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Tang L, Chen Y, Wang F, Liu Y, Song Z, Wang M, Zhou Y, Liu H, Zheng J. Safety and efficacy of day anterior cervical discectomy and fusion procedure for degenerative cervical spondylosis: a retrospective analysis. BMC Musculoskelet Disord 2024; 25:223. [PMID: 38504222 PMCID: PMC10953196 DOI: 10.1186/s12891-024-07356-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVE Our study aimed to develop a day anterior cervical discectomy and fusion (ACDF) procedure to treat degenerative cervical spondylosis (DCS). The goal was to analyze its clinical implications, safety, and early effects to provide a better surgical option for eligible DCS patients. METHODS A retrospective analysis was performed to identify DCS patients who underwent day ACDF from September 2022 to August 2023. The operative time, intraoperative blood loss, postoperative drainage, preoperative and postoperative visual analog scale (VAS) scores, neck disability index (NDI) scores, Japanese Orthopedic Association (JOA) scores, JOA recovery rate (RR), incidence of dysphagia-related symptoms, 30-day hospital readmission rate, and incidence of other complications were recorded to evaluate early clinical outcomes. Radiography was performed to assess the location of the implants, neurological decompression, and cervical physiological curvature. RESULTS All 33 patients (23 women and 10 men) underwent successful surgery and experienced significant symptomatic and neurological improvements. Among them, 26 patients underwent one-segment ACDF, 5 underwent two-segment ACDF, and 2 underwent three-segment ACDF. The average operative time was 71.1 ± 20.2 min, intraoperative blood loss was 19.1 ± 6.2 mL, and postoperative drainage was 9.6 ± 5.8 mL. The preoperative VAS and NDI scores improved postoperatively (7.1 ± 1.2 vs. 3.1 ± 1.3 and 66.7% ± 4.8% vs. 24.1% ± 2.5%, respectively), with a significant difference (P < 0.01). Moreover, the preoperative JOA scores improved significantly postoperatively (7.7 ± 1.3 vs. 14.2 ± 1.4; P < 0.01) with an RR of 93.9% in good or excellent. Postoperative dysphagia-related symptoms occurred in one patient (3.0%). During the follow-up period, no patient was readmitted within 30 days after discharge; however, an incisional hematoma was reported in one patient on the 6th day after discharge, which was cured by pressure dressing. The postoperative radiographs revealed perfect implant positions and sufficient nerve decompression in all patients. Furthermore, the preoperative cervical physiological curvature improved significantly after the operation (14.5° ± 4.0° vs. 26.3° ± 5.4°; P < 0.01). CONCLUSIONS Day ACDF has good safety and early clinical efficacy, and it could be an appropriate choice for eligible DCS patients.
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Affiliation(s)
- Long Tang
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University of Munich, Ismaninger Straße 22, Munich, 81675, Germany
| | - Yu Chen
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Fandong Wang
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Yuanbin Liu
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Zhaojun Song
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Miao Wang
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Yong Zhou
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Huiyi Liu
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China
| | - Jiazhuang Zheng
- Department of Spine Surgery, Suining Central Hospital, 127 Desheng West Road, Suining, Sichuan Province, 629000, China.
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Kim LJY, Mazur MD, Dailey AT. Mid-term and Long-term Outcomes After Total Cervical Disk Arthroplasty Compared With Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clin Spine Surg 2023; 36:339-355. [PMID: 37735768 DOI: 10.1097/bsd.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023]
Abstract
STUDY DESIGN A meta-analysis of randomized controlled trials (RCTs). OBJECTIVE The aim of this study was to compare mid-term to long-term outcomes of cervical disk arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical degenerative disk disease. SUMMARY OF BACKGROUND DATA After ACDF to treat symptomatic cervical degenerative disk disease, the loss of motion at the index level due to fusion may accelerate adjacent-level disk degeneration. CDA was developed to preserve motion and reduce the risk of adjacent segment degeneration. Early-term to mid-term clinical outcomes from RCTs suggest noninferiority of CDA compared with ACDF, but it remains unclear whether CDA yields better mid-term to long-term outcomes than ACDF. MATERIALS AND METHODS Two independent reviewers searched PubMed, Embase, and the Cochrane Library for RCTs with at least 60 months of follow-up. The risk ratio or standardized mean difference (and 95% CIs) were calculated for dichotomous or continuous variables, respectively. RESULTS Eighteen reports of 14 RCTs published in 2014-2023 were included. The pooled analysis demonstrated that the CDA group had a significantly greater improvement in neurological success and Neck Disability Index than the ACDF group. The ACDF group exhibited a significantly better improvement in the Short Form-36 Health Survey Physical Component Summary than the CDA group. Radiographic adjacent segment degeneration was significantly lower in the CDA group at 60- and 84-month follow-ups; at 120-month follow-up, there was no significant difference between the 2 groups. Although the overall rate of secondary surgical procedures was significantly lower in the CDA group, we did not observe any significant difference at 60-month follow-up between the CDA and ACDF group and appreciated statistically significant lower rates of radiographic adjacent segment degeneration, and symptomatic adjacent-level disease requiring surgery at 84-month and 108- to 120-month follow-up. The rate of adverse events and the neck and arm pain scores in the CDA group were not significantly different from those of the ACDF group. CONCLUSIONS In this meta-analysis of 14 RCTs with 5- to 10-year follow-up data, CDA resulted in significantly better neurological success and Neck Disability Index scores and lower rates of radiographic adjacent segment degeneration, secondary surgical procedures, and symptomatic adjacent-level disease requiring surgery than ACDF. ACDF resulted in improved Short Form-36 Health Survey Physical Component Summary scores. However, the CDA and ACDF groups did not exhibit significant differences in overall changes in neck and arm pain scores or rates of adverse events.
