning shift (MS): at the beginning of the morning shift, 07:00h
-
afternoon shift (AS): at the beginning of the afternoon shift, 14:00h
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night shift (NS): at the beginning of the night shift, 21:00h.
Removal of the drainage tube was performed by a surgeon if either drainage volume was below 50mL per 24h or at last 72h after surgery, due to clinic standards.
If the postoperative patients were referred from the intensive care unit to the orthopaedic ward, ongoing documentation of DV was performed.
2.3. Statistical analysis and material
Statistical analysis was performed using SPSS 26.0 (SPSS Inc., Chicago, IL, USA). The paired t-test (one-sided) for paired samples was used to detect statistically significant differences in DV development between times of measurement. The unpaired t-test was performed to evaluate differences between sex, technique and type of anticoagulation.
A p‐value less than p=0.05 was regarded statistically significant in all comparisons.
3. Results
In total, 32 patients were enrolled in the study over a period of 12 months. After exclusion of patients with insufficient measurement documentation, 27 patients (12 males, 15 females) remained in the study population.
The mean overall age was 59.2 years (range 23.0–84.8 years). Five patients receiving TLIF had therapeutic anticoagulant medication.
Due to later inclusion of intensive care patients, the number of patients per time of measurement increased over the observed duration. No patient needed revision surgery as a result of SEH.
Total drainage volume (TDV) differed significantly between techniques (p=0.047). The TDV in the PLIF group (337.14mL±165.0mL, n=7) was higher than that in the TLIF group (215.5mL±120.2mL, n=20).
Type of anticoagulation (p=0.137) and sex (p=0.109) did not account for significant differences. Although insignificant, it should be mentioned that the TDV in patients with therapeutic anticoagulation (162mL±107mL, n=5) was lower than in individuals with standard prophylactic anticoagulation (266.4mL±142.1mL, n=22). Average overall DV is shown in Table 1.
Table 1
Average drainage volume at times of measurement and distribution of independent parameters among operative techniques; mean and standard deviation in millilitres (ml), relative (Rel.) volume in percent (%), number of individuals (n). Times of measurement read as follows: NS0=night shift of the day of surgery; MS1=morning shift of the first postoperative day; AS1=afternoon shift of the first postoperative day.
| Time of Measurement | TLIF | PLIF | ||||||
|---|---|---|---|---|---|---|---|---|
| Mean (mL) | Std. deviation (mL) | Rel. volume (%) | Individuals (n) | Mean (mL) | Std. deviation (mL) | Rel. volume (%) | Individuals (n) | |
| Postop. | 114.0 | 71.1 | 45.5 | 15 | 130.0 | 63.2 | 37.9 | 6 |
| NS0 | 170.7 | 102.1 | 68.3 | 15 | 237.1 | 102.9 | 70.6 | 7 |
| MS1 | 190.3 | 96.8 | 86.3 | 19 | 308.6 | 170.4 | 90.6 | 7 |
| AS1 | 193.5 | 103.8 | 89.6 | 20 | 320.0 | 165.1 | 95.1 | 7 |
| NS1 | 202.5 | 106.6 | 93.3 | 20 | 330.0 | 162.9 | 98.2 | 7 |
| MS2 | 206.0 | 105.6 | 96.3 | 20 | 337.1 | 165.0 | 100.0 | 7 |
| AS2 | 213.0 | 114.4 | 99.5 | 20 | 337.1 | 165.0 | 100.0 | 7 |
| TDV | 215.5 | 120.2 | 100.0 | 20 | 337.1 | 165.0 | 100.0 | 7 |
| Independent parameters | TLIF | PLIF | ||||||
| Age (years) | 59.7 | 16.0 | 20 | 57.5 | 9.3 | 7 | ||
| Male gender | 55.0 | 11 | 14.3 | 1 | ||||
| Female gender | 45.0 | 9 | 85.7 | 6 | ||||
| Prophylactic anticoagulation | 75.0 | 15 | 100 | 7 | ||||
| Therapeutic anticoagulation | 25.0 | 5 | 0 | 0 | ||||
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The paired T-test showed a significant difference in DV until NS1 in the TLIF group (Table 2). On average, this was 33.0h (±1.8h) or 1.37 days after the end of surgery. At this point, overall DV equalled 93.3% (±18.9%) of individuals’ TDV.
