Routinely Placing Drainage Tube in Patients with Anterior Cervical Surgery: Is It Really Necessary?
With the global acceleration of aging populations and changes in work and living habits, cervical spondylopathy has become increasingly prevalent, imposing significant economic and medical burdens on societies and governments. In the early stages of the condition, conservative treatment is typically employed. However, for patients with severe radicular symptoms and spinal cord compression, surgical intervention becomes necessary. Among the surgical options, anterior cervical spine surgery (ACSS) is the most widely used technique, encompassing procedures such as anterior cervical corpectomy and fusion, anterior cervical discectomy and fusion, and artificial cervical disc replacement. Since its introduction in 1955, ACSS has gained popularity due to its minimal trauma and low bleeding rates, effectively addressing compression caused by herniated discs and osteophytes. However, one of the most critical complications of ACSS is postoperative hematoma, which can lead to dyspnea and even life-threatening situations. To mitigate this risk, it has become conventional practice to place a drainage tube during ACSS, facilitating the removal of blood from the wound cavity and reducing the incidence of hematoma.
Despite the benefits of drainage tubes, there are notable drawbacks, particularly concerning the implementation of enhanced recovery after surgery (ERAS). ERAS, first proposed in 1997, emphasizes minimizing postoperative complications and accelerating patient recovery. The use of drainage tubes in ACSS can hinder ERAS by necessitating bed rest for one to three days post-surgery, increasing the risk of complications such as low back pain, urinary tract infections, and deep vein thrombosis. Additionally, the insertion of a drainage tube can cause localized pain and scarring, and the removal process can induce fear and anxiety in patients, thereby reducing overall satisfaction and experience. These disadvantages have led to the exploration of “no drainage” concepts in orthopedic surgery, which align more closely with ERAS principles.
Advancements in surgical techniques and hemostasis materials have significantly reduced operation times and intraoperative blood loss in ACSS, leading to a decreased incidence of postoperative hematoma. This progress has raised the question of whether routine drainage tube placement is still necessary. To investigate this, a retrospective analysis was conducted on 92 patients who underwent single- or double-level ACSS at West China Hospital of Sichuan University between 2016 and 2017. The study found that with sufficient hemostasis, 83.7% of patients had postoperative drainage volumes of less than 10 mL, and 94.6% had volumes of less than 30 mL. According to an expert consensus on ERAS in ACSS, the standard for removing drainage tubes is a volume of less than 50 mL per day. Therefore, the majority of patients in the study met the criteria for “no placement of drainage.”
The study identified several key factors influencing the decision to place a drainage tube. Preoperative clinical characteristics such as poorly controlled hypertension, weakened blood coagulation, and multi-level surgery (exceeding double levels) were associated with increased postoperative drainage volumes, indicating the need for drainage in these cases. On the other hand, postoperative drainage volume also depends on surgical techniques and intraoperative observations. Best practices include exposing the vertebral body through the intermuscular space using sharp dissection to avoid significant bleeding, verifying the absence of active bleeding or oozing within the spinal canal and around implants after decompression and implantation, ensuring careful hemostasis and observing for one to two minutes after suturing the longus colli, and reconfirming the absence of active bleeding before closing the incision. Additionally, drainage should be placed if the operation exceeds two hours or if cerebrospinal fluid leakage occurs.
Based on these findings, since 2018, Professor Hao Liu’s team has ceased placing drainage tubes in patients undergoing single- or double-level ACSS. In May 2020, a retrospective analysis of 488 patients with similar baseline characteristics was conducted. Among these, 236 patients underwent “no drainage tube” ACSS, and none experienced postoperative hematoma, suggesting that this approach is safe and feasible when postoperative drainage volumes are accurately evaluated. Furthermore, the clinical data of patients with and without drainage tubes were compared. While there were no significant differences in postoperative neurological functions and the incidence of dysphagia between the two groups, patients without drainage tubes had significantly shorter bed rest and hospitalization periods, experienced less pain and psychological stress, and reported higher satisfaction levels during the perioperative period.
In conclusion, the evidence suggests that not placing drainage tubes in ACSS patients is safe and feasible under meticulous surgical techniques and strict evaluation of postoperative drainage volumes. Patients without drainage tubes benefit from shorter recovery times, reduced pain, and improved overall satisfaction. However, the decision to forgo drainage requires a high level of surgical expertise and is not suitable for beginners. Future studies should focus on multi-factorial analysis of the factors influencing postoperative drainage volume in ACSS to further refine the criteria for drainage tube placement.
doi.org/10.1097/CM9.0000000000001253
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