Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

ABSTRACT

INTRODUCTION The unnecessary overuse of ED services in the United States leads to an estimated wasteful spending of $38 billion yearly. The burden of these visits is multiplied in pandemics and times of crisis, such as the COVID-19 pandemic, during which ED resources may already be overwhelmed. Post-operative Emergency Department (ED) visits following suboccipital decompression in CM-1 patients are not well described. METHODS A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. Pre-operatively and post-operatively prior to hospital discharge, patients are counselled extensively on activity restrictions after surgery, incision care, expectations of severe headache and neck stiffness for the first few weeks after surgery, the variability in degree and timing of symptom improvement from patient to patient, and the proper intake of analgesics, as prescribed. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS). RESULTS In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%). Concentration disturbance at presentation was the only factor significantly associated with a post-operative ED visit (P = .023). The occurrence of a post-operative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted OR of CCOS≥13 = 0.35, P = .021;adjusted OR of CCOS≥14 = 0.38, P = .016). CONCLUSION Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of post-operative ED visits, which are mostly due to pain-related complaints, despite preoperative and postoperative counselling. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of post-operative ED service utilization are warranted.