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Affiliation(s)
- Leo J Y Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
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A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy. Spine (Phila Pa 1976) 2023; 48:330-334. [PMID: 36730850 DOI: 10.1097/brs.0000000000004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cost-utility analysis. OBJECTIVE To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon. SUMMARY OF BACKGROUND DATA SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence. MATERIALS AND METHODS A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model. RESULTS The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty. CONCLUSION Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.
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Mooney J, Michalopoulos GD, Zeitouni D, Sammak SE, Alvi MA, Wang MY, Coric D, Chan AK, Mummaneni PV, Bisson EF, Sherrod B, Haid RW, Knightly JJ, Devin CJ, Pennicooke BH, Asher AL, Bydon M. Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes. J Neurosurg Spine 2022; 37:485-497. [PMID: 35523251 DOI: 10.3171/2022.3.spine211558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery. METHODS The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval. RESULTS A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery. CONCLUSIONS Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.
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Affiliation(s)
- James Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Giorgos D Michalopoulos
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 4School of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Sally El Sammak
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 5Department of Neurological Surgery, University of Miami, Florida
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Andrew K Chan
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Brandon Sherrod
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | | | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Clinton J Devin
- 11Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado; and
| | - Brenton H Pennicooke
- 12Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Mohamad Bydon
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Jung SB, Kim N. Biportal endoscopic spine surgery for cervical disk herniation: A technical notes and preliminary report. Medicine (Baltimore) 2022; 101:e29751. [PMID: 35801784 PMCID: PMC9259155 DOI: 10.1097/md.0000000000029751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Biportal endoscopic spine surgery (BESS) for cervical disk herniation (CDH) has been rarely reported. The aim of the article is to describe a novel BESS as a posterior approach for CDH and report the preliminary outcomes and complications. This single-centered retrospective chart review included 109 consecutive patients who underwent BESS for symptomatic single-level CDH. Working and viewing portals were created in each unilateral paravertebral area at the target disk level. Endoscopic exploration allowed for effective and minimally invasive decompression via safe access to the medial foramen with minimal laminectomy and facetectomy. Clinical outcomes, including the visual analog scale, neck disability index, Macnab criteria, and the motor function of the involved arm, were evaluated at 4, 8, 12, and 24 postoperative weeks. Visual analog scale and neck disability index improved significantly at 24 weeks postoperatively (P < .01). According to the Macnab criteria, "excellent," "good," and "fair" results were obtained for 55.9%, 30.3%, and 13.8% of patients, respectively. The post 24-week distribution of the involved upper extremity strength grade was significantly improved compared to the initial value (P = .02). One patient had a motor weakness with a decreased grade over 4 weeks from excessive irrigation. The posterior approach of BESS was efficient and feasible for the treatment of CDH.
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Affiliation(s)
- Seok Bong Jung
- Spine Center, Jinju Bon Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Nackhwan Kim
- Department of Physical Medicine and Rehabilitation, Korea University Ansan Hospital, Ansan-si, Gyeonggi-do, Republic of Korea
- *Correspondence: Nackhwan Kim, Department of Physical Medicine and Rehabilitation, Korea University Ansan Hospital, 15355, Jeokgeum-Ro 123, Danwon-gu, Ansan-si, Gyeonggi-do, Republic of Korea (e-mail: )
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Hardman M, Bhandarkar AR, Jarrah RM, Bydon M. Predictors of Airway, Respiratory, and Pulmonary Complications Following Elective Anterior Cervical Discectomy and Fusion. Clin Neurol Neurosurg 2022; 217:107245. [DOI: 10.1016/j.clineuro.2022.107245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/02/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
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Rogerson A, Aidlen J, Mason A, Pierce A, Tybor D, Salzler MJ. Predictors of Inpatient Morbidity and Mortality After 1- and 2-Level Anterior Cervical Diskectomy and Fusion Based on the National Inpatient Sample Database From 2006 Through 2010. Orthopedics 2021; 44:e675-e681. [PMID: 34590947 DOI: 10.3928/01477447-20210817-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Spine procedures, including anterior cervical diskectomy and fusion (ACDF), are more commonly being performed in an outpatient setting to maximize value. Early complications after ACDF are rare but can have devastating consequences. The authors sought to determine risk factors for inpatient complications after 1-and 2-level ACDF by performing a retrospective review of the National Inpatient Sample (NIS) administrative database from 2006 through 2010. A total of 78,771 patients were identified. Multivariate logistic regression analysis was performed to identify preoperative risk factors for medical and surgical complications, including mortality, airway compromise, new neurologic deficit, and surgical-site infection. Inpatient mortality and overall complication rates were 0.074% and 3.73%, respectively. The risk of any medical complication was 3.13%. Airway compromise, neurologic deficit, and surgical-site infection occurred in 0.75%, 0.05%, and 0.04% of cases, respectively. Chronic kidney disease was the strongest predictor of mortality, with an odds ratio (OR) of 11.14 (P<.001). Airway complication was associated with age older than 65 years, male sex, myelopathy, diabetes mellitus, anemia, bleeding disorder, chronic obstructive pulmonary disease, obesity, and obstructive sleep apnea (P<.05). Preoperative diagnosis of myelopathy was most strongly associated with an increased rate of neurologic complication (OR, 6.67; P<.001). Anemia was associated with a significantly increased rate of surgical-site infection, with an OR of 14.34 (P<.001). Age older than 65 years; certain medical comorbidities, particularly kidney disease and anemia; and a preoperative diagnosis of myelopathy are associated with increased risk of early complication following ACDF surgery. Surgeons should consider these risk factors when deciding to perform ACDF surgery in an outpatient setting. [Orthopedics. 2021;44(5):e675-e681.].
