Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion

Abstract

Objective: The aim were to (1) evaluate differences in postoperative outcomes and cost associated with outpatient anterior lumbar interbody fusion (ALIF) compared with inpatient ALIF, and to (2) identify independent factors contributing to complications after outpatient ALIF.Summary of Background: While lumbar fusion is traditionally performed inpatient, outpatient spinal surgery is becoming more commonplace as surgical techniques improve. Methods:The study population included all patients below 85 years of age who underwent elective ALIF (CPT-22558). Patients were then divided into those who underwent single-level fusion and multilevel fusion using the corresponding additional level fusion codes (CPT-22585). These resulting populations were then split into outpatient and inpatient cohorts by using a service location modifier. To account for selection bias, propensity score matching was performed; the inpatient cohorts were matched with respect to the outpatient cohorts based on age, sex, and Charlson Comorbidity Index. Statistical significance was set at P < 0.05 and the Bonferroni correction was used for each multiple comparison (P < 0.004).Results: Patients undergoing outpatient procedure had decreased rates of medical complications following both single-level and multilevel ALIF. In addition, age above 60, female sex, Charlson Comorbidity Index > 3, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, hypertension, and tobacco use were all identified as independent risk factors for increased complications. Finally, the cost of outpatient ALIF was $12,013 while the cost of inpatient ALIF was $27,271 (P < 0.001). Conclusion:The findings add to the growing body of literature advocating for the utilization of ALIF in the outpatient setting for a properly selected group of patients.

Ambulatory Lumbar Fusion

“…Moreover, Parrish et al 22 described a series of outpatient ALIF procedures and found that those patients were less likely to have a diagnosis of herniated nucleus pulposus, less likely to have degenerative disk disease along with foraminal stenosis, less likely to have pathology at L4-5, and less likely to have retrolisthesis or lateral listhesis. Kamalapathy et al 25 reported in ALIF patients, older patients, patients with BMI more than 30, and those with a higher comorbidity burden were more likely to undergo inpatient procedures. Blaginykh et al 19 investigated the NSQIP database and found that outpatient PLF patients were younger and less likely to be receiving steroid therapy, but were more likely to have high BMI and diabetes.…”

“…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.…”

“…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.…”

Impact of gender on outcomes following single-level anterior lumbar interbody fusion

“…17,18 ALIF has demonstrated safety and efficacy when compared to other approaches, even in the ambulatory setting. 17,19,20 However, there is little-to-no published data regarding the influence of gender on outcomes following ALIF. As Gianakos et al (2020) posited, it is necessary to have a better understanding of the influence gender has on spine surgery to provide equitable healthcare to both female and male patients alike.…”

Comparison of the Safety of Inpatient versus Outpatient Lumbar Fusion

“…Nine studies with a total of 70,000 IPS patients and 5043 OPS patients were included for revision surgery. 18,[20][21][22]24,25,27,29,30 The Pooled revision surgery rate was 1.9% (0%-30%) in the OPS cohorts and 3% (0%-24%) in the IPS cohorts. The metaanalysis of 9 studies showed no significant difference in revision surgery rates between inpatient and outpatient fusion [OR = 0.81 (0.57-1.15), P = 0.239, I2 = 65.2%] (Fig.…”