Article

Anterior cervical discectomy and fusion with plate fixation as an outpatient procedure

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Abstract

Outpatient cervical spine surgery has previously been described for posterior laminoforaminotomy and anterior microdiscectomy with allograft fusion. Anterior cervical discectomy and fusion (ACDF) with plate fixation has not, to our knowledge, been described as an outpatient procedure. The objective of this study was to evaluate the safety and feasibility of ACDF with instrumentation when performed as an outpatient in a free-standing ambulatory surgical center. Additionally, the authors sought to determine any patient selection bias and its effect on outcome. This study is a retrospective medical record review. The sample included all patients who underwent one or two level ACDF with plate fixation at levels C4-5 or below as an adjunct to autogenous iliac crest bone graft or structural allograft from 1998 to 2002 by the two senior authors. Complications were assessed clinically with special attention to dysphagia and respiratory complications. Inpatient lengths of stay and postoperative hospital admission or readmission were also measured. Thirty consecutive patients were treated at a free-standing ambulatory surgery center, whereas two control groups, each of 30 consecutive patients, had surgery performed in the hospital and were admitted overnight for observation. The first control group consisted of admitted patients before the commencement of patient selection for the outpatient group; the second control group was comprised of admitted patients who had surgery performed concurrently with the outpatient group. The study group was evaluated on the first postoperative day and 3 weeks after surgery. Ninety patients underwent ACDF plate fixation at 140 different levels. Forty patients were treated at one level, and 50 were treated at two levels. The three groups were comparable in age, sex, and body mass index. There were no major complications. Seven patients (13%) had minor postoperative complications among the controls: transient dysphagia in three (5%) and graft donor site pain in four (14%). Three patients (10%) in the outpatient group had minor complications (all had dysphagia). Among the controls, four patients (7%) had increased length of stay owing to complications. Four patients (7%) in the combined control group were readmitted for early complications; no patient was admitted for a complication after outpatient surgery. In the present study, selection criteria for outpatient surgery included one or two level involvement C4-5 or lower, absence of myelopathy, subjective neck size, and estimated operative time. The data did not otherwise suggest a difference in the surgical populations. The outpatient group had a lower complication rate compared with the controls. This was likely the result of selection bias. Transient dysphagia was the most prevalent complication in the outpatient group.

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... The 53 treated patients had no additional morbidity when compared to a control group. It was 2005 before a second study was published [7]. There has been tremendous growth in this procedure, as there are now 18 publications on this topic featuring more than 5000 patients. ...
... The higher rate in our study (7%) can be attributed to these cases being done early in our practice and to the related precautions. The presence of associated myelopathy [9,12,13] and two-level disc disease [7,9,10,14] is not a contraindication to ambulatory care according to the literature. Conversely, surgery in patients with three-level disc disease is anecdotal and not recommended [9,13]. ...
... In the patients who underwent fusion, we prefer using cages prefilled with bone substitute to prevent any morbidity associated with iliac crest bone graft harvesting, which we feel is too invasive in this context. However, an iliac bone graft with anterior plate has been used by some teams and has not delayed discharge [7,15,16]. Total cervical disc replacement in an ambulatory setting is as safe as performing fusion [17]. ...
Article
Introduction: In France, surgery for lumbar disc herniation is now being done in the outpatient ambulatory setting at select facilities. However, surgery for the cervical spine in this setting is controversial because of the dangers of neck hematoma. We wanted to share our experience with performing ambulatory anterior cervical discectomy in 30 patients at our facility. Results: Since 2014, 30 patients (16 men, 14 women; mean age of 47.2 years) with cervical radiculopathy due to single-level cervical disc disease (19 at C5-C6 and 11 at C6-C7) were operated at our ambulatory surgery center. After anterior cervical discectomy, cervical disc replacement was performed in 13 patients and fusion in 17 patients. The mean operative time was 38minutes and the mean duration of postoperative monitoring was 7hours 30minutes. The patients stayed at the healthcare facility for an average of 10hours 10minutes. One female patient (3%) was transferred to a standard hospital unit due to a neurological deficit requiring surgical revision with no cause identified. Two patients (7%) were rehospitalized on Day 1 due to dysphagia that resolved spontaneously. Thus the "ambulatory success rate" was 90% (27/30). There were no other complications and the overall satisfaction rate was excellent (9.6/10). Discussion: Outpatient anterior cervical discectomy is now widely performed in the United States. Ours is the first study of French patients undergoing this procedure. The complication rate was very low (< 2%) and even lower than patients treated in an inpatient hospital setting in comparative studies. Note that our patients were carefully selected for outpatient surgery as certain risk factors for complications have previously been identified (age, 3+levels, comorbidities / ASA> 2). No deaths in the first 30 days postoperative have been reported in the literature. Wound hematoma leading to airway compromise is rare in the ambulatory setting (0.2%). The few cases that occurred were detected early and the hematoma drained before the patient was discharged. Dysphagia is actually the most common complication (8% to 30%). Conclusion: Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. Our criteria are patients less than 65 years of age, single-level disease, ASA <2, and standard cervical morphology. The complication and readmission rates are low. Careful hemostasis combined with close postoperative monitoring for at least 6hours helps to reduce the risk of neck hematoma. Prevention of postoperative dysphagia must be a focus of the care provided.
... Four studies were based on an analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. 1,10,13,16,18,19,21,25,29,32,34,36 Here, we conducted the first single-institution, singlesurgeon comparison of outcomes between inpatient and outpatient ACDF with the advantage of diminishing the discrepancies that can arise from differences in the experience, technique, treatment protocol, and expertise of different surgeons. Like other authors, we analyzed 1-and 2-level surgeries, but we also evaluated patients who had undergone 3-and 4-level surgeries. ...
... In a literature review of PubMed, MEDLINE, and the Cochrane databases using the keywords "inpatient ACDF" and "outpatient ACDF," we identified a total of 12 peer-reviewed articles that compared different outcome parameters between inpatient and outpatient ACDF. 1,10,13,16,18,20,21,25,29,32,34,36 Four of these papers were multicenter propensity score-adjusted retrospective or prospective cohort studies of the NSQIP database. 10,13,18,21 Five studies were retrospective; 1 was prospective. ...
... The studies by Silvers and colleagues 29 and Liu and associates 16 had fewer than 110 patients each, which makes their results difficult to compare with the results of our study. The studies of Stieber et al. 32 and Trahan et al. 34 -which compared complication rates only between inpatient and outpatient ACDF-were in-cluded in our literature review, although these studies also had fewer than 120 patients each, which again makes comparison with our study difficult. ...
Article
OBJECTIVE Outpatient anterior cervical discectomy and fusion (ACDF) is becoming more common and has been reported to offer advantages over inpatient procedures, including reducing nosocomial infections and costs, as well as improving patient satisfaction. The goal of this retrospective study was to evaluate and compare outcome parameters, complication rates, and costs between inpatient and outpatient ACDF cases performed by 1 surgeon at a single institution. METHODS In a retrospective study, the records of all patients who had undergone first-time ACDF performed by a single surgeon in the period from June 1, 2003, to January 31, 2016, were reviewed. Patients were categorized into 2 groups: those who had undergone ACDF as outpatients in a same-day surgical center and those who had undergone surgery in the hospital with a minimum 1-night stay. Outcomes for all patients were evaluated with respect to the following parameters: age, sex, length of stay, preoperative and postoperative pain (self-reported questionnaires), number of levels fused, fusion, and complications, as well as the presence of risk factors, such as an increased body mass index, smoking, and diabetes mellitus. RESULTS In total, 1123 patients were operated on, 485 (43%) men and 638 (57%) women, whose mean age was 50 years. The mean follow-up time was 25 months. Overall, 40.5% underwent 1-level surgery, 34.3% 2-level, 21.9% 3-level, and 3.2% 4-level. Only 5 patients had nonunion of vertebrae; thus, the fusion rate was 99.6%. Complications occurred in 40 patients (3.6%), with 9 having significant complications (0.8%). Five hundred sixty patients (49.9%) had same-day surgery, and 563 patients (50.1%) stayed overnight in the hospital. The inpatients were older, were more commonly male, and had a higher rate of diabetes. Smoking status did not influence the length of stay. Both groups had a statistically significant reduction in pain (expressed as a visual analog scale score) postoperatively with no significant difference between the groups. One- and 2-level surgeries were done significantly more often in the outpatient setting (p < 0.001). The complication rate was 4.1% in the outpatient group and 3.0% in the inpatient group; there was no statistically significant difference between the 2 groups (p = 0.339). Significantly more complications occurred with 3- and 4-level surgeries than with 1- and 2-level procedures (p < 0.001, chi-square test). The overall average inpatient cost for commercial insurance carriers was 26% higher than those for outpatient surgery. CONCLUSIONS Anterior cervical discectomy and fusion is safe for patients undergoing 1- or 2-level surgery, with a very significant rate of pain reduction and fusion and a low complication rate in both clinical settings. Outpatient and inpatient groups undergoing 3- or 4-level surgery had an increased risk of complications (compared with those undergoing 1- or 2-level surgery), with a negligible difference between the 2 groups. This finding suggests that these procedures can also be included as standard outpatient surgery. Comparable outcome parameters and the same complication rates between inpatient and outpatient groups support both operative environments.
... This proposed strategy involves transitioning traditionally inpatient procedures to an ambulatory setting in appropriately selected patients to avoid costs associated with a standard postoperative hospital stay. Anterior cervical discectomy and fusion (ACDF), which has seen a significant decrease in hospital length of stay and complication rates, has become an increasingly attractive option to be performed on an outpatient basis [2]. At present, length of stay following ACDF averages under 2 days nationwide, with greater than 80% of patients being discharged within that time frame [3,4]. ...
... At present, length of stay following ACDF averages under 2 days nationwide, with greater than 80% of patients being discharged within that time frame [3,4]. To this end, multiple studies published in recent years have demonstrated that ACDF is increasingly performed as an outpatient procedure with discharge within ≤24 hours [2,[5][6][7][8][9][10][11]. ...
... Despite its potential for cost savings and perceived safety, outpatient ACDF is still relatively uncommon, with evidence on safety and outcomes limited to a few reports. Reports of outpatient ACDF date back to 2005 and were primarily in the form of case series from single, highvolume institutions [2,7,9,12,13]. These studies reported successful outcomes but are limited by comparatively small samples sizes, short-term follow-up and outcome measures, and significant practitioner and patient selection bias. ...
Article
Background context: With the changing landscape of healthcare, outpatient spine surgery is being more commonly performed to reduce cost and improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population. Purpose: To determine the nationwide trends and relative complication rates associated with outpatient ACDF. Study design/setting: Large-scale retrospective case control study PATIENT SAMPLE: Humana-insured patients who underwent 1-2 level ACDF as either outpatients or inpatients from 2011-2016 OUTCOME MEASURES: Incidence and adjusted odds ratio (OR) of postoperative medical and surgical complications within one year of the index surgery METHODS: A retrospective review was performed of the PearlDiver® Humana insurance records database to identify patients undergoing 1-2 level ACDF (CPT-22551 AND ICD-9-816.2) as either outpatients or inpatients from 2011-2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF. Results: Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the age 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R(2)=0.82, p=0.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, CI 1.27-1.96, p<0.001) and one year (OR 1.79, CI 1.51-2.13, p<0.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at one year postoperatively (OR 1.46, CI 1.26-1.70, p<0.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient (OR 1.25, CI 1.06-1.49, p=0.010). Adjusted rates of all other queried surgical and medical complications were comparable. Conclusions: Outpatient ACDF is increasing in frequency nationwide over the last several years. Nationwide data demonstrates greater risk of perioperative surgical complications including revision anterior and posterior fusion, as well as higher risk for postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.
... Anterior cervical spine discectomy and fusion (ACDF) is among the most prevalent spinal procedures currently performed in the United States; its indications include with symptomatic cervical spinal stenosis (CS), which can result from cervical spondylosis, or cervical degenerative disk disease [1][2][3][4][5]. ACDF for CS is generally highly successful and leads to symptom resolution in 70% of 90% of patients [6,7]. ...