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Chin KR, Gohel NN, Aloise DM, Seale JA, Pandey DK, Pencle FJ. Effectiveness of a Fully Impregnated Hydroxyapatite Polyetheretherketone Cage on Fusion in Anterior Cervical Spine Surgery. Cureus 2021; 13:e17457. [PMID: 34603859 PMCID: PMC8475745 DOI: 10.7759/cureus.17457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Anterior cervical discectomy and fusion (ACDF) is the gold standard for the treatment of cervical spondylosis. However, new techniques, technologies, and improved implants have aided surgeons in reducing operative time with enhanced patient outcomes. Impregnated hydroxyapatite polyetheretherketone (HA PEEK) cages (Arena-C HA®, LESspine Inc. Malden, MA) are one such option that has aimed to increase the fusion rate. The authors herein aimed to assess the use of HA PEEK interbody cages by looking at outcomes, complications, and radiographic fusion. Methods The medical records of 41 consecutive patients undergoing single-level ACDF with impregnated HA PEEK cages (group 1) were compared to the control group of 47 patients who had single-level ACDF without impregnated HA PEEK cages (group 2). Outcomes assessed included Visual Analog Scale (VAS) neck, Neck Disability Index (NDI) scores, radiographic fusion, and complication rates. Results Of the 41 patients in group 1 (HA PEEK), 48% were female population with a mean age of 58.5+/- 1.7 years and BMI 29.7+/-1.2 kg/m2. Of the 47 patients in group 2 (non-HA PEEK), 53% were female with a mean age of 54.3+/- 1.2 years and BMI 27.8+/-0.8 kg/m2. Using t-test, there was a statistically significant intergroup difference in two-year VAS neck and NDI scores, p=0.007, and p=0.001, respectively. Radiographic fusion occurred as early as three months in the HA PEEK group. Conclusions This study has demonstrated the equivalence of impregnated HA PEEK cages in single-level ACDF. Significant improvements were seen in VAS and NDI scores in the HA PEEK group. There was no incidence of heterotopic bone formation or reaction to HA PEEK cages. Additionally, a trend toward fusion was seen in HA PEEK patients as early as three to five months compared to seven to eight months for the ACDF group. We conclude that HA PEEK cages can be safely placed with excellent outcomes. However, further studies are required to look at added benefits.
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Affiliation(s)
- Kingsley R Chin
- Orthopedics, Florida International University, Miami, USA.,Orthopedics, Less Exposure Surgery (LES) Clinic, Hollywood, USA.,Faculty of Science and Sports, University of Technology, Kingston, JAM
| | - Nishant N Gohel
- Orthopedic Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Daniel M Aloise
- Orthopedics, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Jason A Seale
- Orthopedics, Less Exposure Surgery (LES) Clinic, Hollywood, USA
| | - Deepak K Pandey
- Orthopedics, Less Exposure Surgery (LES) Society, Hollywood, USA
| | - Fabio J Pencle
- Faculty of Science and Sports, University of Technology, Kingston, JAM.,Orthopedics, Less Exposure Surgery (LES) Society, Hollywood, USA
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A Novel Technique of Endoscopic Anterior Transcorporeal Approach with Channel Repair for Adjacent Segment Disease After Anterior Cervical Discectomy and Fusion. World Neurosurg 2021; 154:109-116. [PMID: 34280535 DOI: 10.1016/j.wneu.2021.07.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Mikhail CM, Echt M, Selverian SR, Cho SK. Recoup From Home? Comparison of Relative Cost Savings for ACDF, Lumbar Discectomy, and Short Segment Fusion Performed in the Inpatient Versus Outpatient Setting. Global Spine J 2021; 11:56S-65S. [PMID: 33890802 PMCID: PMC8076805 DOI: 10.1177/2192568220968772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on the cost efficacy of performing ACDF, lumbar discectomy and short segment fusions of the lumbar spine performed in the outpatient setting. METHODS A thorough review of peer- reviewed literature was performed on the relative cost-savings, as well as guidelines, outcomes, and indications for successfully implementing outpatient protocols for routine spine procedures. RESULTS Primary elective 1-2 level ACDF can be safely performed in most patient populations with a higher patient satisfaction rate and no significant difference in 90-day reoperations and readmission rates, and a savings of 4000 to 41 305 USD per case. Lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper by as much as 12 934 USD per case and has better or equivalent outcomes to their inpatient counterparts. Unlike ACDF and lumbar microdiscectomy, short segment fusions are rarely performed in ASCs. However, with the advent of minimally invasive techniques paired with improved pain control, same-day discharge after lumbar fusion has limited clinical data but appears to have potential cost-savings up to 65-70% by reducing admissions. CONCLUSION Performing ACDF, lumbar discectomy and short segment fusions in the outpatient setting is a safe and effective way of reducing cost in select patient populations.
