Predictors of inpatient admission in the setting of anterior lumbar interbody fusion: a Minimally Invasive Spine Study Group (MISSG) investigation

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>While the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications have hindered transition of this procedure to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of ≥ 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist in the development of screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting for this procedure. The purpose of this study was to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A prospectively maintained surgical registry was reviewed for patients undergoing single ALIF between May 2006 and December 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their relative risk (RR) elevation for an inpatient stay of ≥ 24 hours. A Poisson regression model was used to evaluate predictors of inpatient stays of ≥ 24 hours. Risk factors for inpatient admission of ≥ 24 hours were identified with a stepwise backward regression model.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 111 patients underwent single-level ALIF (50.9% female and 52.6% male, ≤ 50 years old). Eleven (9.5%) patients were discharged in &lt; 24 hours and 116 remained admitted for ≥ 24 hours. The average inpatient stay was &gt; 2 days (53.7 hours). The most common postoperative complications were fever (body temperature ≥ 100.4°F; n = 4, 3.5%) and blood transfusions (n = 4, 3.5%). Bivariate analysis revealed a preoperative diagnosis of retrolisthesis or lateral listhesis to elevate the RR for an inpatient stay of ≥ 24 hours (RR 1.11, p = 0.001, both diagnoses). Stepwise multivariate analysis demonstrated significant predictors for inpatient stays of ≥ 24 hours to be an operation on L4–5, coexisting degenerative disc disease (DDD) with foraminal stenosis, and herniated nucleus pulposus (RR 1.11, 95% CI 1.03–1.20, p = 0.009, all covariates).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This study provides data regarding the incidence of demographic and perioperative characteristics and postoperative complications as they pertain to patients undergoing single-level ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients.</jats:p></jats:sec>

Ambulatory Lumbar Fusion

“…In addition, they found that two level procedures were less likely to be conducted in an outpatient setting 24. 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.…”

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions

“…28 Rothenfluh et al 29 also considered the role of age as a risk factor and observed a higher complication rate (29%) among patients above 60 years compared with a younger cohort, although this trend did not reach statistical significance. Parrish et al 13 investigated the role of advanced age in placing patients at increased likelihood for prolonged postoperative length of stay; however, they too did not find this characteristic to be a significant contributor. Nevertheless, the current study deemed age as a clinically significant operative risk factor and was therefore included among modifiers of ALIF risk.…”

“…Operations involving multiple levels of the spine and in particular the L4-L5 level have been implicated as higher risks for complications and increased blood loss. 7,[11][12][13] A range of other factors have been reported to increase risk including a history of prior abdominal surgery, 14 increased body mass index (BMI), 7 male sex, 7 and segmental instability. 11,13 With a large variability in potential risk factors for poorer operative outcomes, the aim of the current study is to provide an objective scoring system to determine the preoperative risk an ALIF presents for a given individual.…”

Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion

“…10,11,15,16 While several studies have analyzed outpatient spine procedures, only a few small institutional cohort studies have specifically evaluated postoperative complications of ALIF in the outpatient setting. 17 There is still concern for intraoperative vascular injury during ALIF that ranges from 1.9% to 24%. 8,18,19 Therefore, the aim of this investigation was to utilize a national database to (1) evaluate differences in postoperative outcomes and cost associated with outpatient ALIF compared with inpatient ALIF, and (2) identify independent factors contributing to complications after outpatient ALIF.…”

“…While several studies have analyzed outpatient spine procedures, only a few small institutional cohort studies have specifically evaluated postoperative complications of ALIF in the outpatient setting 17. There is still concern for intraoperative vascular injury during ALIF that ranges from 1.9% to 24% 8,18,19.…”