... Overall complications are seen in 13.2-19.5% of patients, with higher numbers of operative levels and use of chronic steroids commonly reported as risk factors [8][9][10]. Dysphagia is among the most commonly reported complications following ACDF, with a prevalence of 8.1% reported from the NIS database in 2016-17 and clinical prevalence ranging from 35 to 71% [4,[11][12][13]. Potential changes in swallow physiology post-ACDF includes deficits in epiglottic inversion, reduced pharyngeal constriction, and hyolaryngeal excursion, each of which may be caused by post-surgical edema, muscular, and neurovascular injuries; the result is dysphagia [14,15]. ...
Article
Full-text available
Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016–2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.
... The few studies that include outpatient multilevel fusions also include 1-level fusions, which account for a majority of the study population. 3,[23][24][25][26][27][28][29][30][31][32] A number of large database studies, which include nationwide and state-wide data, have studied the outcomes and safety of 1-and 2-level ACDF in the outpatient setting. These include studies by McGirt et al 30 Humana insurance records database. ...
... A few smaller studies have also reported on the feasibility and safety of 1-and 2-level ACDF on an outpatient basis 26 and in outpatient ambulatory surgery centers. 3,24 These studies also found no increase in complication rates in the outpatient setting. ...
Article
Full-text available
Study design: Retrospective cohort study. Objective: To evaluate differences in patient factors, procedural factors, early outcomes and safety in mutlilevel anterior cervical discectomy and fusion (ACDF) in the inpatient versus outpatient setting. Methods: Patient demographics, operative factors, and outcomes of multilevel ACDF performed in an inpatient and outpatient setting were compared using Fisher's exact test for categorical and Student's t test for continuous variables. Results: Fifty-seven patients had surgery on an outpatient and 46 on an inpatient basis. Inpatients were older (56.7 vs 52.2 years, P = .012) and had a higher ASA (American Society of Anesthesiologists) class (P = .002). Sixty percent of 2-level cases were outpatient surgeries, compared with 35% of 3-level cases (P = .042). Outpatients had shorter operative times (71.26 vs 83.59 minutes, P < .0001) and shorter lengths of stay (8.51 vs 35.76 hours, P < .0001), lower blood loss (33.04 vs 45.87 mL, P = .003), and fewer in-hospital complications (5.3% vs 37.0%, P < .0001). Outpatients had better early outcomes in terms of 6-week Neck Disability Index (NDI) (27.97 vs 37.59, P = .014), visual analogue scale (VAS) neck (2.92 vs 4.02, P = .044), and Short Form-12 Physical Health Score (SF-12 PHS) (35.66 vs 30.79, P = .008). However, these differences did not persist at 6 months. Conclusions: The results of our study suggest that multilevel ACDF can be performed safely in the outpatient setting without an increased risk of complications compared with the inpatient setting in an appropriately selected patient. Specifically, patients' age, ASA class, and number of levels being fused should be taken into consideration. At our institution, ASA class 3, body mass index >40 kg/m2, age >80 years, intubation time >2.5 hours, or not having a responsible adult with the patient warrant inpatient admission. Importantly, the setting of the surgery does not affect patient-reported outcomes.
... A small number of studies that have reported on 1-level and 2-level cervical fusion surgery performed in the ASC setting, but the large majority of the cases in these studies were 1-level. [7][8][9][10] It is our belief that there is a lack of studies that specifically evaluate the safety and outcomes of 2-level ACDF performed in the ASC setting. Given the fact that more of these surgeries will be performed in ASCs, we feel it is important to understand which differences, if any, exist between patients undergoing 2-level ACDF in the ASC versus the hospital setting. ...
... The majority of studies that have reported on cervical fusion surgery performed in the ASC setting have included 1-level and 2-level fusions, with 1-level fusions accounting for over 60% of cases in those reports. [7][8][9][10] Sheperd and Young 7 evaluated the safety of 1-level and 2-level ACDF with instrumentation in the ASC setting. Of the 152 patients in this study, 67.8% were singlelevel procedures. ...
Article
Study design: This was a retrospective review of prospectively collected data. Objective: To evaluate differences in patient factors, procedural factors, outcomes and safety in 2-level anterior cervical discectomy and fusion (ACDF) performed in ambulatory surgery centers (ASCs) versus the hospital setting. Background: Emphasis on reducing health care costs has led to numerous surgeries across specialties being performed in ASCs. Because of short operative times and moderate postoperative pain, 1-level ACDF is one of the most common spine surgeries successfully performed in ASCs. Despite the success of single-level ACDF, concerns over postoperative complications, including respiratory compromise have curtailed the performance of 2-level ACDF in ASCs. Materials and methods: Patient demographics, operative factors and outcomes [blood loss, operative time, length of stay, complications and patient-reported outcomes (PROs)] of patients undergoing 2-level ACDF in an ASC and a hospital were compared using the Fisher exact test for categorical and the Student t test for continuous variables. Results: Of the 83 patients included, 25 underwent 2-level ACDF in an ASC, and 58 in a hospital. Mean age for the ASC group was 51.7±7.6 and 53.2±7.9 years for the hospital group (P=0.44). Body mass index was lower in the ASC group, at 27.3 kg/m versus 30.4 in the hospital group (P=0.03). Likewise, the ASC group had a lower ASA grade, favoring ASA 1 and 2 (P<0.001). There were no differences in blood loss (P=0.72) or complication rates, (P=0.16) with urinary retention being most common, and only 1 patient in the hospital setting requiring reintubation. In addition, no patients in the ASC setting required hospitalization. There were no differences in preoperative, 6-week and 6-month PROs. Conclusions: The results of our study suggest that 2-level ACDF can be performed safely in the ASC setting without increased risk of complications compared with the hospital setting in an appropriately selected patient. Specifically, body mass index, and ASA class should be taken into consideration. Importantly, the setting of the surgery does not impact early PROs. Level of evidence: Level 3.
... 13 Several authors have previously reported on the efficacy and safety profile of outpatient ACDF in the form of case series and retrospective reviews. 5,6,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] However, the lack of any large randomized control trial in the current literature coupled with the relatively low incidence of serious ACDF-associated complications, along with disproportionate amount of younger and healthier patients in the outpatient cohorts, have limited the generalizability of these works. More recently, multi-institutional database sources, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and various State Ambulatory Surgery and Services Databases (SASD), have provided groups with the ability to analyze the safety of outpatient ACDF at a more robust level in a much larger number of patients. ...
... Patient grouping is likely further modified by the dynamics of postoperative observation time, which again varies across papers. For example, Stieber et al15 monitored patients in the postanesthesia care unit for at least 10 hr postoperatively. In contrast, Lied et al 22 reported a time range of 3-12 hr observation period following surgery. ...
Article
Full-text available
Background: Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. Objective: To review the medical literature on the safety of outpatient ACDF. Methods: We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. Results: We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). Conclusion: Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.
... [6] Outpatient anterior cervical discectomy and fixation procedures are limited to the primary single level or the second level from C 4/5 to C 6/7 . [7] The surgical time should be limited to <2 h. Patients with recent spine trauma or infection, or those requiring posterior cervical fusion should be excluded from the outpatient surgery protocol. ...
... Patients with recent spine trauma or infection, or those requiring posterior cervical fusion should be excluded from the outpatient surgery protocol. [6,7] Do We Need Daycare Neurosurgery in India? ...
... We identified 1 case report (16), 2 case series (17,18), 10 prospective cohort studies (19)(20)(21)(22)(23)(24)(25)(26)(27)(28), and 53 retrospective cohort studies; the retrospective group comprised 2 studies from 1989 to 1999 (29,30), 13 from 2000 to 2009 (31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43), 13 from 2010 to 2014 (44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56), and 25 from 2015 to 2019 . The case report discussed one patient who presented 8 months after C6-7 ACDF with dysphagia and was found to have a hypopharyngeal diverticulum thought secondary to a spontaneous adhesion of the hypopharynx to the interbody graft. ...
... Among retrospective studies (n=735,073), overall rates of postoperative dysphagia ranged from 0.21% to 87.5% with a pooled incidence of 5.2%. Among retrospective studies reporting rates of chronic dysphagia (lasting greater than 3 months) (n=2,122) (30)(31)(32)(34)(35)(36)38,41,45,55,57,(60)(61)(62)74), incidence ranged from 0% to 21.7% with a pooled incidence of 0.8%. The presence of dysphagia was found to be a predictor for patient re-admission and increased length of stay postoperatively (18). ...
Article
The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
... The typical patient receiving outpatient ACDF is a healthy male 43-50 years of age with a BMI of 27-29 and ≤ 2 medical co-morbidities (most likely hypertension, diabetes, hypercholesterolemia or depres-sion) who has a cervical disc herniation and receives a single-level ACDF. [1][2][3][4][5] The relative good preoperative health of such patients has contributed greatly to the excellent reported outcomes of outpatient ACDF. 3,6 These outcomes, in combination with the potential savings in cost compared with inpatient ACDF have recently led to the rise of ACDF being performed on an outpatient basis. ...
... Further complicating our results is the inability of the NJ SASD to distinguish one-level from two-level operations, as the majority of previous studies have had a majority of onelevel ACDFs, whereas our results may have involved significantly more two-level ACDFs. [1][2][4][5][16][17][18][19] The previous studies were single-center analyses which may have been subject to reporting bias in order to favor the safety of outpatient ACDF, whereas the present study used a state database with larger numbers from multiple centers and standardized reporting. ...
Article
Background: Anterior cervical discectomy and fusion (ACDF) performed as an outpatient has become increasingly common for treating cervical spine pathology. Few reports have attempted to assess readmissions following outpatient ACDF. This study was performed to address this issue using population-based databases. Methods: The State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 was used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were extracted; those with three or more levels fused (ICD-9 codes 81.63-81.64), cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. A series of perioperative complications including durotomy, red blood cell transfusion, acute posthemorrhagic anemia, paraplegia (weakness), and mortality were examined. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of diagnoses. The NJ SASD defined readmission as admission to the same facility within seven days of initial discharge. Results: Two thousand sixteen (2,016) patients were found, 1,528 of whom had readmission data. Of these 1,528 patients, 83 (5.4%) required readmission. PSM was performed prior to comparing readmission versus non-readmission. While there was no difference in perioperative complications between the two groups, the small sample size of the readmission cohort prevented this analysis from having sufficient power. No patient requiring readmission had an initial length of stay greater than one day. Conclusion: Based on a 10-year outpatient analysis, fewer than 6% of outpatient 1-2 level ACDFs require readmission. Future studies involving outpatients from several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.
... A total of 397 articles were initially located in these electronic databases after the primary selection. Twelve [16][17][18][19][20][21][22][23][24][25][26][27] of those met all of the inclusion criteria. The other 388 articles were excluded for duplication, irrelevant studies, inappropriate data, inappropriate comparison, reviews, without a control group or not a full-text. ...
... Figure 1 shows the flow diagram that reflects the search process. Among the 12 article, seven [16,18,21,22,24,25,27] were subsumed into the meta-analysis, and the other five [17,19,20,23,26] were included to present the complications of the outpatient surgery. ...
Article
Full-text available
Background Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries and neurosurgical procedures performed to treat a variety of disorders in the cervical spine. Over the last several years, ACDF has been done in the outpatient setting for less invasive approaches and exposures, as well as modified anesthetic and pain management techniques. Despite the fact that it may be innocuous in other parts of the body, complications in the spine can literally be fatal. The objective of this article is to evaluate the safety of outpatient surgery compared with inpatient surgery in the cervical spine for adult patients. Methods The multiple databases including Pubmed, Springer, EMBASE, EBSCO and China Journal Full-text Database were adopted to search for the relevant studies in English or Chinese. Full-text articles involving to the safety of outpatient cervical spine surgery were selected. Review Manager 5.0 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted. Chi-square tests were conducted with SPSS 20.0 software. ResultsFinally, 12 articles were included. The results of meta-analysis suggested that in the articles included, no death occurred, and compared with inpatient surgery, outpatient surgery has a similar risk (RR = 0.99, 95 % CI [0.98, 1.00], P = 0.02; P for heterogeneity = 0.47, I2 = 0 %). An I2 value of 0 % indicates no heterogeneity observed. All complications were occurred in both outpatients and inpatients. Among the studies selected, after the outpatient spine surgery, the highest incidences of complication were dysphagia (18/29) and hematoma (4/29). Compared with the overall complication rate in inpatient group, no significant difference was observed (x2 = 1.820, P = 0.177). Conclusion In this study, outpatient surgery has a similar risk with inpatient surgery, and no difference of morbidity between outpatient and inpatient was found. Because of short operative time and moderate postoperative pain, we believe that outpatient cervical spine surgery is a safe and convenient alternative procedure, which also decrease the cost of care. Besides, postoperative complications including dysphagia and hematoma should be noticed.