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Affiliation(s)
- Christopher M. Mikhail
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stephen R. Selverian
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, MD, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Yu T, Wu JP, Zhang J, Yu HC, Liu QY. Comparative evaluation of posterior percutaneous endoscopy cervical discectomy using a 3.7 mm endoscope and a 6.9 mm endoscope for cervical disc herniation: a retrospective comparative cohort study. BMC Musculoskelet Disord 2021; 22:131. [PMID: 33530967 PMCID: PMC7856779 DOI: 10.1186/s12891-021-03980-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background Posterior percutaneous endoscopy cervical discectomy (p-PECD) is an effective strategy for the treatment of cervical diseases, with a working cannula ranging from 3.7 mm to 6.9 mm in diameter. However, to date, no studies have been performed to compare the clinical outcomes of the use of endoscopes with different diameters in cervical disc herniation (CDH) patients. The purpose of this study was to compare the clinical outcomes of patients with unilateral CDH treated with p-PECD using a 3.7 mm endoscope and a 6.9 mm endoscope. Methods From January 2016 to June 2018, a total of 28 consecutive patients with single-level CDH who received p-PECD using either the 3.7 mm or the 6.9 mm endoscope were enrolled. The clinical results, including the surgical duration, hospitalization, visual analog scale (VAS) score and modified MacNab criteria, were evaluated. Cervical fluoroscopy, CT, and MRI were also performed during follow-up. Results Tthere was a significant difference in regard to the average identification time of the “V” point (18.608 ± 3.7607 min vs. 11.256 ± 2.7161 min, p < 0.001) and the mean removal time of the overlying tissue (16.650 ± 4.1730 min vs. 12.712 ± 3.3079 min, p < 0.05) for the use of the 3.7 mm endoscope and the 6.9 mm endoscope, respectively. The postoperative VAS and MacNab scores of the two endoscopes were significantly improved compared with those the preoperative scores (p < 0.05). Conclusion The application of both the 3.7 mm endoscope and 6.9 mm endoscope represent an effective method for the treatment of CDH in selected patients, and no significant difference can be observed in the clinical outcomes of the endoscopes. The 6.9 mm endoscope shows superiority to the 3.7 mm endoscope in terms of the efficiency of “V” point identification, the removal of overlying soft tissue and the prevention of spinal cord injury. However, the 6.9 mm endoscope may be inferior to the 3.7 mm endoscope in regards to anterior foraminal decompression due to its large diameter; this result needs to be further evaluated with the support of a large number of randomized controlled trials.
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Affiliation(s)
- Tong Yu
- Department of orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jiu-Ping Wu
- Department of orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jun Zhang
- Department of orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Hai-Chi Yu
- Department of orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qin-Yi Liu
- Department of orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China.
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12
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Are outpatient three- and four-level anterior cervical discectomies and fusion safe? Spine J 2021; 21:231-238. [PMID: 33049410 DOI: 10.1016/j.spinee.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT 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. PURPOSE The present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGN Retrospective cohort study PATIENT SAMPLE: 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. OUTCOME MEASURES The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Yerneni K, Burke JF, Chunduru P, Molinaro AM, Riew KD, Traynelis VC, Tan LA. Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 86:30-45. [PMID: 30690479 DOI: 10.1093/neuros/nyy636] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 01/06/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. OBJECTIVE To review the medical literature on the safety of outpatient ACDF. METHODS We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. RESULTS We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). CONCLUSION Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - John F Burke
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Pranathi Chunduru
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - K Daniel Riew
- The Daniel and Jane Och Spine Hospital, Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Vincent C Traynelis
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
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Lee R, Lee D, Iweala U, Ramamurti P, Weinreb JH, O’Brien JR. Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy. J Clin Orthop Trauma 2020; 15:161-167. [PMID: 33717932 PMCID: PMC7920123 DOI: 10.1016/j.jcot.2020.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/14/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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%). CONCLUSION 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.
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Affiliation(s)
- Ryan Lee
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA,Corresponding author. The George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC, 20037, USA.
| | - Danny Lee
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Uchechi Iweala
- Division of Spine Surgery, New York University Langone Orthopaedic Hospital in New York, NY, USA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Jeffrey H. Weinreb
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Joseph R. O’Brien
- Washington Spine and Scoliosis Clinic, OrthoBethesda in Bethesda, MD, USA
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Shen J, Telfeian AE, Shaaya E, Oyelese A, Fridley J, Gokaslan ZL. Full endoscopic cervical spine surgery. JOURNAL OF SPINE SURGERY 2020; 6:383-390. [PMID: 32656375 DOI: 10.21037/jss.2019.10.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The authors present 4 techniques for fully-endoscopic cervical spine surgery with accompanying case series: (I) posterior cervical unilateral laminectomy and bilateral decompression, (II) posterior cervical foraminotomy (PCF), (III) anterior cervical discectomy, and (IV) anterior transcorporeal discectomy. Methods We retrospectively reviewed fully endoscopic cervical spine surgery cases at one high-volume endoscopic center in the United States and present clinical data extracted from endoscopic spine surgery performed over a 6-year period with a minimum clinical follow up of 1 year. Results A series of 114 patients who underwent fully endoscopic cervical spine surgery between 2012 and 2018 is presented. Clinical results and technical data are presented. Conclusions Fully endoscopic cervical spine surgery is an emerging surgical technique for addressing cervical radiculopathy and myelopathy through a minimally invasive approach.
