Clinical study
Early outcomes and safety of outpatient (surgery center) vs inpatient based L5-S1 Anterior Lumbar Interbody Fusion

https://doi.org/10.1016/j.jocn.2019.11.001Get rights and content

Highlights

  • 62 consecutive patients underwent ALIF at a single site ASC and inpatient hospital.

  • There were 8 total complications, none vascular related.

  • Both groups showed improvement in outcome scores postoperatively.

  • Our consecutive series demonstrates ALIF can be done safely in outpatient settings.

Abstract

We seek to determine the outcomes of patients undergoing outpatient-based ALIF compared to a consecutive series of inpatient based ALIF performed during the same time period. 58 consecutive patients at a single outpatient surgery center underwent ALIF from June 2015 - August 2017 and 79 ALIF's were performed at 2 Inpatient hospitals. Electronic medical records were reviewed for perioperative and postoperative complications as well as secondary interventions. 62 patients met inclusion criteria (29 Outpatient, 33 Inpatient). The inpatient group was significantly older (44 vs 51; p = 0.01). There were 8 postoperative complications. There was no difference in secondary interventions; 28 patients underwent a total of 36 interventions postoperatively for pain. Secondary interventions were performed at an average of 128(outpatient) and 158(inpatient) days (p = 0.55). There was no difference in outcome scores between the inpatient/outpatient groups at any time. Patients receiving a secondary intervention showed no significant improvement in Back VAS scores but, demonstrated a strong trend (p = 0.06) towards leg pain improvement. Patients who did not undergo secondary intervention had significant improvement in both Back and Leg VAS scores at all time points (p < 0.05). Outpatient ALIF is a safe and reproducible procedure with complication rates consistent with or lower than published rates. Patients outcome scores were no different in the inpatient versus outpatient group. Interestingly, there was a high number of secondary interventions performed in both groups. Patients undergoing a secondary procedure did not get statistically significant improvement in Back VAS but, demonstrated a strong trend in Leg VAS patient reported outcome scores.

Introduction

There has been an increasing movement toward cervical and lumbar surgery being performed in an ambulatory setting [9], [16], [30], [31], [37]. This trend is likely driven by newer minimally invasive techniques which often have the advantage of improved perioperative outcomes including operative time, estimated blood loss, and length of stay with no significant difference in patient-reported outcomes or complication rates [2], [10] An ambulatory surgery setting has the potential to build upon the benefits offered by MIS, including length of postoperative hospital stay and the associated direct and indirect costs without compromising patient safety or efficacy [11], [12], [13], [14], [18], [35], [39], [33].

Anterior Lumbar Interbody Fusion (ALIF) is a common operation used to treat a variety of pathologies with excellent outcomes [3], [5], [6], [15], [19], [21], [23], [24], [25], [27], [34], [36], [38]. While not traditionally considered in the context of MIS surgery, when done with an experienced vascular surgeon, utilizing a minimal anterior transverse incision, patients undergoing ALIF may see many of the benefits. To our knowledge there are no reports of outcomes of ALIF being performed in an ambulatory setting. We now seek to determine pain, safety, and secondary intervention, based outcomes of patients undergoing outpatient-based ALIF compared to a consecutive series of inpatient based ALIF performed during the same time period.

Section snippets

Materials and methods

Data was collected from consecutive patients treated by a total of 5 spine fellowship trained surgeons operating at the Indiana Spine Group from June 2015 to August 2017, beginning with the first outpatient ALIF performed in June 2015. Inclusion criteria were L5-S1 ALIF with or without posterior fixation. Diagnosis included degenerative disc disease (DDD), foraminal stenosis, recurrent disc herniation, pseudoarthrosis and isthmic spondylolisthesis. Patients were excluded for diagnosis other

Results

A total of 62 consecutive patients met the inclusion criteria and were available for review: 29 included in the Outpatient group and 33 included in the Inpatient group. There was no difference between groups with regard to sex (48.2% Female Outpatient, 60.6% Female Inpatient). The inpatient group was significantly older (44 vs 51 years of age; p = 0.01). The majority of patients underwent treatment for Degenerative Disc Disease (75.8% Outpatient, 90.9% Inpatient). All patients were ASA 1–2.

Discussion

Anterior Lumbar Interbody fusion is a common procedure to address multiple pathologies particularly at L5-S1 [21]. Fusion and outcomes following ALIF are typically as good if not better than posteriorly based procedures [6], [19], [24], [36], [38]. Advantages of ALIF include decreased adjacent segment degeneration [19], decreased morbidity, decreased blood loss, and shorted operative times [6], [15], [24], [34]. However, safety of ALIF necessitates navigating visceral and vascular structures.

Conclusion

In appropriately selected patients, outpatient ALIF is a safe and reproducible procedure with complication rates consistent with or lower than published rates. Patients outcome scores were no different in the inpatient versus outpatient group. Interestingly, there was a high number of secondary interventions performed in both inpatient and outpatient groups. Patients who underwent a secondary intervention did not get statistically significant improvement in VAS Back but, trended toward VAS leg

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