... 31 These findings have been reproduced throughout the literature, validating ambulatory ACDF as safe and efficacious means to reduce hospital stays and their associated economic burdens to the health care system. [32][33][34][35][36] However, these studies were all performed utilizing anterior cervical plating methods, suggesting same-day discharge is safe for single-and 2-level ACDF. Our findings assist in extrapolating these results to include zero-profile implants utilized for ACDF, further validating the body of evidence for same-day discharge for single-and 2-level ACDF, regardless of implant design, as a safe practice. ...
Article
Full-text available
Study Design Retrospective cohort study. Objective To compare perioperative characteristics of stand-alone cages and anterior cervical plates used for anterior cervical discectomy and fusion (ACDF). Methods We reviewed 40 adult patients who received a stand-alone cage for elective ACDF and matched them with 40 patients who received an anterior cervical plate. We statistically compared operative time, length of stay, proportion of ambulatory cases, overall complications necessitating a trip to the ED, readmission, or reoperation related to index procedure. Results There were 21 women and 19 men in the plate cohort with average ages of 53 years ± 12 and 20 women and 20 men in the stand-alone group with an average age of 52 years ± 11. With no statistical difference in total number, the plate group experienced 4 short-term (within 90 days of discharge) complications, including 3 patients who visited the emergency department for dysphagia and 1 who visited the emergency department for severe back pain, while the stand-alone group experienced 0 complications. There was no significant difference in operative time between the stand-alone group (75.35 min) and the plate group (81.35 min; P = .37). There was a significant difference between the proportion of ambulatory cases in the stand-alone group (25) and the plate group (6; P < .0001). Conclusion Our results demonstrate that stand-alone cages have fewer complications compared to anterior plating, with a lower trend of incidence of postoperative dysphagia. Stand-alone cages may offer the advantage of sending patients home ambulatory after ACDF surgery.
... UKAs in the two settings generally utilize the same surgical technique and the same set of stan-dard operating procedures for the surgery, however the inpatient setting will have a longer process time. [9] The UKA standard operating procedure involves the removal of the damaged tissue, [5,10,11] as well as multiple measurements taken throughout the surgery using guides and sizing pieces for the different components of the implant. However, the one minute difference may not, in the end, be financially or clinically meaningful to the patient, payer, or provider. ...
Article
Objective: There is a lack of research on the impact of transitioning inpatient procedures to the outpatient setting, specifically on process time. Unicondylar knee arthroplasty (UKA) presents an opportunity for further investigation as it is already in the early stages of transitioning to the outpatient setting.Methods: This study analyzed the medical records of 1,075 patients who received UKA from a single surgeon (400 in the outpatient setting and 675 in the inpatient setting). Time in Pre-Op, surgery time, and time in post-anesthesia care unit (PACU) were recorded and compared between inpatient and outpatient settings using Ordinary Least Squares Regression models.Results: Outpatient UKAs outperformed inpatient UKAs across two out of three process time variables even after controlling for comorbidities, social history, demographics, and surgery related characteristics. Actual surgery time was no different between the two settings.Conclusions: This study demonstrated that UKA performed in the outpatient setting is associated substantial time savings preoperatively and postoperatively compared with cases performed in the inpatient setting. More research is needed to compare other outcome measures such as patient outcomes of UKA between the two settings. Implications beyond time savings should consider supply and human resources costs.
... Surgical mortality: 0 (0%), any complication: 51 (3.5%), same-day admission: 3 (0.2%), ad- mission w/in 3 mos: 22 (1.5%), hematoma: 9 (0.6%), neurological deterioration: 4 (0.3%), deep wound infection: 13 (0.9%), dural lesion & CSF leakage: 15 (1.0%), persistent dysphagia: 2 (0.1%), persistent hoarseness: 38,40,42,43 There were no reported deaths, and overall complication rates ranged from 0% to 2%. In these reports, only 1 patient required conversion to inpatient status for neck swelling and this patient did not require reoperation. ...
Article
Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.
... Several outpatient studies have demonstrated the safety of ACDF, as it relates to postoperative hematoma. 11,37,45,46 There was a 0% incidence rate of hematoma formation in this study similar to previous outpatient studies. A team member called all patients postoperatively and drain was removed after 24 hours by a trained medical staff member once there is no active drainage in the office. ...
Article
Study design: A single-center, retrospective study. Objective: To determine the safety and outcomes of total disc replacement (TDR) as an outpatient procedure in the ambulatory surgery center (ASC). Summary of background data: Anterior cervical discectomy and fusion (ACDF) has been demonstrated to be safe in the outpatient setting. As the awareness of same day surgery procedures is on the rise due to better outcome and shorter recovery time. There is a need for motion preservation in a subset of patients total disc replacement provides a solution. Transitioning spine surgery to the outpatient setting including cervical TDR is the next logical step. Methods: The medical records of 55 consecutive patients undergoing single level total disc replacement (Group 1) were compared to our control group of 55 patients who had single-level ACDF (Group 2). Outcomes assessed included VAS neck, arm, NDI scores, and complication rate. Results: 55 patients in Group 1 (TDR) 60% were male with the group's mean age being 42.6+/- 1.4 years and BMI 24.8+/-1.2 kg/m. 55 patients in Group 2 (ACDF) 57% were male with the group's mean age being 53+/-1.0 years and mean body mass index (BMI) 27.9+/-0.8 kg/m. There was no statistically significant intergroup difference in two year VAS neck, arm and NDI scores. Dysphagia was the most common postoperative compliant in both groups (6 patients), with no intergroup significance, p = 0.4. Conclusion: In the ambulatory setting, TDR has shown statistical significant intragroup improvement in VAS neck, arm pain scores and NDI scores (p < 0.001). In this study no patients reported serious complications; no incidence of hematoma formation or worsening postop pain. We conclude that single level TDR can be safely done in an ambulatory surgery center with satisfactory clinical and patient-reported outcomes. This is comparable to single level ACDF in the outpatient setting and previous 2 year TDR studies. Level of evidence: 3.
... Criteria for outpatient lumbar surgery have been stated to include stable chronic comorbidities, a BMI ≤ 42 kg/m 2 , as well as clearance from a [27]. Outpatient ACDF procedures are best limited to primary single or 2-level from C4/5 to C6/7 [28]. Surgical time should be limited to less than 2 h. ...
Article
Full-text available
Purpose of Review In this review, we will discuss the anesthetic approach to outpatient neurosurgical procedures: craniotomy for tumor, anterior cervical decompression and fusion, and lumbar discectomy. Recent Findings The anesthesia team must be involved for the entire perioperative period: preoperative screening in preadmission clinic to optimize patient comorbidities and to assess suitability for same-day discharge; judicious sedation and anesthesia with short-acting agents and minimally invasive surgical techniques to expedite surgeries and minimize complications; and aggressive treatment of pain, nausea, and vomiting coupled with vigilance for complications and assessment of readiness for discharge. Summary Successful day surgery programs focus on patient safety, optimized surgical and anesthetic techniques, and the selection and education of appropriate patients. The safety and feasibility of ambulatory neurosurgery depend on the development of stringent protocols and collaboration from nursing, surgery, and anesthesia teams.
... They typically report the incidence of dysphagia to be in the range of 1.25%-13.3%. 2,4,7,[12][13][14]18,19,23,24,29,35,[41][42][43][44]46,47 Prospective analyses featuring questionnaires report a higher rate of dysphagia, ranging from 20% to 71%. 5,15,[25][26][27][28][30][31][32]34,35,37,38,48,49 These prospective studies are comparable to the present study. ...
Article
OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors’ knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.
... 4 However, the true incidence is likely higher, as the subjective nature and underreporting by surgeons may decrease the reported incidence. 17,[27][28][29][30][31] Furthermore, some surgeons believe that dysphagia is an inevitable event during the postoperative period and not a complication. 7 Delayed dysphagia in the postoperative period can be associated with serious morbidity. ...
Article
Background: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure. Cerebrospinal fluid (CSF) leaks, although uncommon, may occur and can be a potentially serious complication. Little is known regarding the fusion rate after durotomy in ACDF. This study sought to investigate the clinical outcomes and fusion rates of patients with CSF leak after ACDF. Methods: In this single-institution retrospective review, 14 patients who experienced CSF leak after ACDF between 1995 and September 2014 were identified. Results: The median follow-up was 13.1 months. The diagnoses included spondylosis/degenerative disc disease (n = 10), disc herniation with radiculopathy (n = 3), and kyphotic deformity (n = 1). Of ACDFs, 7 were 1-level, 5 were 2-level, and 2 were 3-level procedures. The posterior longitudinal ligament was intentionally opened in all cases, and the microscope was used in 9 cases. Durotomy was discovered intraoperatively in all cases and was generally repaired with a combination of fibrin glue and synthetic dural replacement. Lumbar drainage was used in 5 patients, and 3 patients reported orthostatic headaches, which resolved within 1 month. Two patients reported hoarseness, and 8 patients reported dysphagia; all cases were transient. Follow-up imaging for fusion assessment was available for 12 patients, and a 100% fusion rate was achieved with no postoperative infections. Conclusions: ACDFs with CSF leak had a 100% fusion rate in this series, with generally excellent clinical outcomes, although it is difficult to conclude definitively that there is no effect on fusion rates because of the small sample size. However, given the relative rarity of this complication, this study provides important data in the clinical literature regarding outcomes after CSF leak in ACDFs.
... For spine surgery, the advancement of minimally invasive surgery is a key factor. Performing lumbar discectomies, lumbar laminectomies and anterior cervical discectomies and fusions (ACDFs) in the outpatient setting is certainly not a new phenomenon, but it is becoming increasingly more commonplace (5)(6)(7)(8)(9)(10). Minimally invasive lumbar fusions cases as well are now being performed in the ASC setting with success (11)(12)(13). ...
Article
Full-text available
Outpatient spine surgery performed in ambulatory surgery centers (ASCs) has grown dramatically over the last decade because of significant clinical and economic advantages to patients, physicians and the health care industry. Physicians benefit from the efficiencies of the outpatient setting and potential profit from ownership. There are various ownership models which differ primarily on the amount of ownership attributed to physicians, management companies and hospital systems, the key players in the space. The majority of ASCs are still solely owned by physicians, which gives physicians the benefit of maximum control but brings the challenges of management and contracting as well. Joint ventures involving various combinations of physicians, ASC management companies and hospital systems strive to find a balance between physician influence and management expertise from their partners. ASCs owned solely by hospital systems are on the rise and seek to involve physicians in a co-management role. Overall, the ASC market will continue to grow and alternative business models will arise as the key players look for the right combination to maximize efficiency and clinical success.
... ACDFs have been increasingly performed on an outpatient basis since 1996, when it was first introduced as a feasible option by Silvers et al. 14 Further early studies confirmed the safety of performing 1-2 level ACDFs on a carefully selected patient population. [15][16][17][18] These studies identified a very low rate of complications of up to 2% and only 1 patient converted to inpatient status for monitoring. However, as the largest sample size in these studies was 99 patients treated on an outpatient basis, they lacked power to demonstrate any statistical difference between the outpatient and inpatient cohorts. ...