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Affiliation(s)
- Jian Shen
- Mohawk Valley Orthopedics, Amsterdam, NY, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Elias Shaaya
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Adetokunbo Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jared Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Outcomes of Discectomy by Using Full-Endoscopic Visualization Technique via the Transcorporeal and Transdiscal Approaches in the Treatment of Cervical Intervertebral Disc Herniation: A Comparative Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5613459. [PMID: 32596328 PMCID: PMC7277067 DOI: 10.1155/2020/5613459] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/07/2019] [Accepted: 12/27/2019] [Indexed: 11/17/2022]
Abstract
Objective To compare the difference in clinical and radiographic outcomes between anterior transcorporeal and transdiscal percutaneous endoscopic cervical discectomy (ATc-PECD/ATd-PECD) approaches for treating patients with cervical intervertebral disc herniation (CIVDH). Method We selected 77 patients with single-segment CIVDH and received ATc-PECD or ATd-PECD in the Second Affiliated Hospital of Chongqing Medical University between March 1, 2010, and July 1, 2015. 35 patients suffered from ATc-PECD, and there were 42 patients in the ATd-PECD group. Obtaining the data of 1, 3, 6, 12, and 24 months postoperatively, the VAS for neck and arm pain and the modified MacNab criteria were used to evaluate the clinical outcomes, comparing radiographic outcomes and complications of these two groups. Results We found that the mean operative time was significantly longer in the ATc-PECD group (P < 0.05). At the 2-year follow-up, the mean VAS score for neck and arm pain was significantly decreased in both two groups. There was no significant difference in the VAS score for arm pain and neck pain between the two groups at the 2-year follow-up (P=0.783 and P=0.785, respectively). For the ATc-PECD group, the difference in the height of IVS or vertebral body was significant between the preoperative and postoperative groups (P < 0.05, respectively). For the ATd-PECD group, there was only a significant decrease in the height of the IVS (P < 0.05); the decrease in the surgical vertebral body was not significant between the preoperative and postoperative groups (P > 0.05). Conclusion In the 2-year follow-up, there is no significant difference in the clinical outcomes between the 2 approaches. While the longer time was consumed in the ATc-PECD group, the lower rate of disc collapse and recurrence is notable. Additionally, when the center diameter of tunnel was limited to 6 mm, the bony defect can be healed without the occurrence of the collapse of the superior endplate, and ATc-PECD may be preferable in the endoscopic treatment of CIVDH.
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Neifert SN, Martini ML, Yuk F, McNeill IT, Caridi JM, Steinberger J, Oermann EK. Predicting Trends in Cervical Spinal Surgery in the United States from 2020 to 2040. World Neurosurg 2020; 141:e175-e181. [PMID: 32416237 DOI: 10.1016/j.wneu.2020.05.055] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to predict surgical volumes for 2 common cervical spine procedures from 2020 to 2040. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Frank Yuk
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Ian T McNeill
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Jeremy Steinberger
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Eric Karl Oermann
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA.
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Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. JOURNAL OF SPINE SURGERY 2020; 6:302-322. [PMID: 32309668 DOI: 10.21037/jss.2020.01.14] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Swong
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Vaishnav A, Hill P, McAnany S, Patel DV, Haws BE, Khechen B, Singh K, Gang CH, Qureshi S. Comparison of Multilevel Anterior Cervical Discectomy and Fusion Performed in an Inpatient Versus Outpatient Setting. Global Spine J 2019; 9:834-842. [PMID: 31819849 PMCID: PMC6882097 DOI: 10.1177/2192568219834894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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.
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Affiliation(s)
| | | | - Steven McAnany
- Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Dil V. Patel
- Rush University Medical Center, Chicago, IL, USA
| | | | | | - Kern Singh
- Rush University Medical Center, Chicago, IL, USA
| | | | - Sheeraz Qureshi
- Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA,Sheeraz Qureshi, Weill Cornell Medical College, 5 East 98th Street, New York, NY 10029, USA.
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Helseth Ø, Lied B, Heskestad B, Ekseth K, Helseth E. Retrospective single-centre series of 1300 consecutive cases of outpatient cervical spine surgery: complications, hospital readmissions, and reoperations. Br J Neurosurg 2019; 33:613-619. [PMID: 31607163 DOI: 10.1080/02688697.2019.1675587] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Outpatient surgery is becoming more common and is more cost-effective than inpatient surgery. Nonetheless, many surgeons and health care administrators are still hesitant to accept outpatient surgery for cervical degenerative spinal disease (C-DSD). This study assesses the types and rates of complications, hospital admissions, and reoperations after outpatient surgery of C-DSD.Methods: Complications, hospital admissions within 90 days of surgery, and reoperations within one year of surgery were recorded retrospectively in 1300 outpatients undergoing microsurgical decompression for C-DSD at the Oslofjord Clinic from 2008 to 2017. The surgical procedures performed were anterior cervical decompression and fusion (ACDF) in 1083 patients and posterior cervical foraminotomy in 217 patients.Results: The surgical mortality rate was 0%. Sixteen major complications were recorded in 15/1300 (1.2%) patients. The complications were neurological deterioration in four patients, postoperative hematoma in two, dural lesions with cerebrospinal fluid leakage in one, deep surgical-site infection in one, persistent hoarseness in three, and persistent dysphagia in five. The two potentially life-threatening hematomas were detected within the planned six-hour observation period. Two (0.2%) patients were admitted to hospital within hours of surgery completion with stroke-like signs and symptoms, and four (0.3%) patients were admitted to hospital within 90 days due to surgery-related events. The rate of reoperations for cervical radiculopathy within 12 months was 25/1171 (2%); eight patients' reoperations were due to inadequate primary decompression, one was due to recurrent disc herniation at the same level and side, and 16 were due to new-onset radiculopathy from an adjacent level or other side.Conclusions: Outpatient microsurgical decompression of the degenerative cervical spine in carefully selected patients appears to be safe and carries a low major complication rate, low hospital admission rate, and low one-year reoperation rate.
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Affiliation(s)
- Øystein Helseth
- Oslofjordklinikken, Sandvika, Norway.,Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Bjarne Lied
- Oslofjordklinikken, Sandvika, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.,Department of Neurosurgery, Faculty of Medicine, University of Oslo, Oslo, Norway
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Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database. Clin Spine Surg 2019; 32:E372-E379. [PMID: 31180992 DOI: 10.1097/bsd.0000000000000840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures. OBJECTIVE The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR. MATERIALS AND METHODS Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. RESULTS A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001). CONCLUSIONS ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.
