The safety of instrumented outpatient anterior cervical discectomy and fusion

doi:10.1016/j.spinee.2006.04.009

The Spine Journal

Volume 7, Issue 2, March–April 2007, Pages 148-153

https://doi.org/10.1016/j.spinee.2006.04.009 Get rights and content

Abstract

Background context

Reported hospitalization times after an anterior cervical discectomy and fusion (ACDF) procedure range between 20 hours to 4 days. Reasons for this wide variation are manifold, but the safety of an instrumented ACDF in the setting of a hostile medical-legal climate is most likely the primary concern influencing such a discrepancy.

Purpose

The purpose of this study was to evaluate the safety and feasibility of performing single, two- and three-level ACDF with instrumentation on an outpatient or 23-hour observation period basis in order to potentially diminish the additional cost of hardware without compromising the purported benefits of surgery.

Study design/setting

A retrospective chart review of patients undergoing instrumented ACDF on an outpatient basis was performed.

Patient sample

A total of 103 patients with neck pain and/or radiculopathy undergoing ACDF were enrolled into this study.

Outcome measures

Included the evaluation of intraoperative and perioperative complications, which were reported for a total of 6 months after surgery. Clinical examination and radiographical assessment, including plain radiographs and computed tomography and magnetic resonance imaging (when required), were performed to assess complications.

Methods

Complications were divided into two groups: major and minor. Major complications included vertebral fracture and dehydration resulting in readmission. Minor complications included allergic reactions to medications that did not require hospitalization, and transient (≤3 months) neurologic deficit. A comprehensive literature search and meta-analysis was performed to generate a large comparison group in order to compare the complication rates in our outpatient series to those reported in the literature.

Results

A total of 99 patients (96.1%) undergoing single and two-level ACDF were discharged less than 15 hours after their surgeries (median time: 8 hours; range: 2–15 hours), and 4 patients (3.9%) were discharged after a 23-hour observation period following three-level ACDF. The overall complication rate in our outpatient series was 3.8% (n=4), including 1.9% (n=2) major and 1.9% (n=2) minor complications. The overall complication rate in the 633 patient meta-analysis derived comparison group was 0.95% (n=6). The difference between overall complication rates was not found to be significantly different (p=.12). The hardware-related complication rate in the meta-analysis comparison group was 0.5% (n=3), and was not found to be significantly different from our rate of 0% (p≤1).

Conclusion

Performing ACDF with instrumentation on an outpatient basis is feasible, and it is not associated with higher overall or hardware-related complication rates as compared with complication rates reported in the literature, suggesting that this procedure is safe to perform on an outpatient basis.

Introduction

Anterior cervical discectomy and fusion (ACDF) has proven to be a safe and effective procedure for the treatment of a multitude of spinal disorders [1], [2], [3], [4], [5], [6], [7], [8], [9]. A considerable controversy exists regarding the necessity of fusion [10], [11], [12], [13], [14] and instrumentation [4], [15], [16]. However, complication rates are low with instrumented ACDF [17], [18], [19], and there are substantial benefits that have been reported in adding instrumentation, such as beneficial effects on long-term stabilization [1], increased fusion rates for one- and two-level procedures [18], [20], and decreased kyphotic deformity associated with pseudoarthroses [19], [20], [21]. Additionally, the use of plating has been demonstrated to significantly reduce convalescent time, thus decreasing the economic impact of undergoing ACDF [6].

One way to potentially reduce the total cost of surgery is to perform procedures on an outpatient basis. There are substantial benefits to outpatient surgeries besides overall reduced costs, including decreased exposure to nosocomial infections [22], [23]. In a series of 103 patients, Silvers et al. [22] reported that converting single and two-level noninstrumented ACDF from an admitted to an ambulatory procedure is safe, effective, and can substantially reduce the economic impact of the surgery. However, currently there is only one study which assesses outpatient instrumented ACDF, the investigation by Stieber et al. [24].

The purpose of our study was to evaluate the safety and feasibility of performing single, two- and three-level ACDF with instrumentation on an outpatient basis (including patients who would not have met the outpatient inclusion criteria from the Stieber [24] study), in order to potentially diminish the additional cost of hardware, without compromising the purported benefits of instrumentation.