Article
Full-text available
Study design: Broad narrative review. Objective: To review and summarize the current literature on the cost efficacy of performing ACDF, lumbar discectomy and short segment fusions of the lumbar spine performed in the outpatient setting. Methods: A thorough review of peer- reviewed literature was performed on the relative cost-savings, as well as guidelines, outcomes, and indications for successfully implementing outpatient protocols for routine spine procedures. Results: Primary elective 1-2 level ACDF can be safely performed in most patient populations with a higher patient satisfaction rate and no significant difference in 90-day reoperations and readmission rates, and a savings of 4000 to 41 305 USD per case. Lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper by as much as 12 934 USD per case and has better or equivalent outcomes to their inpatient counterparts. Unlike ACDF and lumbar microdiscectomy, short segment fusions are rarely performed in ASCs. However, with the advent of minimally invasive techniques paired with improved pain control, same-day discharge after lumbar fusion has limited clinical data but appears to have potential cost-savings up to 65-70% by reducing admissions. Conclusion: Performing ACDF, lumbar discectomy and short segment fusions in the outpatient setting is a safe and effective way of reducing cost in select patient populations.
... There is growing evidence in support of minimally invasive techniques for a number of spine surgeries that were traditionally performed in an open fashion (2)(3)(4). Additionally, there is evidence that performing these surgeries in an ASC setting can decrease medical costs compared to similar procedures previously performed in the hospital setting (5). However, for the surgeon considering performing ASC spine surgeries, there are a number of considerations that may not be immediately apparent. ...
... 18e23 Readmission rates following outpatient ACDF are also low, with some studies demonstrating readmission rates as low as 0%. 17,18,24,25 More recently, studies have shown favorable outcomes in the outpatient setting for multi-level ACDF's with similar outcomes and no associated increased risk of complications when compared to inpatient ACDF's. 16,26 Indeed, Fu et al. report increased complication rates following inpatient one-and-two level ACDF's when compared to outpatient counterparts. ...
Article
Introduction Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy. Methods 14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer's Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts. Results Upon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%). Conclusion ACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF's for myelopathy in comparison to their inpatient counterparts. Performing ACDF's for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.
... Despite the success of single-level ACDF in the ambulatory setting, concerns over post-operative complications have curtailed the performance of multilevel ACDF in the same setting. Even in studies that included 1-and 2-level procedures, 60-70% of reported cases were single-level surgeries (35,(40)(41)(42). Thus, there is little evidence to determine whether a greater number of operative levels is likely to result in an increased risk of complications and warrant a longer observation period. ...
Article
Full-text available
Due to the high societal and financial burden of spinal disorders, spine surgery is thought to be one of the most impactful targets for healthcare cost reduction. One avenue for cost-reduction that is increasingly being explored not just in spine surgery but across specialties is the performance of surgeries in ambulatory surgery centers (ASCs). Despite potential cost-savings, the utilization of ASCs for spine surgery remains largely limited to high-volume centers in the US, and predominantly for single- or two-level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) procedures. Factors most commonly cited for the lack of wider adoption include the risk of life-threatening complications, paucity of guidelines, and limited accessibility of these procedures to various patient populations. Thus, the future growth and adoption of ambulatory spine surgery depends on addressing these concerns by developing evidence-based guidelines for patient- and procedure selection, creating risk-stratification tools, devising appropriate discharge recommendations, and optimizing care protocols to ensure that safety, efficacy and outcomes are maintained. Other avenues that may allow for more widespread use of ASCs include the use of electronic health tools for post-operative monitoring after discharge from the ASC, increasing accessibility of ambulatory procedures to eligible populations, and identifying systemic inefficiencies and implementing process-improvement measures to optimize patient-selection, scheduling and peri-operative management. The success of ambulatory surgery ultimately depends not only on the surgical procedure, but also on its organization upstream and downstream. It provides an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.
Article
Objective: This study aims to assess the relationship of comorbidities and postoperative complications to rates of readmission for geriatric patients undergoing anterior cervical discectomy and fusion (ACDF) involving more than 2 levels on an inpatient or outpatient basis. With the rising costs of healthcare in the United States, understanding the safety and efficacy of performing common surgical interventions (including ACDF) as outpatient procedures could prove to be of great economic impact.Objective This study aims to assess the effect of comorbidities and postoperative complications on the rates of readmission of geriatric patients undergoing multilevel anterior cervical discectomy and fusion (ACDF) procedures (i.e., ACDF involving 3 or more levels) on an inpatient or outpatient basis. Same-day surgery has been demonstrated to be a safe and cost-effective alternative to the traditional inpatient option for many surgical interventions. With the rising costs of healthcare, understanding the safety and efficacy of performing common surgical interventions as outpatient procedures could prove to be of great economic impact. Methods: The study population included total of 2492 patients: 2348 inpatients and 144 outpatients having ACDF procedures involving 3 or more levels in the Medicare Standard Analytical Files database. Age, sex, comorbidities, postoperative complications, readmission rates, and surgical procedure charges were compared between both cohorts. For selected variables, logistic regression was used to model odds ratios for various comorbidities against readmission rates for both inpatient and outpatient cohorts. Chi-square tests were also calculated to compare these comorbidities with readmission in each cohort. Results: Overall complication rates within 30 postoperative days were greater for inpatients than for outpatients (44.2% vs 12.5%, p < 0.001). More inpatients developed postoperative urinary tract infection (7.9% vs 0%, p < 0.001), and the inpatient cohort had increased risk of readmission with comorbidities of anemia (OR 1.52, p < 0.001), smoking (OR 2.12, p < 0.001), and BMI ≥ 30 (OR 1.43, p < 0.001). Outpatients had increased risk of readmission with comorbidities of anemia (OR 2.78, p = 0.047), diabetes mellitus type 1 or 2 (OR 3.25, p = 0.033), and BMI ≥ 30 (OR 3.95, p = 0.008). Inpatients also had increased readmission risk with a postoperative complication of surgical site infection (OR 2.38, p < 0.001). The average charges for inpatient multilevel ACDF were significantly higher than for multilevel ACDF performed on an outpatient basis ($12,734.27 vs $12,152.18, p = 0.0019). Conclusions: This study suggests that ACDF surgery involving 3 or more levels performed as an outpatient procedure in the geriatric population may be associated with lower rates of readmissions, complications, and surgical charges.
Article
Study design: This was a systematic review study. Purpose: This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). Background: Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. Methods: This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. Results: Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). Conclusions: After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.
Article
Study design: This is a prospective cohort study. Objective: To define the probability of successful morning-after discharge after adult spine surgery achieved with a standard care protocol as applied to patients with a large variety of common degenerative spine disorders. Summary of background data: Qualifying criteria for ambulatory or overnight-stay adult spine surgery are not well defined in either the spine or anesthesia literature. Most reports simply go to ASA risk classification or surgical technique alternatives and do not present a clearly defined patient care and case management protocol. Methods: A standardize protocol of patient preparation, preoperative comorbidities optimization and perioperative care was applied in a prospective cohort of 126 patients including 83 lumbar and 41 cervical procedures. Office and hospital chart records were reviewed for relevant outcomes. Results: Fully 122 of 124 appropriately selected cases were able to successfully achieve uneventful same-day discharge without any need for readmission, unscheduled early ER or clinic visits, or other major complications. Both failures were for urinary retention in senior males and resolved after a single-day admission to the main hospital. Conclusions: A wide variety of common degenerative spinal pathology in adults can be routinely and safely managed on an overnight-stay basis without requirement for formal hospital inpatient admission in patients appropriately selected and pre-educated to the experience and whose major comorbidities are preoperatively optimized. Level of evidence: N/A.
Article
Study design: Delphi Panel expert panel consensus and narrative literature review OBJECTIVE.: To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)). Summary of background data: Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings is lacking. Methods: A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Pre-determined consensus was set at 70% for each best-practice statement. Results: A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and sub-categories) achieved consensus, including pre-operative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6). Conclusions: This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment. Level of evidence: 4.
Article
Spine procedures, including anterior cervical diskectomy and fusion (ACDF), are more commonly being performed in an outpatient setting to maximize value. Early complications after ACDF are rare but can have devastating consequences. The authors sought to determine risk factors for inpatient complications after 1-and 2-level ACDF by performing a retrospective review of the National Inpatient Sample (NIS) administrative database from 2006 through 2010. A total of 78,771 patients were identified. Multivariate logistic regression analysis was performed to identify preoperative risk factors for medical and surgical complications, including mortality, airway compromise, new neurologic deficit, and surgical-site infection. Inpatient mortality and overall complication rates were 0.074% and 3.73%, respectively. The risk of any medical complication was 3.13%. Airway compromise, neurologic deficit, and surgical-site infection occurred in 0.75%, 0.05%, and 0.04% of cases, respectively. Chronic kidney disease was the strongest predictor of mortality, with an odds ratio (OR) of 11.14 (P<.001). Airway complication was associated with age older than 65 years, male sex, myelopathy, diabetes mellitus, anemia, bleeding disorder, chronic obstructive pulmonary disease, obesity, and obstructive sleep apnea (P<.05). Preoperative diagnosis of myelopathy was most strongly associated with an increased rate of neurologic complication (OR, 6.67; P<.001). Anemia was associated with a significantly increased rate of surgical-site infection, with an OR of 14.34 (P<.001). Age older than 65 years; certain medical comorbidities, particularly kidney disease and anemia; and a preoperative diagnosis of myelopathy are associated with increased risk of early complication following ACDF surgery. Surgeons should consider these risk factors when deciding to perform ACDF surgery in an outpatient setting. [Orthopedics. 2021;44(5):e675-e681.].
Given the shift toward value-based healthcare, strategies that decrease risk in commonly performed procedures such as anterior cervical discectomy and fusion (ACDF) are of interest. The objective of this study was to analyze the effect of a two-attending surgeon team on the outcomes of patients undergoing single-level ACDF. A retrospective matched-cohort study of patients undergoing single-level ACDF for degenerative cervical spondylosis, with minimum 2-year follow-up was performed. Patients were subdivided into two cohorts: cases with procedures performed by one attending surgeon assisted by a resident physician and cases with procedures performed by an attending surgeon with another attending surgeon as first-assist. Patients were matched by age, sex, body mass index, smoking status, American Society of Anesthesia grade and Charlson Comorbidity Index. Perioperative data and complications were compared. Standard binomial and categorical comparative analysis were performed. Forty-two patients were included (21 in each group). There were 22 males and 20 females, with a mean age of 47.7 years and mean follow-up of 43.4 months. There were no differences in any demographic variable between groups, indicating successful matching. Cohort B had decreased anesthesia time (114.9 vs. 157.1 minutes, P < 0.001), operative time (58.1 vs. 98.9 minutes, P < 0.001) and blood loss (14.8 vs. 24.3 mL, P = 0.012). There were no significant differences in terms of post-operative complications including dysphagia, wound infection, neurologic or cardiovascular related complications. A two-attending surgeon team significantly reduces anesthesia time, surgical time, and blood loss in single-level ACDF procedures without an increase in complications or a decrease in fusion rates.
Article
Anterior cervical discectomy and fusion (ACDF) performed as an outpatient has become increasingly common for treating cervical spine pathology, largely due to its cost savings compared with inpatient ACDF. Nearly all outpatient ACDF patient reports have originated from single-center studies, with the procedure yet to be addressed via a meta-analysis of the peer-reviewed literature. The Entrez gateway of the PubMed database was used to conduct a comprehensive literature search for articles published in English up to 3/9/16. Data from studies meeting inclusion criteria (minimum of 25 patients, control group of inpatient ACDF patients, non-duplicative data source) was then categorized and assimilated for analysis. Seven studies met inclusion criteria, encompassing a 21-year timespan. Each provided Oxford Center for Evidence-Based Medicine Level 3 evidence. The studies yielded a total of 2448 outpatient ACDF patients; only 125 (5.1%) originated from studies published prior to 2011. Single-level surgery occurred in 63.8% of patients, with 0.5% extending beyond two-level fusions. The overall complication rate was 1.8% (mean follow-up of 141.2 days); only 2% of patients required readmission. In conclusion, outpatient ACDF has become increasingly popular, with more than 95% of patients represented by studies published since 2011. Nearly two-thirds of outpatient ACDFs underwent single-level fusion, with virtually none undergoing 3+ level ACDF. Outpatient ACDF is safe, with a low readmission rate and complication rates comparable to those (2–5%) associated with inpatient ACDF. These findings support an argument for increasing ACDFs performed on an outpatient basis in appropriately selected patients.