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DelSole EM, Makanji HS, Kurd MF. Current trends in ambulatory spine surgery: a systematic review. JOURNAL OF SPINE SURGERY 2019; 5:S124-S132. [PMID: 31656865 DOI: 10.21037/jss.2019.04.12] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spine surgery continues to move into the ambulatory setting in an effort to pair high-quality care delivery with low-cost facilities. The purpose of this review was to assess the current literature for trends in the practice of ambulatory spine surgery. A systematic review of the English language literature from the past five years was performed utilizing PRISMA standards. The results demonstrate that current focus of research emphasizes the safety of ambulatory surgery-with several studies commenting on complication rates, patient selection, and postoperative protocols to prevent readmissions or complications. Research is also focused on quality of care, and ensuring non-inferiority of ambulatory surgery when compared with traditional inpatient hospitalizations. Importantly, no level I or II literature has been published on the topic in the past five years, suggesting a renewed need for high quality prospective studies.
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Affiliation(s)
- Edward M DelSole
- Department of Spine Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Heeren S Makanji
- Department of Spine Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Mark F Kurd
- Department of Spine Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Khalid SI, Kelly R, Wu R, Peta A, Carlton A, Adogwa O. A comparison of readmission and complication rates and charges of inpatient and outpatient multiple-level anterior cervical discectomy and fusion surgeries in the Medicare population. J Neurosurg Spine 2019; 31:486-492. [PMID: 31174183 DOI: 10.3171/2019.3.spine181257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aims to assess the relationship of comorbidities and postoperative complications to rates of readmission for geriatric patients undergoing anterior cervical discectomy and fusion (ACDF) involving more than 2 levels on an inpatient or outpatient basis. With the rising costs of healthcare in the United States, understanding the safety and efficacy of performing common surgical interventions (including ACDF) as outpatient procedures could prove to be of great economic impact.Objective This study aims to assess the effect of comorbidities and postoperative complications on the rates of readmission of geriatric patients undergoing multilevel anterior cervical discectomy and fusion (ACDF) procedures (i.e., ACDF involving 3 or more levels) on an inpatient or outpatient basis. Same-day surgery has been demonstrated to be a safe and cost-effective alternative to the traditional inpatient option for many surgical interventions. With the rising costs of healthcare, understanding the safety and efficacy of performing common surgical interventions as outpatient procedures could prove to be of great economic impact. METHODS The study population included total of 2492 patients: 2348 inpatients and 144 outpatients having ACDF procedures involving 3 or more levels in the Medicare Standard Analytical Files database. Age, sex, comorbidities, postoperative complications, readmission rates, and surgical procedure charges were compared between both cohorts. For selected variables, logistic regression was used to model odds ratios for various comorbidities against readmission rates for both inpatient and outpatient cohorts. Chi-square tests were also calculated to compare these comorbidities with readmission in each cohort. RESULTS Overall complication rates within 30 postoperative days were greater for inpatients than for outpatients (44.2% vs 12.5%, p < 0.001). More inpatients developed postoperative urinary tract infection (7.9% vs 0%, p < 0.001), and the inpatient cohort had increased risk of readmission with comorbidities of anemia (OR 1.52, p < 0.001), smoking (OR 2.12, p < 0.001), and BMI ≥ 30 (OR 1.43, p < 0.001). Outpatients had increased risk of readmission with comorbidities of anemia (OR 2.78, p = 0.047), diabetes mellitus type 1 or 2 (OR 3.25, p = 0.033), and BMI ≥ 30 (OR 3.95, p = 0.008). Inpatients also had increased readmission risk with a postoperative complication of surgical site infection (OR 2.38, p < 0.001). The average charges for inpatient multilevel ACDF were significantly higher than for multilevel ACDF performed on an outpatient basis ($12,734.27 vs $12,152.18, p = 0.0019). CONCLUSIONS This study suggests that ACDF surgery involving 3 or more levels performed as an outpatient procedure in the geriatric population may be associated with lower rates of readmissions, complications, and surgical charges.
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Affiliation(s)
- Syed I Khalid
- Departments of1Neurosurgery and
- 2Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, Illinois; and
- 3General Surgery, Rush University Medical Center, Chicago
| | - Ryan Kelly
- 4Georgetown University School of Medicine, Washington, DC
| | - Rita Wu
- 2Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, Illinois; and
| | - Akhil Peta
- 2Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, Illinois; and
| | - Adam Carlton
- 2Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, Illinois; and
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Khalid SI, Adogwa O, Ni A, Cheng J, Bagley C. A Comparison of 30-Day Hospital Readmission and Complication Rates After Outpatient Versus Inpatient 1 and 2 Level Anterior Cervical Discectomy and Fusion Surgery: An Analysis of a Medicare Patient Sample. World Neurosurg 2019; 129:e233-e239. [PMID: 31128307 DOI: 10.1016/j.wneu.2019.05.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Same-day surgery has been demonstrated to be a safe and cost-effective alternative to traditional inpatient surgery. Several studies have demonstrated no differences in the postoperative complication profile or 30-day hospital readmission rates with outpatient versus inpatient anterior cervical discectomy and fusion (ACDF). However, none of these studies compared the outcomes in elderly patients (aged >65 years) undergoing ACDF. Whether the results from previous studies can be applied to this subgroup pf patients remains unknown. The aim of the present study was to compare the 30-day hospital readmission rates for Medicare patients (aged >65 years) undergoing outpatient versus inpatient ACDF. METHODS We performed a retrospective analysis of a Medicare database, including data from 17,421 patients. Of the 17,421 patients, 16,386 had undergone inpatient ACDF and 1035, outpatient ACDF. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial costs were compared between the 2 cohorts. RESULTS In a Medicare sample (aged >65 years), inpatient ACDF was associated with a greater incidence of postoperative complications compared with outpatient ACDF. Outpatient surgery was associated with significantly lower rates of postoperative complications (urinary tract infection, surgical site infection, deep vein thrombosis, pulmonary embolism, and myocardial infarction) and significantly lower treatment costs (P ≤ 0.001). All-cause 30-day hospital readmission rates were also greater for inpatients (10.1% vs. 4%; P = 0.17). CONCLUSION The results from the present study suggest that outpatient ACDF appears to be safe and effective with low complication and readmission rates in a Medicare patient sample.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA; Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA.