Section snippets

Study design

Over a 2-year period from April 2003 to April 2005, 103 patients were enrolled in our study in order to evaluate the feasibility and safety of performing ACDF with instrumentation procedures on an outpatient basis. This study was a retrospective chart review evaluating the safety of outpatient ACDF with plating. The safety and feasibility of performing ACDF as an outpatient procedure were assessed comparing intraoperative and perioperative complications, which were reported for a 6-month

Complications

Incidences of complications in the patient population are presented as major and minor (Table 3) according to the criteria described in the Methods section. The overall complication rate was 3.8% (n=4), including 1.9% (n=2) major and 1.9% (n=2) minor complications. Six patients (5.8%) in the study had dysphagia, and four (3.9%) had hoarseness of voice. These complications were transient, did not require any treatment, and were not included in the analysis of complication rates. One adverse

Discussion

Anterior cervical discectomy and fusion has long been the treatment of choice for many different spinal disorders. Since originally described by Smith and Robinson [25] and Cloward [26], the ACDF procedure has evolved to include plating. The addition of instrumentation has been shown to be safe, with a low hardware-related complication rate that varies from 0 to 5% [3], [5], [6], [18], [19], [20], [21] for a wide range of clinical indications. There are substantial clinical and financial

Conclusion

Performing ACDF with instrumentation on an outpatient basis is feasible, and it is not associated with higher overall or hardware-related complication rates as compared with a meta-analysis comparison group, suggesting that this procedure is safe to perform on an outpatient basis.

Acknowledgment

This work was supported by the Justin Parker Neurosurgical Research Foundation.

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Cited by (94)

Predictors of Airway, Respiratory,airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion
2022, Clinical Neurology and Neurosurgery
Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure on the cervical spine. While the procedure is generally well tolerated, respiratory and pulmonary complications (RPC) are an unlikely yet possible complication following ACDF. Few previous studies have specifically identified risk factors associated with RPC following ACDF. As the incidence of an RPC is rare at a single institution, a large national database is required for meaningful analysis.
The goal of this study is to characterize the predictors for RPC following an ACDF by utilizing a large national database.
The National Inpatient Sample (NIS) was queried from 2016 to 2018 for all patients who had received elective ACDF for degenerative cervical spine disease. We categorized several complications as airway complications including various abscess, angioedema, laryngeal edema, vocal cord paralysis, dysphonia, various etiologies of pneumonia, and acute respiratory distress syndrome. A Firth’s logistic regression model was used to identify predictors of RPC.
We identified a final cohort of 52,575 admissions in which an ACDF was performed of which 1454 admissions had an RPC. Older patients were 1.03 times more likely to have an RPC (OR = 1.03, 95%CI: 1.02–1.04). African American patients compared to Caucasian patients were 1.44 times more likely to have an RPC (OR = 1.44, 95%CI: 1.23–1.68). Obese patients were found to be 1.64 to have an RPC (OR = 1.64, 95%CI: 1.45–1.85). Diabetic patients are 2.07 times more likely to have an RPC (OR = 2.07, 95%CI: 1.76–2.44). Hypertensive patients are 1.91 times more likely to have an RPC (OR = 1.91, 95%CI: 1.59–2.27). Urban based hospitals were 1.11 and 1.46 times more likely to have an RPC (OR = 1.11, 95%CI: 0.79–1.59; OR = 1.46, 95%CI: 1.06–2.08; teaching and non-teaching respectively). Patients who underwent multilevel procedure were 1.32 times more likely to experience a follow-on RPC (OR = 1.32, 95%CI: 1.17–1.49)
Our study identified modifiable predictors of RPC after elective ACDF (e.g. obesity, diabetes) which can be used to guide preoperative patient optimization.
A Novel Technique of Endoscopic Anterior Transcorporeal Approach with Channel Repair for Adjacent Segment Disease After Anterior Cervical Discectomy and Fusion
2021, World Neurosurgery
Citation Excerpt :
Cervical disc herniation (CDH) can be severely enfeebling to patients, causing limb numbness, pain, and/or weakness.1 Anterior cervical discectomy and fusion (ACDF) has been the gold standard procedure for CDH since it is introduced in the 1950s.2-9 However, malfunction may occur at the levels adjacent to the fused segment according to some follow-up studies after ACDF.10
To first report the application of percutaneous full-endoscopic anterior transcorporeal cervical discectomy (PEATCD) with channel repair for a patient with adjacent segment disease (ASD) after anterior cervical discectomy and fusion.
PEATCD with channel repair was performed for a patient with ASD at the cranial level adjacent to previous fusion at the C5–C6 level. The pre- and postoperative clinical symptoms were evaluated with Japanese Orthopedic Association and visual analog scale (VAS). The radiological examinations included magnetic resonance imaging, computed tomography, and plain radiographs, which were used to evaluate the cervical alignment, stability, intraoperative decompression, and bony channel.
The procedure was successfully completed within 70 minutes. The drainage tube was unnecessary. No surgery-related complications were recorded. The postoperative neck pain immediately improved to VAS 3 from preoperative VAS 6. The Japanese Orthopedic Association scores also took a turn for the better gradually from preoperative 10 to final 16 (improvement rate 85.7%). The muscle power recovered completely, and the Hoffman sign turned to negative during follow-up periods. Magnetic resonance imaging 1 week postoperatively showed a total removal of the herniation. The bony channel was almost disappeared on computed tomography images 3 months postoperatively. During postoperative periods, no relapse, channel collapse, bone plug migration, or instability was observed.
As a novel and supplemental procedure for ASD after anterior cervical discectomy and fusion, PEATCD combines the advantages of transcorporeal approach and endoscopy together, which decreases iatrogenic damage to disc, preserves the cervical motion segment, and reduces surgical trauma. As the limitations of 1 case show, the effectiveness and reliability of PEATCD for patients with ASD should be verified in further studies.
Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy
2021, Journal of Clinical Orthopaedics and Trauma
Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy.
14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer’s Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts.
Upon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%).
ACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF’s for myelopathy in comparison to their inpatient counterparts. Performing ACDF’s for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.
Are outpatient three- and four-level anterior cervical discectomies and fusion safe?
2021, Spine Journal
The safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management.
The present study aimed to investigate the safety of outpatient three- and four-level ACDF.
Retrospective cohort study
The National Surgical Quality Improvement Program – a large, prospectively-collected registry – was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting.
The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status.
Baseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF.
In total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not.
This present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.
Predicting Trends in Cervical Spinal Surgery in the United States from 2020 to 2040
2020, World Neurosurgery
We sought to predict surgical volumes for 2 common cervical spine procedures from 2020 to 2040.
Using the National Inpatient Sample from 2003–2016, nationwide estimates of anterior cervical diskectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) volumes were calculated using International Classification of Diseases, Ninth and Tenth Revision (ICD-9, ICD-10) procedure codes. With data from the U.S. Census Bureau, estimates of the U.S. population were used to create Poisson models controlling for age and sex. Age was categorized into ranges (<25 years old, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and >85), and estimates of surgical volume for each age group were created.
From 2020–2040, increases in surgical volume from 13.3% (153,288–173,699) and 19.3% (29,620–35,335) are expected for ACDF and PCDF, respectively. For ACDF, the largest increases are expected in the 45–54 (42,077–49,827) and 75–84 (8065–14,862) age groups, whereas for PCDF, the largest increases will be seen in the 75–84 (3710–6836) age group. In accordance with an aging population, modest increases will be seen for ACDF (858–1847) and PCDF (730–1573) in the >85-year-old cohort.
As expected, large growth in cervical spine surgical volumes is likely to be seen, which could indicate a need for increased numbers of spinal neurosurgeons and orthopedic surgeons. Further studies are needed to investigate the needs of the field in light of these expected increases in volume.
Safety and efficacy of day anterior cervical discectomy and fusion procedure for degenerative cervical spondylosis: a retrospective analysis
2024, BMC Musculoskeletal Disorders

