Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases

Abstract

BACKGROUND In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety. OBJECTIVE To analyze 2000 ASC-ACDF cases, describe patient selection and perioperative protocol, and report associated safety profile. METHODS A total of 2000 patients who underwent 1 to 3 level ACDF in a single ASC from 2006 to 2018 were included in this retrospective analysis. Patients were observed in a 4-h postanesthesia care unit (PACU) with a multimodal pain management regiment. Data were collected on patient demographics, comorbidities, operative details, and 30- and 90-d morbidity. RESULTS Of the 2000 patients, 10 (0.5%) required transfer to an inpatient setting within the 4-h observation. Reasons for transfer included hematoma (2), pain control (2), cerebrospinal fluid leak (1), and medical complications (5). Six patients (0.3%) underwent reoperation within 30 d. All-cause 30-d readmission was 1.9%. CONCLUSION An analysis of 2000 ACDF patients in an ASC setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in a 4-h PACU. In an effort to decrease healthcare costs, surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here.

Life-threatening delayed arterial hemorrhage following anterior cervical spine surgery: A case report and literature review

“…Anterior cervical spine operations are among the most commonly performed procedures among spine surgeons and have low complication rates. [7,2,10,13] Although postoperative retropharyngeal hematomas are rare, typically occurring within hours of surgery, they can lead to acute airway compromise. [14][15][16][17] erefore, immediate recognition and removal are critical to limit morbidity and mortality.…”

“…Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal operations. [10,13] Following ACDF, life-threatening postoperative acute and occasionally delayed hematomas with airway obstruction are observed warranting emergent/urgent decompression/vessel ligation. [14,18] Herein, we reported a 52-year-old male who developed delayed arterial bleeding from a branch of the superior thyroid artery 5 days following a C45-C56 ACDF.…”

Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities

“…series involving 2000 1–3 level ACDF (2006–2018) observed for 4 h in an OSD PACU; these included 2 hematomas, 2 instances of intractable pain, 1 cerebrospinal fluid leak, and 5 medical complications. [ 14 ]…”

“…[ 6 ] Six other clinical series involving cervical surgery performed in OSD/ASC documented 0% mortality rates [ Table 1 ]. [ 1 , 7 - 9 , 13 , 14 ] These latter studies involved a total of 5071 patients, with between 30 and 2000 patients/study; most patients underwent 1–2 level ACDF, with fewer having 3–4 level ACDF, or CDA.…”

Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time

“…A number of studies conducted over the past decade have demonstrated that following careful patient selection, outpatient anterior cervical surgery can be performed with similar outcomes and morbidity relative to the inpatient setting [17] , [18] , [19] , [20] , [21] , [22] , [23] . Thus, the observed increase in outpatient volume may stem from more surgeons performing this procedure in the outpatient setting after being convinced by the findings of these studies.…”