Outpatient Versus Inpatient Anterior Lumbar Spine Surgery: A Multisite, Comparative Analysis of Patient Safety Measures

Abstract

Background: The frequency and complexity of spinal surgery performed in an ambulatory surgery center (ASC) is increasing. However, safety and efficacy data of most spinal procedures adapted to the ASC are sparse and have focused on anterior cervical surgery. The purpose of this study was to compare the 90-day complication and readmission rates of anterior lumbar spine surgery performed in an ASC or inpatient setting.Methods: We performed a retrospective comparative analysis of 226 consecutive anterior lumbar surgeries (283 levels treated) completed in an ASC (n ¼ 124) or in an inpatient tertiary care hospital (n ¼ 102) over a 3-year period. These included anterior lumbar interbody fusion (ALIF), artificial disc replacement (ADR), and hybrids. Patients undergoing simultaneous or staged posterior procedures within 3 months were excluded. Patient demographics and surgical parameters between the two surgical settings were compared. Ninety-day medical complications and readmission rates were assessed. One-way analysis of variance and Chi-square analysis were used. A P value of less than .05 was considered statistically significant.Results: The two study groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations, and readmissions for the ASC cohort, the differences were not statistically significant. There were 7 intraoperative complications (5.6% minor vascular injury) in the inpatient cohort and 0 in the ASC cohort. The overall 90-day postoperative complication rate was 5.6% for the inpatient cohort and 0.9% for the ASC cohort. The 90-day readmission rate was 1.9% in the ASC cohort and 1.6% in the inpatient cohort. The 90-day reoperation rate was 0.8% for the inpatient cohort and 0% in the ASC cohort. The average hospital stay was 2.3 6 1.5 days for the inpatient cohort. Conclusion:The 90-day readmission rates were lower for outpatients than for inpatients, while the complication and reoperation rates were similar. Our results demonstrate that anterior lumbar procedures, including single-level and multilevel ALIF, ADR, and hybrid procedures, can be performed safely in an ASC. This has significant cost savings implications for the ASC setting.

Ambulatory Lumbar Fusion

“…In most of the studies in which an outpatient or ambulatory cohort was compared to an inpatient cohort, the outpatient/ambulatory arm was found to have either lower or similar odds of a complication 10,12,14,15,18,24,25. Only one paper, Arshi et al ,5 did report statistically significant higher rates of complications for the outpatient group compared to the inpatient group following a PLF procedure.…”

“…Cuellar et al 20 also reported on an outpatient ALIF cohort and included patients with BMI <30, minimal comorbidities, and no prior anterior surgery. In a separate analysis, Cuellar described the importance of patient selection and specifically body habitus in determining eligibility for an ambulatory procedure 24. In addition, they found that two level procedures were less likely to be conducted in an outpatient setting 24.…”

“…In most of the studies in which an outpatient or ambulatory cohort was compared to an inpatient cohort, the outpatient/ambulatory arm was found to have either lower or similar odds of a complication. 10,12,14,15,18,24,25 Only one 26 2.3* 0* -0* paper, Arshi et al, 5 did report statistically significant higher rates of complications for the outpatient group compared to the inpatient group following a PLF procedure. Specifically, patients undergoing an outpatient PLF procedure had higher likelihood of a needing a revision/extension of the posterior fusion, anterior fusion, or laminectomy within one year postoperatively.…”

Assessment of Spine Patient Preferences for the Location of Surgery Between a Hospital and an Ambulatory Surgical Center in the Time of COVID-19: An Analysis of Patient Surveys

“…While the increased length of stay of hospitals compared to ASCs was mentioned to patients in the survey, its influence in the survey was not directly measured. It is worth noting that hospital admission lengths for lumbar spine procedures average roughly 2.5 days, as compared to ASCs that almost always discharge their patients on the same day [ 16 ]. However, this difference is less significant due to the patients who undergo their procedures in hospitals typically being older, sicker, and undergoing more complex operations that require more time under observation.…”

“…Concern given the out-of-hospital setting of ASCs is understandable. However, a systematic review has shown procedures being performed in hospitals have significantly higher rates of intraoperative events, postoperative complications, readmissions, and reoperations [ 16 ]. Using this information, surgeons can offer the concerned patient further education on how complications at an ASC are handled and reassure that carefully selected and planned operations are very safe to take place in an ASC.…”