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. 2025 May;13(3):789-799.
doi: 10.1007/s43390-024-01032-5. Epub 2025 Mar 25.

Longitudinal impact of a perioperative pathway for spinal fusion in adolescent idiopathic scoliosis: a quality improvement project

Lorena V Floccari  1 , Michael T Bigham  2 , Matthew Holloway  3   4 , Kenzie D Lundqvist  3 , Alexandria Rundell  3 , Richard P Steiner  3 , Kenneth T Bono  3 , Todd F Ritzman  3
Affiliations

Longitudinal impact of a perioperative pathway for spinal fusion in adolescent idiopathic scoliosis: a quality improvement project

Lorena V Floccari et al. Spine Deform. 2025 May.

Abstract

Objective: Prior studies show that recovery pathway implementation after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) reduces length of stay (LOS) without increasing complications, but little is known about the sustainability and longitudinal outcomes of these initiatives. This study aimed to establish and continually improve a perioperative pathway for AIS patients undergoing PSF while tracking long-term LOS performance with iterative improvements.

Methods: Implementation of the AIS care pathway at a single freestanding tertiary children's hospital was initiated in January 2016 (Phase 1) with iterative annual changes and a comprehensive update in September 2021 (Phase 2). The pathway involves preoperative optimization, standardized protocols, multi-modal pain regimen, early transition to oral pain medications, and early and frequent mobilization. Outcomes were tracked longitudinally using quality-improvement methodology, and comparisons between each group were performed.

Results: Four hundred thirty six AIS patients (86 pre-implementation, 257 Phase 1, 93 Phase 2) who underwent PSF were included. Baseline patient demographics and Cobb angles were similar. Hospital LOS decreased from 5.1 days pre-implementation to 2.3 days in a stepwise fashion corresponding with pathway modifications. Intensive care unit (ICU) admissions decreased from 100% pre-implementation to 0% during Phase 2. Perioperative order set compliance increased from 0% pre-implementation to 100%. There were no significant increases in readmissions or reoperations. Direct hospitalization costs decreased by $5854.95 per case.

Conclusions: A multidisciplinary perioperative pathway for AIS patients undergoing PSF significantly reduced hospital LOS by 55% and direct costs by 11.3%. Continuous improvement and data monitoring led to sustained positive outcomes over eight years.

Level of evidence: III.

Keywords: Adolescent idiopathic scoliosis; Perioperative pathway; Posterior spinal fusion; Quality improvement.

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Conflict of interest statement

Declarations. Conflict of interest: The authors have no competing interests to declare that are relevant to the content of this article. JMP statistical software, v. 17, was used for statistical analyses. Ethical approval: This quality project did not require Institutional Research Board (IRB) approval for implementation, as it was not considered research. However, prior to additional retrospective chart review for analysis used in this publication, this study was reviewed and approved by the IRB as it was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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