Study Design. Retrospective analysis of prospectively collected data. Objective. Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. Summary of Background Data. Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. Materials and Methods. A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. Results. Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. Conclusion. Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

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BACKGROUND: Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series. OBJECTIVE: To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting. METHODS: A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed. RESULTS: There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery. CONCLUSION: In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.

Background: Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) have gained significant popularity for management of lumbar degenerative spine over the last 3 decades. Expandable interbody spacers are a newer technology that can increase in size after placement, theoretically minimizing the operative risks of static spacers without sacrificing radiographic correction. The goal of this study is to further evaluate the radiographic and clinical outcomes of expandable spacers.Methods: This was a retrospective analysis of a prospective cohort that underwent elective 1-to 3-level PLIF/ TLIF with expandable interbody spacers from 2014 to 2020 at a single institution. Patient-reported outcome measures (PROMs) Oswestry Disability Index and Visual Analog Scale were collected at 6 weeks, 3 months, 6 months, and 12 months. Imaging was performed at 12 months, with follow up at 24 months in case of nonunion. Retrospective outcomes were computer tomography (CT) based and Bridwell-Lenke classification of fusion, radiographic parameters, and adverse events.Results: A total of 50/53 (94.3%) otherwise eligible patients had 12-month PROMs and CT imaging for analysis. Here, 50% were obese (body mass index . 30), 58% had a smoking history, and 24% had a prior lumbar procedure. Also, 46/50 (92%) patients fused by CT criteria. Significant decrease in PROMs was seen as early as 6 weeks postoperatively. The mean change in preoperative-to-postoperative global lordosis values was 3.88 6 15.68. There were 4 (8%) intraoperative durotomies and 5 (10%) patients requiring reoperation for nonunion.Conclusions: Our study demonstrates the use of expandable spacers in a high comorbidity cohort with low complications, excellent improvement in PROMs despite minimal lordotic improvement, and high rates of fusion without recombinant human bone morphogenetic protein-2 (rhBMP-2) or iliac crest bone graft.Level of Evidence: 4. Clinical Relevance: Expandable interbody fusion can significantly improve outcomes for degenerative lumbar spondylosis, with good safety profile, and high fusion rates.

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