Study Design. A retrospective cohort study of prospectively collected data. Objective. The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. Summary of Background Data. ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. Methods. An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. Results. The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195–398 minutes] overall, 298 minutes (IQR 192–811) for lumbar decompression and 285 minutes (IQR 200–372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). Conclusion. This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. Level of Evidence: 3

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/m2 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.

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.

ObjectiveThe purpose of this study was to evaluate factors associated with inpatient admission following 2-level cervical disc arthroplasty (CDA). A secondary aim was to compare outcomes between those treated on an inpatient versus outpatient basis. MethodsUsing data from the American College of Surgeons National Surgical Quality Improvement Program database, multivariate logistic regression analysis was used to assess the independent effect of each variable on inpatient or outpatient selection for surgery. Statistical significance was defined by p-values <0.05. The factors considered were age, sex, body mass index (BMI), smoking status, American Society of Anesthesiologists physical status classification, and comorbidities including hypertension, diabetes, history of dyspnea or chronic obstructive pulmonary disease, previous cardiac intervention or surgery, steroid usage, and history of bleeding. In addition, whether the operation was performed by an orthopedic or neurosurgical specialist was analyzed. ResultsThe number of 2-level CDA procedures increased from 6 cases reported in 2014 to 142 in 2016, although a statistically significant increase in the number of outpatient cases performed was not seen (p=0.2). The factors found to be significantly associated with inpatient status following surgery were BMI (p=0.019) and diabetes mellitus requiring insulin (p=0.043). There were no significant differences in complication and readmission rates between the inpatient and outpatient groups. ConclusionPatients undergoing inpatient 2-level CDA had significantly higher rates of obesity and diabetes requiring insulin than did patients undergoing the same procedure in the outpatient setting. With no difference in complication or readmission rates, 2-level CDA may be considered safe in the outpatient setting in appropriately selected patients.

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.

Study Design. Prospective cohort study. Objective. To examine preoperative urinary cross-linked n-telopeptide (uNTx) and assess for association with fusion rates in patients undergoing single and multi-level anterior cervical decompression and fusion (ACDF). Summary of Background Data. Although high rates of fusion have been reported for ACDF, the risk of pseudarthrosis remains substantial. An established marker of bone turnover, uNTx may prove useful as a predictor of fusion. Methods. Patients undergoing primary ACDF with allograft/plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preoperative uNTx was collected. Patients undergoing revision, with creatinine >1.2, and with improperly-collected uNTx were excluded. Demographics, laboratory values, and fusion status were assessed at 6 months, 1 year, and 2 years postoperatively. Results. Of the 97 patients enrolled, 69 met inclusion criteria. Of included cases, 41%, 33%, 18%, and 8% underwent 1-, 2-, 3-, and 4-level ACDF, respectively. Overall, fusion rates were 37.3%, 70.9%, and 95.3% at 6 months, 1 year, and 2 years, respectively. uNTx was higher in the fusion group (31.1 vs. 22.2, P = 0.001) at 6 months and 1 year (30.0 vs. 21.0, P = 0.006), with no difference at 2 years. No differences were identified in the proportion of smokers, immunomodulatory agents, corpectomies, or fusion levels between groups. Multivariate regression analysis demonstrated that uNTx is an independent predictor of fusion (odds ratio, OR, 1.124, P = 0.003). Both groups experienced improvements in NDI and VAS neck pain at 6 months with no significant differences noted between groups. Of 16 patients with pseudarthrosis at 1 year, 2 underwent posterior cervical fusion for symptoms. Conclusion. Preoperative uNTx was greater in patients with successful ACDF fusion compared with patients with pseudarthrosis at 6 months and 1 year. A negative correlation was found between preoperative uNTx and motion on dynamic imaging. These results suggest that uNTx could serve to identify patients at risk for pseudarthrosis after ACDF. Level of Evidence: 3

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