Article
Because of the increasing pressure to contain health-care-related costs, the number of spinal surgeries performed in the outpatient setting has significantly increased. The higher perioperative efficiency and greater predictability of associated costs offer significant incentives for payers and providers to move surgical procedures into the outpatient setting. Nonetheless, judicious patient selection is advised to optimize outcomes.
Article
Study design: Retrospective cohort. Objective: To compare time to discharge for anterior cervical discectomy and fusions (ACDF) when performed as either a first case versus later surgical start times. Summary of background data: ACDF is a commonly performed spinal procedure that typically has a short acute recovery period. With an increasing focus on reducing hospital costs and a shift toward outpatient surgical practices, early patient discharge has become a priority for hospitals and physicians alike. However, the impact of surgery start time on the ability for same-day discharge has not been explored in spine surgery. Methods: A surgical database of patients who underwent ACDF from 2013 to 2015 was reviewed. Patients were stratified into two cohorts: those whose surgery was the first of the day (early cohort), and those who underwent later surgeries. Baseline patient characteristics and perioperative variables were compared between cohorts using Student t test and χ test. Same-day discharge was tested for association with surgical start time using Poisson regression with robust error variance controlling for preoperative variables. Results: A total of 106 patients, divided into early and late cohorts of 60 and 46 patients, respectively, were included in the analysis. There were no significant differences in pre- or perioperative characteristics between cohorts (). Same-day discharge was achieved in 36.8% (n = 39) of all ACDF patients. The later cohort was significantly more likely to require an overnight stay compared with the early cohort (RR = 1.61 ± 0.30; P = 0.010).(Table is included in full-text article.)CONCLUSION.: Patients undergoing ACDF later in the day are at a higher risk for staying overnight than those who have the first surgery of the day. These results may influence operative scheduling, as performing ACDFs early in the day may result in a greater likelihood of same-day discharge, eliminating the increased resource utilization associated with an overnight hospital stay. Level of evidence: 4.
Article
Technological advances in neurosurgery, aided by improvements in anesthesia have resulted in surgery that is faster, simpler and safer with excellent perioperative recovery. As a result of improved outcomes, several centers are performing certain neurosurgical procedures on an outpatient basis; where patients arrive at the hospital the morning of their procedure and leave the hospital the same evening, thus avoiding an overnight stay in the hospital. Apart from the medical benefits of the outpatient procedure, its impact on patient satisfaction is substantial. The economic benefits are extremely favorable for the patient, physician, as well as the hospital. However, due to skepticism surrounding medico-legal aspects, and how radical the concept at first sounds, these procedures have not gained widespread popularity. We provide an overview of outpatient neurosurgery discussing results, outcomes related to patients' quality of life, and impact on the economic burden on currently burgeoning health care costs.
Article
Background Context: Studies demonstrate comparable clinical results with the use of either autogenous hip bone (autograft) or cadaver bone (allograft) for both single and multilevel anterior cervical decompression and fusion (ACDF) with rigid plate fixation. Purpose: Very few studies, however, have analyzed the economic implications of these two ACDF variations. We analyze the short-term hospital economic impact of these alternatives. Study Design and Setting: A retrospective study in a tertiary care center in central Georgia. Patient Sample: 550 consecutive elective 1- or 2-level ACDF patients met inclusion criteria for our study. 305 consecutive patients undergoing 1-level ACDF with rigid plate fixation (mean age 50.5 years) and 245 consecutive 2-level patients (mean age 52.6 years) received allograft implants (1-level n=86, 2-level n=33) or autograft (1 level n=219, 2-level n=212) bone. 32 patients were treated in an outpatient setting. Outcome Measures: Hospital charges were reviewed for cost factors such as procedure time, hospital supplies, labor, and length of stay. Methods: T-tests were used to establish statistical significance of any differences between the studied variables with respect to the choice of allograft vs. autograft. Results: Allograft usage led to statistically insignificant faster average procedure times for both 1-level (80.9 vs. 83.3 min, p>0.05) and 2-level patients (97.6 vs. 99.8 min, p>0.05). Allograft resulted in significant reductions in average length of stay (LOS) for 1-level patients (0.78 vs. 1.37 days, p<0.01), but insignificant reductions in average LOS for 2-level patients (1.21 vs. 1.42 days, p>0.05). For hospital charges, allograft usage resulted in insignificantly higher mean hospital charges for 1-level patients (allograft $17,243, autograft $16,969, p>0.05), but significantly increased hospital charges for 2-level patients (allograft $21,240, autograft $19,056, p<0.01). Significant variances in cost included allograft implants in allograft procedures 1 s and pain pumps in autograft procedures. Conclusion: In 1-level patients undergoing ACDF, allograft usage yielded a shorter length of hospital stay with comparable hospital charges as autograft. However, for 2-level patients undergoing ACDF, allograft yielded higher hospital charges at a statistically significant rate, without yielding statistically significant reductions in LOS. As with many issues, the decision as to which graft type to use for ACDF procedures is a multi-factorial issue. Both short and long term cost considerations must be heavily weighed. The limitations of our study must also be weighed against our conclusions.
Article
Background: Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission. Objective: To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF. Methods: Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. Results: A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients ( P < .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P < .05; inpatient OR 1.289, P < .0001) and readmission (ambulatory OR 1.746, P < .0001; inpatient OR 1.685, P < .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P < .0001). Conclusion: ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.
Chapter
Outpatient spine surgery has grown dramatically over the last decade because of significant clinical and economic advantages to patients, physicians, and the healthcare industry. Improving technology, increased patient and physician satisfaction, as well as a desire to control healthcare costs are key drivers of this growth. Patients prefer outpatient procedures because of the increased convenience and quality of care. Physicians benefit from the efficiencies of the outpatient setting and potential profit from ownership. The healthcare market continues to evolve because of ambulatory surgery centers providing a disruptive innovation to the existing industry structure. Shifting site of surgery to the outpatient setting leads to an overall decentralization of heathcare and significant cost saving opportunities. The trend toward moving spine surgery to the outpatient setting will continue as patients and physicians become more comfortable with the process and evidence continues to show excellent outcomes, low complications, and economic efficiencies.
Article
Background: In order to identify any changes in the utilization of new and old techniques, we investigated trends in the operative management of cervical stenosis by orthopaedic surgeons applying for board certification. Methods: We queried the American Board of Orthopaedic Surgery database from 1998 to 2013 to identify all of the cervical spine procedures for stenosis that had been performed by candidates taking Part II of the licensing examination. Longitudinal trends were determined for the utilized approach, the individual procedures that had been performed, and whether a motion-preserving technique had been employed. Results: There were 5,068 cervical spine procedures performed by 1,025 candidates. Procedure totals remained relatively constant until 2011, when a sudden increase of 280% (202 to 768 procedures) was noted. This trend continued, reaching a 460% increase (202 to 1,131 procedures) compared with 2010. The number of candidates only rose by 150% (42 to 105) over the entire study period. The proportion of procedures performed via an anterior approach saw a bimodal distribution; early on, this approach predominated over posterior procedures and was largely driven by the number of corpectomies that were performed. From 2004 to 2011, posterior procedures became more prevalent, but there was a sharp decline in 2011, driven by the large number of anterior cervical discectomies and fusions that were performed. This remained constant through 2013. Lastly, motion-preserving techniques, which included total disc replacement and laminoplasty, had modest increases in utilization from 2005 to 2007. This increased prevalence was short-lived, and it steadily declined through 2014 to <5% utilization. Conclusions: The number of candidates performing cervical spine procedures increased more than twofold over a 16-year period. This reflects a larger proportion of the orthopaedic graduates who subspecialize in spine surgery. While the number of surgeons performing spine surgery has increased, the sheer number of procedures that each surgeon performed greatly outpaced the increased number of surgeons. Motion-preserving techniques had their peak utilization in 2007, and have since decreased to <5%, in contrast to fusion techniques, which predominate, comprising >90% of the performed procedures.
Article
Background: Same-day surgery has been demonstrated to be a safe and cost-effective alternative to traditional inpatient surgery. Several studies have demonstrated no differences in the postoperative complication profile or 30-day hospital readmission rates with outpatient versus inpatient anterior cervical discectomy and fusion (ACDF). However, none of these studies compared the outcomes in elderly patients (aged >65 years) undergoing ACDF. Whether the results from previous studies can be applied to this subgroup pf patients remains unknown. The aim of the present study was to compare the 30-day hospital readmission rates for Medicare patients (aged >65 years) undergoing outpatient versus inpatient ACDF. Methods: We performed a retrospective analysis of a Medicare database, including data from 17,421 patients. Of the 17,421 patients, 16,386 had undergone inpatient ACDF and 1035, outpatient ACDF. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial costs were compared between the 2 cohorts. Results: In a Medicare sample (aged >65 years), inpatient ACDF was associated with a greater incidence of postoperative complications compared with outpatient ACDF. Outpatient surgery was associated with significantly lower rates of postoperative complications (urinary tract infection, surgical site infection, deep vein thrombosis, pulmonary embolism, and myocardial infarction) and significantly lower treatment costs (P ≤ 0.001). All-cause 30-day hospital readmission rates were also greater for inpatients (10.1% vs. 4%; P = 0.17). Conclusion: The results from the present study suggest that outpatient ACDF appears to be safe and effective with low complication and readmission rates in a Medicare patient sample.
Article
Here, we systematically review clinical studies that report morbidity and outcomes data for cervical and lumbar surgeries performed in ambulatory surgery centers (ASCs). We focus on anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, cervical arthroplasty, lumbar microdiscectomy, lumbar laminectomy, and minimally invasive transforaminal interbody fusion (TLIF) and lateral lumbar interbody fusion, as these are prevalent and surgical spine procedures that are becoming more commonly performed in ASC settings. A systematic search of PubMed was conducted, using combinations of the following phrases: “outpatient,” “ambulatory,” or “ASC” with “anterior cervical discectomy fusion,” “ACDF,” “cervical arthroplasty,” “lumbar,” “microdiscectomy,” “laminectomy,” “transforaminal lumbar interbody fusion,” “spine surgery,” or “TLIF.” In reviewing the available literature to date, there is ample level 3 (retrospective comparisons) and level 4 (case series) evidence to support both the safety and effectiveness of outpatient cervical and lumbar surgery. While no level 1 or 2 (randomized clinical trials) evidence currently exists, the plethora of real-world clinical data creates a formidable argument for serious investments in ASCs for multiple spine procedures.
Chapter
Spine surgery has been successfully performed in the outpatient setting for the past 30 years. An overwhelming number of reports indicate performing select spine procedures, on appropriate patients, in the outpatient setting is as safe and effective as performing them in the hospital setting. The rapid adaptation of minimally invasive techniques has significantly contributed to this paradigm shift and has been repeatedly shown to be associated with decreased bleeding, pain, and infection rates while maintaining equivalent outcomes when compared to traditional techniques. Careful patient selection has been paramount to this transition, and those with significant cardiac and pulmonary comorbidities are typically unfit for outpatient spine surgery. Outpatient surgery candidacy can be further limited based on age, BMI, and opioid dependency. In addition to being safe and effective, ambulatory spine surgery is also associated with improved patient and physician satisfaction. Furthermore, its cost benefits are robustly documented resulting in a progressively increasing number of spine surgery CPT codes being approved for the outpatient setting and an associated increase in reimbursement rates.
Article
Background: Outpatient anterior cervical discectomy and fusion (ACDF) is performed frequently, with studies demonstrating similar complication and readmission rates compared to traditional admission. Advantages include cost effectiveness, as well as lower risk of nosocomial infections and medical errors, which lead to quicker recovery and higher patient satisfaction. Protocols are needed to ensure that outpatient ACDF occurs safely. The objective of this study was to develop and implement a protocol with patient selection and discharge criteria for patients undergoing same-day discharge (SDD) ACDF and assess readmission rates. Methods: A retrospective chart review was performed to identify patients undergoing 1 or 2 level primary ACDF between March 2016 and March 2017 who were eligible for SDD according to the institutional protocol (Figure 1, Table 2). Patients with identical surgery and discharge dates were grouped as SDD, and admitted patients were grouped as same-day admission (SDA). Using our electronic health record's analytics, readmissions in the 90-day postoperative period were identified. Results: Of the 434 patients identified, 126 patients were SDD, and 308 were SDA. Baseline characteristics such as age, operative time, and time in the recovery room were significantly different between the 2 groups (Table 2). The average length of stay of admitted patients was 1.48 days, with 77% discharged on postoperative day 1. There was an overall, noninferior readmission rate of 0.8% in the SDD group compared to 0.6% in the SDA group (P = .86). Conclusions: The results of this study support the feasibility of outpatient ACDF and add a patient selection and discharge criteria to the literature. Proper identification of suitable patients using our protocol results in a noninferior readmission rate, allowing surgeons to continue to safely perform these surgeries with a low readmission rate. Level of evidence: 3. Clinical relevance: SDD is safe in the appropriate patient population.
