Comparison of Multilevel Anterior Cervical Discectomy and Fusion Performed in an Inpatient Versus Outpatient Setting

Abstract

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.

Is It Safe to Perform True Outpatient Multilevel ACDFs in a Surgery Center?

“…Patients with significant comorbidities should undergo preoperative medical evaluation and optimization to assess their appropriateness as outpatient surgical candidates. Other common complications related to systemic effects such as nausea and urinary retention are identified early in PACU and can be managed as outpatients or admitted overnight, as needed 2…”

“…Other common complications related to systemic effects such as nausea and urinary retention are identified early in PACU and can be managed as outpatients or admitted overnight, as needed. 2 The most immediate postoperative concern after ACDFs is potential airway compromise. An expanding postoperative retropharyngeal hematoma poses a catastrophic complication and serves as the predominant indication for a 23-hour observation admission.…”

Advanced Technologies for Outpatient Lumbar Fusion: Barriers and Opportunities

“…To this end, many studies have reported on the feasibility of ACDF, cervical arthroplasty, posterior cervical foraminotomy, and lumbar decompression in the outpatient setting. [2][3][4][5]15 Only in the past few years, however, can the same be said for lumbar fusions. In 2013 and 2014, the first 3 case series of outpatient transforaminal lumbar interbody fusions (TLIFs) were published.…”

“…1 Spinal decompression procedures and anterior cervical discectomy and fusions (ACDFs) are responsible for the majority of this trend, whereas lumbar fusions have lagged behind. [2][3][4][5] As a case in point, one study reported that the incidence of outpatient lumbar fusions was stagnant between 2008 and 2018. 6 In recent years, however, multiple studies have demonstrated favorable outcomes after outpatient lumbar fusion-particularly with the use of minimally invasive techniques.…”

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion

“…Complication rates with ACDF are low enough that it can be performed even in an outpatient setting. 1,2 However, the surgery is not without risks and some can be devastating such as postoperative hematoma compression of the airway. [3][4][5][6][7] Some surgeons routinely place a suction drain to address postoperative hematoma.…”