| | - Amelia Ni
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Carlos Bagley
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Khalid SI, Carlton A, Wu R, Kelly R, Peta A, Adogwa O. Outpatient and Inpatient Readmission Rates of 1- and 2-Level Anterior Cervical Discectomy and Fusion Surgeries. World Neurosurg 2019; 126:e1475-e1481. [PMID: 30904810 DOI: 10.1016/j.wneu.2019.03.124] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study looks at the various comorbidities and postoperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 1- and 2-level anterior cervical discectomy and fusion (ACDF). With increasing costs within the United States medical system, one emerging cost-saving strategy is to evolve traditional inpatient procedures into outpatient same-day surgeries. However, patient safety remains a crucial priority. METHODS A total of 28,427 patients were analyzed, with 26,368 undergoing inpatient ACDF surgery and 2059 undergoing outpatient ACDF surgery. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial cost were compared between both cohorts. RESULTS Data from 28,427 one- and two-level ACDF procedures that were split between inpatient and outpatient were collected. Thirty-day readmission rates were significantly lower in outpatients than inpatients (4% vs. 10.1%, P < 0.001). Inpatients had higher rates of urinary tract infection (2.4% vs. 1.4%), deep vein thrombosis (0.6% vs. 0%), and myocardial infarction (0.2% vs. 0%), whereas outpatients had higher rates of pulmonary embolism (7.7% vs. 0.4%). Outpatients had increased readmission risk with comorbidities of diabetes (odds ratio [OR], 48.93; P < 0.001), smoking (OR, 4.6; P < 0.001), body mass index ≥30 (OR, 2392; P < 0.001). The average cost of outpatient surgery was less than that of inpatient surgery ($7774.8 vs. $7956.75, P = 0.0444). CONCLUSION This study suggests that in the appropriately selected patients, ACDF can safely be performed in an outpatient setting.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA; Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.
| | - Adam Carlton
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Rita Wu
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Ryan Kelly
- Georgetown University School of Medicine, Washington, DC, USA
| | - Akhil Peta
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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Chen YC, Wu JC, Chang HK, Huang WC. Early Discharge for Anterior Cervical Fusion Surgery: Prediction of Readmission and Special Considerations for Older Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16040641. [PMID: 30795609 PMCID: PMC6406524 DOI: 10.3390/ijerph16040641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/05/2019] [Accepted: 02/14/2019] [Indexed: 12/18/2022]
Abstract
Anterior cervical discectomy and fusion (ACDF) is the standard surgical management for disc herniation and spondylosis worldwide and reportedly performed with short hospitalization and early discharge (ED). However, it is unknown if ED improves the outcomes of ACDF including among older adults. This cohort study included patients who underwent ACDF surgery in Taiwan over two years analyzed in two groups: the ED group (discharged within 48 hours), and the comparison group (hospitalized for more than 48 h). Both groups were followed-up for at least 180 days. Pre- and post-operative comorbidities, re-admissions and re-operations were analyzed using a multivariate cox-regression model, with bootstrapping, and Kaplan–Meier analysis. Among 5565 ACDF patients, the ED group (n = 405) had a higher chance (crude and adjusted hazard ratio = 2.33 and 2.39, both p < 0.001) of re-admission than the comparison group (n = 5160). The ED group had an insignificant trend toward more re-admissions for spinal problems and re-operations within 180 days. In the ED group, older age (≥60) and hypertension were predictive of re-admission. For ACDF surgery, the ED group had higher rates of re-admission within 180 days of post-op, suggesting that the current approach to ED requires modification or more cautious selection criteria be adopted, particularly for older adults.
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Affiliation(s)
- Yu-Chun Chen
- Department of Family Medicine, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Family Medicine, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Biomedical Engineering, School of Biomedical Science and Engineering, National Yang-Ming University, Taipei 11221, Taiwan.
| | - Jau-Ching Wu
- Department of Neurosurgery, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
| | - Hsuan-Kan Chang
- Department of Neurosurgery, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
| | - Wen-Cheng Huang
- Department of Neurosurgery, School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan.
- Department of Neurosurgery, Neurological Institute, Taipei Veterans' General Hospital, Taipei 11217, Taiwan.
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Liu C, Liu K, Chu L, Chen L, Deng Z. Posterior percutaneous endoscopic cervical discectomy through lamina-hole approach for cervical intervertebral disc herniation. Int J Neurosci 2019; 129:627-634. [PMID: 30238849 DOI: 10.1080/00207454.2018.1503176] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The optimal PECD surgical approach for cervical intervertebral disc herniation (CIVDH) remains controversial. The conventional posterior K-hole approach for PECD leads to damage of facet joint. OBJECTIVES This article is to first describe a novel posterior lamina-hole approach of percutaneous endoscopic cervical discectomy (PECD) for CIVDH. The objective of this study is to evaluate the feasibility and short-term clinical effect of this approach. METHODS Single-center retrospective observational study of all patients managed with posterior percutaneous endoscopic cervical discectomy (PPECD) using the lamina-hole approach for symptomatic single-level CIVDH between January 2015 and January 2016. The clinical outcomes were evaluated with the visual analog scale, modified MacNab criteria and radiographical results. RESULTS Twelve patients (seven women, five men) were enrolled in the study. Positive clinical response for pain relief was achieved in these patients receiving PPECD through lamina-hole approach for CIVDH. Postoperative MRI showed complete removal of the disc material in all the patients, no failure due to residual fragment was observed. CONCLUSION As an alternative surgical approach of PPECD, PPECD through lamina-hole approach is a novel access for CIVDH and may be considered a valid and safe therapeutic option for CIVDH. The advantages of this approach are not only providing a valid and secure access to herniated cervical intervertebral fragment but also avoiding the iatrogenic damage to the facet joint and relevant functional spinal unit (FSU). Theoretically, the potential of secondary degeneration of FSU is low.