Table 2
Development of absolute and relative drainage volume (DV) at times of measurement (measurement interval), separated by operative technique (TLIF/PLIF); mean and standard deviation (Std. dev.) in millilitres (mL) for absolute DV, in percent (%) for relative DV. p-values were calculated compared to the previous measurement interval. *=correlation cannot be computed because the standard error of the difference is 0.
| PLIF | TLIF | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| DV, absolute (mL) | Std. dev. (mL) | Significance, one-sided p | DV, relative (%) | Std. dev. (%) | DV, absolute (mL) | Std. dev. (mL) | Significance, one-sided p | DV, relative (%) | Std. dev. (%) |
| 130,0 | 63,2 | – | 32,5 | 15,8 | 140,0 | 71,1 | – | 45,5 | 20,5 |
| 237,1 | 102,9 | 0.003 | 70,6 | 10,8 | 200,0 | 102,1 | 0.001 | 68,3 | 25,3 |
| 308,6 | 170,4 | 0.032 | 90,6 | 8,7 | 220,0 | 96,8 | 0.001 | 86,3 | 13,9 |
| 320,0 | 165,1 | 0.033 | 95,1 | 8,3 | 220,0 | 103,8 | 0.001 | 89,6 | 19,9 |
| 330,0 | 162,9 | 0.108 | 98,2 | 4,7 | 220,0 | 106,6 | 0.01 | 93,3 | 18,9 |
| 337,1 | 165,0 | 0.178 | 100,0 | 0,0 | 220,0 | 105,6 | 0.065 | 96,3 | 11,1 |
| 337,1 | 165,0 | * | 100,0 | 0,0 | 220,0 | 114,4 | 0.110 | 99,5 | 2,2 |
| 337,1 | 165,0 | * | 100,0 | 0,0 | 220,0 | 120,2 | 0.165 | 100,0 | 0,0 |
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In the PLIF group, a significant increase in DV was measured until AS1, which was 25.3h (±1.7h) or 1.1 days after end of surgery (Table 2). On average, 95.1% (±4.7%) of individuals’ TDV was excavated.
Evaluation of the actual time until extraction in our clinical practice in accordance with our clinic standards revealed a mean indwelling time of 1.57 days after surgery (TLIF=1.7 days, PLIF=1.3 days).
4. Discussion
The aim of this study was to monitor drainage volume after lumbar spine fusion to indicate a safe window to remove the drain and limit indwelling duration.
DV increased significantly until the evening of the first postoperative day (NS1) in TLIF and the afternoon of the postoperative day (AS1) in PLIF patients. Having reached a mean of at least 93.3% of individual's DV at these points, a relevant EDH seems unlikely. The different times until reaching a DV plateau could be a result of different sample sizes between the two groups, resulting in a type II error in the PLIF group.
In comparison to our previous mean indwelling time in accordance to clinic standards, the point of DV saturation was reached earlier. Since no EDH was reported in the observed cases, the results of this study support earlier drain extraction without safety concerns.
TDV did not differ between sexes, which is in accordance with the literature.11,12,14 Mentioned authors also did not find differences in weight, age and operating time. A correlation of these additional factors with DV was impossible due to the limited number of patients.
In accordance with previous studies, TLIF and PLIF did significantly vary in drainage volume.19,20 The differences may result from TLIF's lesser surgical time, muscle dissection and decompression region. While one might argue that the relatively small numbers per group do not allow for generalization, the intraindividual interpretation (relative DV) allowed for partial hom*ogeneous evaluation. However, sample size is a limitation of our study.
Regarding anticoagulant drugs, Awad et al. described anticoagulation and coagulopathy as a risk factor for increased perioperative blood loss. The foundation of this conclusion was their retrospective analysis of 14,932 patients.21 Awad et al. pointed out, that LMWH does not increase the risk for EDH, if overmedication is avoided. Our results support this observation. DV of patients with therapeutic anticoagulation did not vary significantly from those receiving prophylactic anticoagulation. Therefor a bias of the results through inclusion of these patients is unlikely.
The strength of our observational study is its close meshed measurement protocol with relatively short intervals. Hereby, we were able to closely observe the progression of DV and were the first to define a point of saturation. The main limitation of this study lies in its relatively low sample size (n=28). As a result, it lacks strong evidence for generalization. Nevertheless, documented TDV matched previous observations for natural pressure drainage, supporting our results.14
5. Conclusions
In conclusion, DV increased significantly until the evening of the first postoperative day at last, which equalled a mean of 33.0h after surgery. Knowledge of our results can encourage surgeons to minimize the indwelling time of drains, resulting in reduced duration of hospitalization and higher patient safety.
Author statement
Philipp Egenolf.: Methodology, Formal analysis, Original Draft, Maximilian Lenz.: Visualization, Investigation, Klaus John Schnake.: Conceptualization, Review&Editing, Arne Harland: Investigation, Review&Editing, Stavros Oikonomidis: Review&Editing, Supervision, Peer Eysel: Supervision, Project administration, Max Joseph Scheyerer: Conceptualization, Review&Editing, Project administration.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Informed consent
All patients gave their informed consent prior to inclusion in this study.
Institutional ethical committee approval
This study was approved by the institutional review board of the authors’ affiliated institutions (Ethics approval number: 20–1100_2). Written consent was obtained from all participants.
Compliance with ethical standards
This study was approved by the institutional review board of the University Hospital Cologne (Ethics approval number: 20–1100_2). Written consent was obtained from all participants.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
None.
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