Article
Purpose: Anterior cervical discectomy and fusion has a low but well-established profile of adverse events. The goal of this study was to gauge surgeon opinion regarding the frequency and acceptability of these events. Methods: A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: "common and acceptable," "uncommon and acceptable," "uncommon and sometimes acceptable," or "uncommon and unacceptable." Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice. Results: Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons. Conclusions: These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives.
Article
Background: Outpatient surgery is becoming more common and is more cost-effective than inpatient surgery. Nonetheless, many surgeons and health care administrators are still hesitant to accept outpatient surgery for cervical degenerative spinal disease (C-DSD). This study assesses the types and rates of complications, hospital admissions, and reoperations after outpatient surgery of C-DSD. Methods: Complications, hospital admissions within 90 days of surgery, and reoperations within one year of surgery were recorded retrospectively in 1300 outpatients undergoing microsurgical decompression for C-DSD at the Oslofjord Clinic from 2008 to 2017. The surgical procedures performed were anterior cervical decompression and fusion (ACDF) in 1083 patients and posterior cervical foraminotomy in 217 patients. Results: The surgical mortality rate was 0%. Sixteen major complications were recorded in 15/1300 (1.2%) patients. The complications were neurological deterioration in four patients, postoperative hematoma in two, dural lesions with cerebrospinal fluid leakage in one, deep surgical-site infection in one, persistent hoarseness in three, and persistent dysphagia in five. The two potentially life-threatening hematomas were detected within the planned six-hour observation period. Two (0.2%) patients were admitted to hospital within hours of surgery completion with stroke-like signs and symptoms, and four (0.3%) patients were admitted to hospital within 90 days due to surgery-related events. The rate of reoperations for cervical radiculopathy within 12 months was 25/1171 (2%); eight patients’ reoperations were due to inadequate primary decompression, one was due to recurrent disc herniation at the same level and side, and 16 were due to new-onset radiculopathy from an adjacent level or other side. Conclusions: Outpatient microsurgical decompression of the degenerative cervical spine in carefully selected patients appears to be safe and carries a low major complication rate, low hospital admission rate, and low one-year reoperation rate.
Article
Study design: Epidemiologic Study. Objectives: To identify the trends in utilization of outpatient discharge for single level anterior cervical discectomy and fusion (ACDF), between 2007 and 2014, and to compare the costs and incidence of complications against a cohort of inpatients. Methods: We retrospectively reviewed 18,386 patients from the PearlDiver database from between 2007 and 2014. Discharge status was determined from billing codes. The total cost of all procedures and diagnostic tests, was determined for the global period from the time of diagnosis up until 90-days post-operatively, and the incidence of complications was recorded for 30-days. Results: The proportion of outpatient discharges was stable around 20% from 2007 to 2014 (range17-23%). The mean 90-day cost was lower for outpatients ($39,528 v. $47,330) but reimbursement fell nearly 1/3 from 2007-2014 for both groups, and the difference between the two narrowed over time ($13,745 difference in 2008, to $3,834 in 2014). Outpatients had a lower incidence of overall 30-day complications (9.5% v. 18.6%, p<0.0001), but were also significantly less comorbid (mean Charlson comorbidity index 2.32 v. 3.85, p<0.001). Older patient age, obesity, cardiac, renal, and pulmonary comorbidity were each more common in the inpatients (p<0.05 for each). Conclusions: Outpatient discharge after ACDF is a viable treatment option with a reasonable safety profile and decreased costs relative to inpatient admission. Appropriate patient selection is key, and the standard of care nationally for the comorbid patient remains inpatient admission. The economic trends and epidemiologic data presented here should be useful for health policy decisions.
Article
OBJECTIVE From 1994 to 2006 outpatient spinal surgery increased 5-fold. The perceived cost savings with outcomes comparable to or better than those achieved with inpatient admission for the same procedures are desirable in an era where health expenditures are scrutinized. The increase in outpatient spine surgery is also driven by the proliferation of ambulatory surgery centers. In this study, the authors hypothesized that the total savings in outpatient spine surgery is largely driven by patient selection and biases toward healthier patients. METHODS A meta-analysis assessed patient selection factors and outcomes associated with outpatient spine procedures. Pooled odds ratios and mean differences were calculated using a Bayesian random-effects model. The authors extended this analysis in a novel way by using the results of the meta-analysis to examine cost data from an administrative database of academically affiliated hospitals. A Bayesian approach with priors informed by the meta-analysis was used to compare costs for inpatient and outpatient performance of anterior cervical discectomy and fusion (ACDF) and lumbar laminectomy. RESULTS Sixteen studies with a total of 370,195 patients met the inclusion criteria. Outpatient procedures were associated with younger patient age (mean difference [MD] −2.34, 95% credible interval [CrI] −4.39 to −0.34) and no diabetes diagnosis (odds ratio [OR] 0.78, 95% CrI 0.54–0.97). Outpatient procedures were associated with a lower likelihood of reoperation (OR 0.42, 95% CrI 0.16–0.80), 30-day readmission (OR 0.39, 95% CrI 0.16–0.74), and complications (OR 0.29, 95% CrI 0.15–0.50) and with lower overall costs (MD −$121,392.72, 95% CrI −$216,824.81 to −$23,632.92). Additional analysis of the national administrative data revealed more modest cost savings than those found in the meta-analysis for outpatient spine surgeries relative to inpatient spine surgeries. Estimated cost savings for both younger patients ($555 for those age 30–35 years [95% CrI −$733 to −$374]) and older patients ($7290 for those age 65–70 years [95% CrI −$7380 to −$7190]) were less than the overall cost savings found in the meta-analysis. CONCLUSIONS Compared to inpatient spine surgery, outpatient spine surgery was associated with better short-term outcomes and an initial reduction in direct costs. A selection bias for outpatient procedures toward younger, healthier patients may confound these results. The additional analysis of the national database suggests that cost savings in the outpatient setting may be less than previously reported and a result of outpatient procedures being offered more frequently to younger and healthier individuals.
Article
Objectives Reported incidence of dysphagia after ACDFs has been as high as 79%. There, however, have been no studies that have specifically looked at developing a criteria for reducing the incidence of dysphagia for outpatient ACDFs. The aim of this study was to determine the risks factors for significant dysphagia that will exclude patients from outpatient single-level anterior cervical discectomy and fusions (ACDFs). Patients and methods Using the Kaiser Permanente Spine registry database, between January 2009 and September 2013, we identified all inpatients (there were no outpatients) who underwent primary elective one-level ACDFs. A cohort of patients were identified with in-hospital length of stay (LOS) > 48 h in which the reason for continued admission was primarily significant dysphagia (DG). Patient’s demographics and intraoperative data (ACDF levels (upper [C2-3, C3-4], middle [C4-5, C5-6], lower [C6-7, C7-T1]), and operative times (<100, 100–199, ≥ 200, minutes)) was used to determine risk factors for dysphagia. Results We found 747 single-level ACDF cases with a cohort of 239 (32.0%) who met the criteria for dysphagia (DG) with > 48 h admission. The DG group and non-dysphagia group (NDG) had similar demographics. Diabetes was excluded from regression analysis due to the low frequency. Compared to the lower spine level (C5-6, C7-T1), the upper spine level (C2-3, C3-4) ACDF had a higher likelihood for dysphagia (OR = 2.23, 95% CI = 1.35–3.68, p = 0.0016); no difference was found for middle spine level (C4-5, C5-6) ACDF. Conclusion Single-level ACDF at the upper cervical spine (C2-3, C3-4) was found to be the only risk factor for dysphagia with LOS > 48 h based on inpatient data from a spine registry. Age, BMI category, gender, ASA classification, smoking, and operative time were not predictive factors. These findings should be used for excluding patients who undergo outpatient single-level ACDF surgery to reduce significant postoperative dysphagia.
Article
Background: Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures. Objective: The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR. Materials and methods: Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. Results: A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001). Conclusions: ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.
Article
Objective: This study looks at the various comorbidities and postoperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 1- and 2-level anterior cervical discectomy and fusion (ACDF). With increasing costs within the United States medical system, one emerging cost-saving strategy is to evolve traditional inpatient procedures into outpatient same-day surgeries. However, patient safety remains a crucial priority. Methods: A total of 28,427 patients were analyzed, with 26,368 undergoing inpatient ACDF surgery and 2059 undergoing outpatient ACDF surgery. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial cost were compared between both cohorts. Results: Data from 28,427 one- and two-level ACDF procedures that were split between inpatient and outpatient were collected. Thirty-day readmission rates were significantly lower in outpatients than inpatients (4% vs. 10.1%, P < 0.001). Inpatients had higher rates of urinary tract infection (2.4% vs. 1.4%), deep vein thrombosis (0.6% vs. 0%), and myocardial infarction (0.2% vs. 0%), whereas outpatients had higher rates of pulmonary embolism (7.7% vs. 0.4%). Outpatients had increased readmission risk with comorbidities of diabetes (odds ratio [OR], 48.93; P < 0.001), smoking (OR, 4.6; P < 0.001), body mass index ≥30 (OR, 2392; P < 0.001). The average cost of outpatient surgery was less than that of inpatient surgery ($7774.8 vs. $7956.75, P = 0.0444). Conclusion: This study suggests that in the appropriately selected patients, ACDF can safely be performed in an outpatient setting.
Article
Full-text available
Background: Outpatient surgery has been shown safe and effective for anterior cervical discectomy and fusion (ACDF), and more recently, for 1-level cervical disc arthroplasty (CDA). The purpose of this analysis is to compare the safety and efficiency of 1-level and 2-level CDA performed in an ambulatory surgery center (ASC) and in a hospital setting. Methods: The study was a retrospective collection and analysis of data from consecutive CDA patients treated in ASCs compared to a historical control group of patients treated in hospital settings who were classified as outpatient (0 or 1-night stay) or inpatient (2 or more nights). Surgery time, blood loss, return to work, adverse events (AEs), and subsequent surgeries were compared. Results: The sample consisted of 145 ASC patients, 348 hospital outpatients, and 65 hospital inpatients. A greater proportion of 2-level surgeries were performed in hospital than ASC. Surgery times were significantly shorter in ASCs than outpatient or inpatient 1-level (63.6 ± 21.6, 86.5 ± 35.8, and 116.7 ± 48.4 minutes, respectively) and 2-level (92.4 ± 37.3, 126.7 ± 43.8, and 140.3 ± 54.5 minutes, respectively) surgeries. Estimated blood loss was also significantly less in ASC than outpatient and inpatient 1-level (18.5 ± 30.6, 43.7 ± 35.9, and 85.7 ± 98.0 mL, respectively) and 2-level (21.1 ± 12.3, 67.8 ± 94.9, and 64.9 ± 66.1 mL). There were no hospital admissions and no subsequent surgeries among ASC patients. ASC patients had 1 AE (0.7%) and hospital patients had 10 AEs (2.4%). Working patients returned to work after a similar number of days off, but fewer ASC patients had returned to work by the end of the 90-day period. Conclusions: Both 1- and 2-level CDA may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs.
