Implementation and perioperative safety of a standardized multidisciplinary care pathway for percutaneous endoscopic transforaminal discectomy in patients aged ≥ 85 years: a two-center retrospective study

Abstract

Although the comparative effectiveness of multidisciplinary team (MDT)-supported percutaneous endoscopic transforaminal discectomy (PETD) has been reported in selected patients aged ≥ 85 years, less is known about the implementation and perioperative safety of a standardized MDT care pathway in routine practice. This study evaluated the implementation of such a pathway and characterized perioperative safety and process outcomes in this high-risk population. This two-center retrospective study included 80 consecutive patients aged ≥ 85 years with single-level lumbar disc herniation (LDH) and multiple comorbidities who underwent PETD under local anesthesia between July 2022 and July 2024. Twenty-eight patients (35.0%) from the First Affiliated Hospital of Guizhou University of Chinese Medicine (Center A) overlapped with the surgical cohort of our previously published multicenter study, whereas 52 patients (65.0%) from Qianxinan Autonomous Prefecture Hospital of Traditional Chinese Medicine (Center B) were newly included. The primary outcomes were pathway implementation and perioperative safety, including specialty-specific preoperative interventions, surgical postponement following MDT review, preoperative preparation time, intraoperative adverse events, Clavien-Dindo postoperative complications, time to ambulation, and postoperative length of stay. Pain and disability trajectories were assessed as secondary descriptive outcomes. Quantitative MRI findings in 25 patients, all from Center B and none overlapping with the previous cohort, were analyzed exploratorily. Preoperative medication or risk-factor optimization was performed in 73/80 patients (91.3%), including antihypertensive medication adjustment in 38, glycemic optimization in 23, geriatric assessment-based intervention in 13, and respiratory training in 3. Surgery was postponed after MDT review in 2 patients, both of whom subsequently underwent PETD after optimization. Mean preoperative preparation time was 2.31 ± 0.48 days, time to first ambulation was 3.35 ± 0.85 h, and postoperative stay was 2.30 ± 0.45 days. Four intraoperative adverse events were documented; all resolved without conversion to general or neuraxial anesthesia. Three postoperative Clavien-Dindo grade I events occurred, with no grade II-V complications recorded. Secondary VAS and ODI measures improved over follow-up. In the exploratory MRI subgroup, maximum disc-herniation diameter decreased from 6.3 ± 1.6 mm preoperatively to 2.0 ± 0.9 mm postoperatively, corresponding to a mean reduction of 4.3 ± 1.4 mm, with interobserver ICC 0.94 (95% CI 0.87–0.97). The findings support the feasibility of implementing a structured MDT perioperative pathway for carefully selected patients aged ≥ 85 years undergoing PETD but should not be interpreted as independent evidence of PETD efficacy or as evidence of a causal effect of MDT care. Prospective studies incorporating predefined pathway-adherence metrics and an appropriate comparator are warranted.