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Clinical StudyThe safety of instrumented outpatient anterior cervical discectomy and fusion

Abstract

Background context

Purpose

Study design/setting

Patient sample

Outcome measures

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Complications

Discussion

Conclusion

Acknowledgment

Surg Neurol

Surg Neurol

Spine J

Am J Surg

Spine J

Spine J

Spine J

Three-level and four-level anterior cervical discectomies and titanium cage-augmented fusion with and without plate fixation

J Neurosurg Spine

Anterior cervical fusion for degenerated or protruded discs: a review of one hundred forty-six patients

Spine

Anterior cervical fusion using dense cancellous allografts and dynamic plating

Neurosurgery

Outcome analysis of noninstrumented anterior cervical discectomy and interbody fusion in 348 patients

Spine

Cadaveric fibula, locking plate, and allogeneic bone matrix for anterior cervical fusions after cervical discectomy for radiculopathy or myelopathy

J Neurosurg

Anterior discectomy and fusion for the management of neck pain

Spine

Upper cervical anterior diskectomy and fusion improves discogenic cervical headaches

Spine

Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain

Spine

Anterior cervical discectomy: is fusion necessary?

J Neurosurg

A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: surgical fusion is unnecessary

Neurosurgery

Anterior cervical discectomy for one- and two-level cervical disc disease: the controversy surrounding the question of whether to fuse, plate, or both

Crit Rev Neurosurg

Indications for surgical fusion of the cervical and lumbar motion segment

Spine

Clinical Study
The safety of instrumented outpatient anterior cervical discectomy and fusion