Article
The objective of this pilot study was to evaluate the safety and efficacy of cervical discectomy with fusion performed on an outpatient basis. The experimental group (50 consecutive patients) was studied prospectively and the outcomes were compared with 53 consecutive, retrospectively analyzed, admitted controls who underwent the same procedure. Outcomes for both groups were assessed by patient-response questionnaires and clinical examination. At follow-up times of 1.3 (outpatient) and 1.6 (inpatient) years, outcomes (outpatient/inpatient) expressed as percent successful were as follows: Relief of arm pain (80/70%); relief of neck pain (78/68%); relief of arm muscle weakness and atrophy (94/96%); return to normal activities (64/70%); return to work (65/68%); and satisfaction with the results of surgery (86/83%). No statistically significant differences between outpatients and inpatients were found for any of the outcome parameters studied. There was no mortality and the operative complication rate was 2% for each study group. The results indicate that conversion of cervical discectomy with fusion from an admitted to an ambulatory practice did not compromise the safety or efficacy of the surgical procedure. Potential economic savings to overall health costs of the United States that might result from such conversion could exceed $100 million annually. (C) Lippincott-Raven Publishers.
Article
Objective: The anterior approach to the cervical spine now serves as the surgical access of choice for cervical spine disease. Vocal fold paralysis (VFP) may follow the procedure as a complication. The authors describe their experience with patients having VFP after anterior cervical diskectomy and fusion (ACDF), with an emphasis on outcome and prognosis. Study design: Retrospective. Methods: Medical records of patients who underwent ACDF between January 1987 and February 1998 were reviewed. Further detailed review of the patients with documented VFP after surgery was then performed. Results: Over the given time period 411 ACDFs were performed and 21 patients with this complication were identified (5%). All 21 patients had right-sided approaches. Eighteen patients had right VFP, 2 had left VFP, and 1 had bilateral VFP. Symptoms included hoarseness (18), persistent cough (7), aspiration (13), and dysphagia (7). The patient with bilateral VFP presented with stridor and respiratory distress requiring tracheotomy. The complete records of 17 patients with 18 VFPs were available for review. Fifteen of 18 VFPs (83.3%) had complete resolution within 12 months. One patient had recovery after 15 months. All patients were treated conservatively with speech and swallowing therapy. One patient required Gelfoam injection and another medialization thyroplasty, both for aspiration symptoms. Conclusions: The data suggest that at least 80% of VFP after ACDF will recover within 12 months of the procedure. The authors recommend regular follow-up and speech therapy for symptomatic patients. Medialization should be considered in patients with aspiration or persistent problems.
Article
A consecutive series of 87 patients undergoing Smith-Robinson anterior cervical fusion were analyzed. Either freeze-dried tricortical iliac crest bone or tricortical autograft bone was used. Surgical technique was otherwise identical. Radiography showed delayed union at 3 months in 13% of patients with autograft and in 37% of patients with freeze-dried allograft. At 1 year, radiography showed nonunion in 8% of patients with autograft and in 22% of patients with allograft. One-level procedures had a delayed union rate of 7% for autograft and 21% for allograft. Nonunion in one-level procedures was 5% for both autograft and allograft. For two-level procedures, the nonunion rate was 17% for autograft and 63% for allograft. Graft collapse was more commonly seen with freeze-dried allograft (30%) than with autograft (5%). Relief of neck and arm pain, however, was similar in both groups.
Article
The complications of anterior discectomy without fusion were analyzed on the basis of 450 consecutive cases treated surgically for degenerative disc disease. There was no death related to the procedure. The most common complication was a worsening of the pre-existing myelopathy. This occurred in 3.3%, including one case with severe medullary contusion. Wound infection developed in 1.6%. Additional radicular symptoms and wound haematoma, respectively, occurred in 1.3%; recurrent nerve palsy, Horner's syndrome, and respiratory insufficiency, respectively, in 1.1% of the cases. Epidural haematoma and instability of the cervical spine, respectively, occurred in 0.9%, nerve root lesion and aseptic spondylodiscitis, respectively, in 0.4%. There was one case each (0.2%) with a pharyngeal lesion, meningitis due to dural perforation, transient additional myelopathy, and epidural abscess. The results and the management of complications are discussed in relation to numerous previously published reports, including posterior procedures and anterior fusion techniques. Precise knowledge of all potential accidents and pitfalls related to the surgical procedure and of their aetiology may contribute to preventing failures. The rate of complications in this series has been reduced in the past years by better patient selection, by paying more attention to correct positioning of the patient during the operation, and by meticulous removal of all offending structures. Discectomy without interbody fusion is now considered to be a reasonably safe procedure with an acceptable operative morbidity and lack of mortality.
Article
Anterior stabilization with combined plate and bone fusion was performed after neural decompression on ten patients for spondylotic cervical myelopathy, and for radiculopathy or trauma in three patients. Medial corpectomy was performed at one to four levels. Iliac crest or fibular bone grafts were secured by plates anchored to the graft and adjacent vertebral bodies. All patients were placed in Minerva braces postoperatively. There was successful fusion in all cases, and no graft dislodgement or kyphosis. Early initiation of rehabilitation was achieved. Morbidity occurred in patients with severe spondylotic cervical myelopathy. This include respiratory depression requiring reintubation in 2/13 procedures, dysphagia (2/13) from loosening of the screws or prominent hardware and graft, and screw loosening (2/13). Neurological improvement was present in 85% (11/13) of patients. There was no deterioration of neurological function in any case. We conclude from this early follow-up that anterior bone fusion with supplemental plates provides effective stabilization for the unstable cervical spine. Greater morbidity risk exists in patients with severe spondylotic cervical myelopathy and spastic quadriparesis who required multilevel medial corpectomies and fusion.
Article
The author review the diagnosis and treatment and of herniation of the nucleus pulposus and of osteoarthritic bony proliferation. They point to two forms of disease, radiculopathy and myelopathy, and consider the results of treatment by differing operative approaches.
Article
The extrapharyngeal approach to the anterior cervical spine is a safe, rapid surgical exposure. Other surgical exposures such as the posterior, lateral, and intraoral (transpharyngeal) have inherent limitations that this approach avoids. By going anterior to the sternocleidomastoid muscle and great vessels, the surgical exposure of the anterior cervical spine is wide and the vital structures of the neck are visualized and not injured. We have used this extrapharyngeal approach to treat various disease states of the anterior cervical spine, such as trauma, osteomyelitis, neoplasia, and degenerative disease. Major complications have been neural injury, and pharyngeal fistula.
Article
Advances in medicine, including diagnostic techniques and therapeutic procedures, have resulted in the ambulatory management of many diseases. A number of surgical procedures previously considered to require hospitalization now are offered on a routine basis as an outpatient or short-stay admission. Although the use of microdiscectomy for the treatment of virgin herniated disc in ambulatory patients has been reported in very limited numbers, it has not been applied to other problems, such as recurrent herniated disc, far lateral disc, or foramenal stenosis. In addition, it only has been used in optimal patients. The authors analyzed a diverse group of patients who underwent outpatient microdiscectomy and found, for most patients studied, hospitalization was not necessary. Seventy-four patients were prospectively studied to determine whether unilateral root decompression for disc or stenosis could be accomplished on an ambulatory basis. Ninety percent of the patients were able to be discharged on the day of surgery. There was no significant morbidity related to the ambulatory approach. The authors also found a significant cost savings for third party reimbursers.
Article
Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body.
Article
The anterior cervical approach is commonly used for access to the cervical spine. Vocal fold paralysis (VFP), a complication of this approach, is underrepresented in the literature. A review of the database of the Vanderbilt Voice Center revealed 289 patients with VFP, including 16 patients who developed paralysis as a result of an anterior cervical approach. The paralysis was on the right side in all but 1 patient. Compared to patients who developed VFP after thyroidectomy and carotid endarterectomy, patients with VFP after an anterior cervical approach have a higher incidence of aspiration and dysphagia, suggesting the presence of trauma to the superior laryngeal and pharyngeal branches as well as the recurrent branch of the vagus nerve. Two patients had partial return and 1 patient had complete return of vocal fold movement within 10 months. Of the remaining 13 patients, 8 underwent vocal fold medialization with improvement of symptoms. Two patients are 6 and 7 months postinjury and await vocal fold medialization. Two patients are 27 months and 45 months postinjury and are considering vocal fold medialization. The remaining patient was lost to follow-up. An anatomic-geometric analysis of the right and left recurrent laryngeal nerves was performed by using measurements obtained from computed tomography scans of 8 patients with idiopathic unilateral VFP, as well as experience gained through surgical and cadaveric dissections. We conclude 1) the anterior cervical approach may place multiple branches of the vagus nerve at risk; 2) because of anatomic-geometric factors, the right-sided anterior cervical approach may carry a greater risk to the ipsilateral recurrent laryngeal nerve than does the left; and 3) an understanding of the anatomy and geometry presented herein allows relatively safe exposure from either side of the neck.
Article
The objective of this pilot study was to evaluate the safety and efficacy of cervical discectomy with fusion performed on an outpatient basis. The experimental group (50 consecutive patients) was studied prospectively and the outcomes were compared with 53 consecutive, retrospectively analyzed, admitted controls who underwent the same procedure. Outcomes for both groups were assessed by patient-response questionnaires and clinical examination. At follow-up times of 1.3 (outpatient) and 1.6 (inpatient) years, outcomes (outpatient/inpatient) expressed as percent successful were as follows: Relief of arm pain (80/70%); relief of neck pain (78/68%); relief of arm muscle weakness and atrophy (94/96%); return to normal activities (64/70%); return to work (65/68%); and satisfaction with the results of surgery (86/83%). No statistically significant differences between outpatients and inpatients were found for any of the outcome parameters studied. There was no mortality and the operative complication rate was 2% for each study group. The results indicate that conversion of cervical discectomy with fusion from an admitted to an ambulatory practice did not compromise the safety or efficacy of the surgical procedure. Potential economic savings to overall health costs of the United States that might result from such conversion could exceed $100 million annually.
Article
A series of 200 patients who underwent outpatient surgical treatment for cervical radiculopathy is presented. The patients were selected on the basis of their willingness to undergo surgery in the outpatient setting and the absence of serious underlying medical conditions. All operations were performed using general anesthetic techniques with limited posterior dissections. A laminoforaminotomy was performed at each affected level, which had been determined by preoperative imaging and clinical examination. After being observed for several hours, the patients were discharged if they met specific criteria. No patient required subsequent hospital admission in the immediate postoperative period. Follow-up review in 183 patients ranged from 3 to 43 months, with a mean of 19 months. In cases in which Workers' Compensation claims were not involved, 92.8% of patients reported an excellent or good outcome and returned to work or comparable duties at a mean of 2.9 weeks. In cases in which Workers' Compensation claims were involved, 77.8% of patients reported excellent or good outcome and returned to work at a mean of 7.6 weeks postoperatively. Two patients whose cases involved Workers' Compensation claims did not return to work. There were seven patients (3.8%) who had a poor outcome. Two of these patients underwent a second posterior procedure and reported a good outcome at the time of follow-up review. The results of this study show that outpatient surgical treatment of cervical radiculopathy can be safely provided in selected patients with outcomes similar to the inpatient surgical management of these individuals.
Article
To review current literature regarding otolaryngologic complications of the anterior approach to the cervical spine with the focus on the etiology, diagnosis, and treatment of these disorders. A review of literature from the introduction of anterior cervical surgery (late 1950s) to the present was conducted by using computer databases and bibliographies of appropriate journal articles and texts. Key words included "anterior cervical surgery," "dysphagia," "surgical complications," and "hoarseness." Dysphagia and dysphonia are common conditions following anterior cervical fusion, and patients should be counseled on this risk preoperatively. The etiologies of these problems have not been clearly elucidated, and these complications are frequently underreported or ignored. Otolaryngologic consultation should be obtained for all patients with dysphagia or dysphonia that persists longer than 1 to 2 months, and consideration should be given to having all patients at risk (previously operated patients) evaluated both preoperatively and postoperatively.
