Postoperative Care Pathways Following Lumbar Total Disc Replacement
Authors: Braxton Ernest , Wohlfeld Bryan J. , Blumenthal Scott , Bozzio Anthony , Buttermann Glenn , Guyer Richard , Idema Jocelyn , Laich Daniel , Morreale Joseph , Nikolakis Michael , Patel Atul , Price John Scott , Witt Jens-Peter , Zigler Jack , Martin Monika 
Published: November 2019

Study Design.
A modified Delphi method was used to establish consensus. Subject matter experts were invited to participate as the expert panel. Best practice statements were distributed to the panel. Panel members were asked to mark “agree” or “disagree” after a series of statements during several rounds until either consensus could be obtained or the practice method was deemed unable to achieve consensus.

Objective.
Lumbar total disc replacement (TDR) is acknowledged as an alternative to spinal fusion in appropriately selected patients. There is a lack of unanimity on the appropriate postoperative patient protocols and rehabilitation expectations for the procedure. The long-term viability of Lumbar TDR, further adoption in the community setting and specific patient outcomes are contingent on the existence of appropriate postoperative recovery programs.

Summary of Background Data.
Currently there are no established methods for postoperative care following lumbar TDR. Establishing a postoperative clinical pathway algorithm may improve patient outcomes with respect to lumbar TDR.

Method.
A lumbar TDR expert panel of 22 spine surgeons employed a modified Delphi method to drive consensus on postoperative care following single-level Lumbar TDR. The panel first reviewed literature and guidelines relevant to postoperative care following lumbar TDR. Panel members considered 21 survey questions intended to determine “standard-practice” postoperative care recommendations for patients who have undergone lumbar TDR for the initial recovery phase (0–4 wk) and rehabilitation (4–20 wk). Each panel member participated in a round of anonymous voting followed by a group discussion. Consensus was defined as 80% agreement or higher among the respondents.

Results.
Consensus was achieved in 11 of the 21 survey questions. There was a high degree of consensus around the key goals for both the initial recovery and rehabilitation phases, ceased use of narcotics for pain management by 4 weeks postoperative, unrestricted walking immediately following surgery, timelines for physical therapy (within 2–4 wk) and return to work based on level of activity (as early as 1 wk postoperative). Lack of agreement included the use of back bracing and timing of postoperative visits. Generally, panel members felt that patient expectations regarding return to function were different following lumbar TDR versus fusion and warrant further study.

Conclusion.
Surgeon and patient alignment around postoperative expectations may significantly affect the long-term results of lumbar TDR. This surgeon consensus study found agreement for immediate postoperative ambulation, rapid reduction in opioids within the first month, and early return to work. When expectations are appropriately set with patients preoperatively, both provider and patient have shared goals in the return-to-function process.

Level of Evidence: 5