Article
A retrospective review of contemporaneously acquired clinical data supplemented by experimental cadaver dissection. To establish the incidence and mechanism of vocal cord paralysis after anterior cervical spine surgery and to determine whether controlling for endotracheal tube (ET)-laryngeal wall interactions induced by the cervical retraction system could decrease the rate of paralysis. Vocal cord paralysis is the most common otolaryngologic complication after anterior cervical spine surgery. However, the quoted frequency of this varies considerably, and the cause of the injury is not clearly defined. As a result, various, and at times contradictory, recommendations to prevent this are presented without data to support their effectiveness. Data gathered at the time of surgery and during follow-up visits on 900 consecutive patients who underwent anterior cervical spine surgery with plating during a 12-year interval were entered into a computerized database and reviewed for complications and procedural risk factors. After the first 250 cases an intervention consisting of monitoring ET cuff pressure and release of pressure after retractor replacement or repositioning was used, which allowed the ET to recenter within the larynx. The ET-laryngeal wall relation also was studied in fresh intubated cadavers using videofluoroscopic images, before and after retractor placement. Thirty incidences of vocal cord paralysis consistent with recurrent laryngeal nerve (RLN) injury were identified: 27 temporary and 3 permanent. The rate of temporary paralysis decreased from 6.4% to 1.69% (P = 0.0002) after institution of the described maneuver. The findings confirmed that the retractor displaced the larynx against the shaft of the ET, allowing impingement on the vulnerable intralaryngeal segment of the RLN. The most common cause of vocal cord paralysis after anterior cervical spine surgery is compression of the RLN within the endolarynx. Monitoring of ET cuff pressure and release after retractor placement may prevent injury to the RLN during anterior cervical spine surgery.
Article
The authors conducted a study to determine how to avoid emergency postoperative reintubation and its associated morbidity in patients who have undergone multilevel anterior-posterior cervical spine surgery. In a group effort between the departments of anesthesia and neurosurgery, a protocol was developed to avoid having to reintubate patients postoperatively. As a preventative measure, patients remained intubated overnight; on the 1st postoperative day or thereafter, based on direct fiberoptic visualization of reactive tracheal swelling, an anesthesiologist extubated the patients. Fifty-eight patients underwent multilevel anterior corpectomy with fusion (ACF; with 41 receiving plates and 17 not receiving plates), posterior wiring and fusion (PWF), and application of a halo. On average, ACF involved three levels, whereas PWF included 6.5 levels. Surgery typically lasted 10 hours, and an average 2.6 U of blood was required. Forty patients were successfully extubated on the 1st, five on the 2nd, three on the 3rd, two on the 4th, two on the 5th, and three on the 7th postoperative day. Three elective tracheostomies were performed on the 7th postoperative day. Risk factors associated with delayed extubation or tracheostomy in 18 patients included: operative time longer than 10 hours (12 patients), obesity greater than 220 lbs (12 patients), transfusion of more than 4 U of blood (10 patients), ACF reoperations (nine patients), ACF including C-2 (seven patients), four-level ACF (five patients), and asthma (five patients). In the only case in which emergency reintubation was required, three risk factors were present. Emergency reintubation following anterior-posterior cervical surgery and fusion can be avoided by maintaining intubation overnight and subsequently having an anesthesiologist remove the tube after healing is fiberoptically confirmed. Familiarity with major risk factors contributing to airway compromise, combined with this protocol, should minimize the significant morbidity associated with reintubation following multilevel anterior-posterior cervical fusion.
Article
A detailed review of anterior cervical fusion procedures from a university-based spine specialty service was completed. Noted were the laterality of approach, number of levels, discectomy or corpectomy, use of instrumentation, and cases of reoperation. The primary purpose of the study is to determine whether there is in fact a greater risk of recurrent laryngeal nerve (RLN) injury with approach on the right or left side. Also evaluated is the risk with corpectomy, reoperative procedures, and instrumentation. Anatomic considerations have been used as justification to determine the side of surgical approach. However, few clinical studies have delineated the side of surgical approach in their results. A total of 328 anterior cervical spine fusion procedures completed between 1989 and 1999 were reviewed. All speech changes reported were noted throughout follow-up. There were 187 anterior discectomy and 141 corpectomy procedures. There were 21 reoperative anterior fusions. There were 173 procedures completed from the right side and 155 from the left. There were nine patients documented to have dysphonia after surgery. Five had a left-sided approach and four had a right-sided approach. The incidence of RLN symptoms after surgery was 2.7% (9 of 328). The incidence of RLN symptoms was 2.1% with anterior cervical discectomy, 3.5% with corpectomy (5 of 141), 3% with instrumentation (8 of 237), and 9.5% with reoperative anterior surgery (2 of 21). There was a significant increase in the rate of injury with reoperative anterior fusion. There was no association between the side of approach and the incidence of RLN symptoms.
Article
Retrospective chart review of 311 anterior cervical procedures. To assess the incidence and variables that predispose to an airway complication in a large series of anterior cervical surgical procedures. A rare but potentially lethal complication after anterior cervical spine surgery is respiratory compromise and airway obstruction. Some risk factors are thought to include two-level corpectomy in myelopathic patients with a history of heavy smoking and asthma. No previous study in the literature has been directed at examining the factors specifically related to airway complications after anterior cervical spine surgery. Each chart was examined for patient characteristics and pathology, anesthetic parameters and problems, operative procedure, and postoperative course and management. Statistical analysis was performed. Nineteen patients (6.1%) had an airway complication and six (1.9%) required reintubation. One patient died. Symptoms developed on average 36 hours postoperatively. All complications except for two were attributable to pharyngeal edema. Variables that were found to be statistically associated with an airway complication (P < 0.05) were exposing more than three vertebral bodies, a blood loss >300 mL, exposures involving C2, C3, or C4, and an operative time >5 hours. A history of myelopathy, spinal cord injury, pulmonary problems, smoking, anesthetic risk factors, and the absence of a drain did not correlate with an airway complication. Patients with prolonged procedures (i.e., >5 hours) exposing more than three vertebral levels that include C2, C3, or C4 with more than 300-mL blood loss should be watched carefully for respiratory insufficiency.
Article
A prospective longitudinal study was conducted to evaluate dysphagia after anterior cervical spine surgery. To evaluate the incidence and natural history of dysphagia after anterior cervical spine surgery, and to identify risk factors for the development of postoperative dysphagia. The literature contains only retrospective evaluations of postoperative dysphagia. A wide range of incidence has been reported in these studies. Altogether, 249 consecutive patients undergoing anterior cervical spine surgery were eligible for the study. These patients were contacted 1, 2, 6, and 12 months after the procedure to evaluate swallowing. Risk factors such as age, gender, procedure type, hardware use, and number and location of surgical levels addressed were assessed. Dysphagia incidences of 50.2%, 32.2%, 17.8%, and 12.5% were found at 1, 2, 6, and 12 months, respectively. At 6 months after the procedure, only 4.8% of the patients were experiencing moderate or severe dysphagia. Patient age, type of procedure (corpectomy vs. discectomy or primary vs. revision), hardware presence, and location of surgical levels were not statistically significant risk factors for the development of postoperative dysphagia. Female gender was significant for increased risk of dysphagia at 6 months. Surgery at multiple disc levels increased the risk of postoperative dysphagia at 1 and 2 months. The etiology of the dysphagia in most of the patients was unknown. However, vocal cord paresis was identified in 1.3% of the patients at 12 months. Dysphagia after anterior cervical spine surgery is a common early finding. However, it decreases significantly by 6 months. The minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels could be identified as risk factors for the development of postoperative dysphagia.
Article
This retrospective, questionnaire-based investigation evaluated iliac crest bone graft (ICBG) site morbidity in patients having undergone a single-level anterior cervical discectomy and fusion (ACDF) procedure performed by a single surgeon (T.J.A.). To evaluate acute and chronic problems associated with anterior ICBG donation, particularly long-term functional outcomes and impairments caused by graft donation. Anterior cervical discectomy and fusion procedures frequently use autologous anterior ICBG to facilitate osseous union. Although autologous ICBG offers several advantages over alternative grafting materials, donor site morbidity can be significant. Acute and chronic complications of donor sites have been reported, yet there are currently no reports of long-term functional outcomes after autologous anterior ICBG donation after single-level ACDF. A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior ICBG harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered yes, no, or not applicable; pain was assessed with a Visual Analogue Scale (VAS). Surveys were completed either by mail or follow-up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24-72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2%; and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 in 10, and 11.2% chronically use pain medication. Twenty-one patients (15.7%) reported abnormal sensations at the donor site, but only 5.2% reported discomfort with clothing. A unique functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5%; and household chores, 6.7%. A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems, and alternative sources of graft material should be considered.
Article
Retrospective clinical studies frequently utilize surgeon records as a source of outcomes data. The accuracy of data derived from surgeon records, however, is unknown. The purpose of the present study was to evaluate the accuracy of surgeon records in documenting the prevalence of subjective adverse outcomes. Consecutive patients who had undergone anterior cervical arthrodesis by four spine surgeons during a ten-month period were included. Surgeon records from the routine six-week, three-month, and six-month postoperative visits were examined for documentation of persistent dysphagia and dysphonia. Patients completed surveys inquiring about the presence and magnitude of symptoms at these three time-points. Agreement between the surgeon records and the patient surveys was analyzed with use of the kappa coefficient. One hundred and sixty-six patients had 342 postoperative visits. Dysphagia was documented twenty-six times in the surgeon records, compared with 107 times on the patient surveys. Dysphagia was thus underreported in 80% of cases. Similarly, dysphonia was documented ten times in the surgeon records, compared with seventy-two times on the patient surveys. Poor correlation between the surgeon records and the patient surveys was observed regardless of symptom severity, previous anterior cervical surgery, anterior arthrodesis of three motion segments or more, arthrodesis cephalad to the fifth cervical level, and anterior cervical plate use. Poor correlation between the surgeon records and the patient surveys also was observed for each surgeon, regardless of subspecialty or institution. Correlation between the surgeon records and the patient surveys was consistently poor, regardless of the specific patient and surgeon factor analyzed. While we chose to study dysphonia and dysphagia, it is conceivable that the results may be generalizable to many situations in which office notes are utilized to ascertain the prevalence of subjective adverse outcomes. These results suggest that the prevalence of such outcomes may be seriously underreported in studies that rely on the retrospective analysis of surgeon records.
Article
Swallowing difficulties and dysphonia may occur in patients undergoing anterior cervical discectomy and fusion. The etiology and incidence of these abnormalities, however, are not well defined. In view of this, we performed a prospective, objective analysis of swallowing function and vocal cord approximation in patients undergoing anterior cervical discectomy and fusion. Twenty-three consecutive patients (22 male and one female, mean age 59 years) undergoing anterior cervical discectomy and fusion had standardized modified barium swallow study and videolaryngoendoscopy performed preoperatively and again at 1 week and 1 month postoperatively. Eleven patients (48%) had radiographic evidence of preoperative swallowing abnormalities. The majority of these patients had myelopathic rather than radicular findings (p = 0.03). None, however, had symptoms of swallowing dysfunction. Among these patients, one had worse function postoperatively, three had improvement, and function remained unchanged in seven. The preoperative swallowing assessment was normal in 12 patients (52%). Postoperative radiographic swallowing abnormalities were demonstrated in eight of these patients (67%). Preoperative vocal cord movement was normal in all patients. Postoperatively, vocal cord paresis was detected in two patients. The paresis was transient in one and permanent in the other. Age, previous medical history, operation duration, and spinal level decompressed were not significantly associated with the incidence of swallowing dysfunction. There was, however, a tendency for patients undergoing multilevel surgery to demonstrate an increased incidence of swallowing abnormalities on postoperative radiographic studies. In addition, soft tissue swelling was more frequent in patients whose swallowing function was worse postoperatively (p = 0.007). Postoperative voice and swallowing dysfunction are common complications of anterior cervical discectomy and fusion, although in the majority of patients these abnormalities are not symptomatic. Patients undergoing multilevel procedures are at an increased risk for these complications, in part because of soft tissue swelling in the neck.
Results of anterior cervical spine fusions done at the hospital of the University of Pennsylvania: a nine-year follow-up
  • Andrews Et Ej
  • Beller
  • Ml
Andrews ET, Gentchos EJ, Beller ML. Results of anterior cervical spine fusions done at the hospital of the University of Pennsylvania: a nine-year follow-up. Clin Orthop 1971;81:15–20.
Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion
  • Silber
Incidence of dysphagia after anterior cervical spine surgery: a prospective study
  • Bazaz