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Affiliation(s)
- Chao Liu
- a Department of Orthopedics , the Second Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | | | - Lei Chu
- a Department of Orthopedics , the Second Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Liang Chen
- a Department of Orthopedics , the Second Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Zhongliang Deng
- a Department of Orthopedics , the Second Affiliated Hospital of Chongqing Medical University , Chongqing , China
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A Novel Posterior Trench Approach Involving Percutaneous Endoscopic Cervical Discectomy for Central Cervical Intervertebral Disc Herniation. Clin Spine Surg 2019; 32:10-17. [PMID: 29979215 DOI: 10.1097/bsd.0000000000000680] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This report describes a novel posterior trench approach involving percutaneous endoscopic cervical discectomy (PECD) for central cervical intervertebral disc herniation (CIVDH) and an evaluation of the feasibility, safety, and short-term clinical effect of this approach. BACKGROUND CONTEXT Central CIVDH is considered the contraindication for posterior PECD. MATERIALS AND METHODS A single-center retrospective observational study was performed with 30 patients managed with posterior PECD using the trench approach for symptomatic single-level central CIVDH. Primary outcomes included the measures of bodily pain and physical function based on the SF-36 and modified MacNab criteria. Radiographical follow-up included the static and dynamic cervical plain radiographs, computed tomographic scans, and magnetic resonance images. RESULTS A positive clinical response for symptom relief was achieved in all patients. The postoperative MRI showed total removal of the herniated disc. CONCLUSIONS As a supplement to the described surgical techniques of PECD, this trench approach provides novel access for the treatment of CIVDH, especially for the central type. The advantages of this technique include the provision of access to decompress the ventral region of the thecal sac and the ability to avoid damage to the facet joint. The steep learning curve might be a major disadvantage, and the sample volume is a limitation of the study; the effectiveness and reliability of the trench approach should be further verified in a comparative cohort study with a large volume of patients.
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Massel DH, Narain AS, Hijji FY, Mayo BC, Bohl DD, Lopez GD, Singh K. A Comparison of Narcotic Consumption Between Hospital and Ambulatory-Based Surgery Centers Following Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2018; 12:595-602. [PMID: 30364866 DOI: 10.14444/5075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Several studies have compared outcomes between hospital-based (HBCs) and ambulatory surgery centers (ASCs) following anterior cervical discectomy and fusion (ACDF). However, the association between narcotic consumption and pain in the early postoperative period has not been well characterized. As such, the purpose of this study is to compare pain, narcotic consumption, and length of stay (LOS) between HBC and ASC patients undergoing same-day-discharge following ACDF. Methods A surgical registry of patients who underwent a primary, 1- or 2-level ACDF during 2013-2015 was reviewed. Patients were stratified by operative location. Differences in demographics were assessed using independent-sample t tests and chi-square analysis. The presence of an association between operative location and outcomes was analyzed using Poisson regression with robust error variance or linear regression adjusted for preoperative characteristics. Results A total of 76 patients were identified, of which 42 and 34 underwent surgery at an HBC or ASC, respectively. The HBC cohort had greater total (P < .001) and hourly (P = .034) narcotic consumption and prolonged LOS (P < .001). Over 90% of ASC patients consumed less than or equal to the 30th percentile (32.0 mg) of oral morphine equivalents (OME), whereas over 57% of HBC patients consumed greater than 32.0 mg OME. The HBC cohort consumed greater average doses of fentanyl and oxycodone (P < .001 for each). Conclusions This study demonstrates that patients undergoing same-day surgery for primary 1- or 2-level ACDF received more narcotics at HBCs compared to at ASCs. The increased narcotic consumption at HBCs may have resulted in longer LOS; however, this did not impact long-term pain, complications, or clinical outcomes. Clinical Relevance Patients scheduled to be discharged on postoperative day 0 following ACDF at HBCs may be able to receive fewer narcotics and be discharged sooner without compromising pain control or increasing their risk for complications.
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Affiliation(s)
- Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Benjamin C Mayo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Gregory D Lopez
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Gornet MF, Buttermann GR, Wohns R, Billinghurst J, Brett DC, Kube R, Rafe Sales J, Wills NJ, Sherban R, Schranck FW, Copay AG. Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs. Hospital Settings. Int J Spine Surg 2018; 12:557-564. [PMID: 30364904 DOI: 10.14444/5068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Outpatient surgery has been shown safe and effective for anterior cervical discectomy and fusion (ACDF), and more recently, for 1-level cervical disc arthroplasty (CDA). The purpose of this analysis is to compare the safety and efficiency of 1-level and 2-level CDA performed in an ambulatory surgery center (ASC) and in a hospital setting. Methods The study was a retrospective collection and analysis of data from consecutive CDA patients treated in ASCs compared to a historical control group of patients treated in hospital settings who were classified as outpatient (0 or 1-night stay) or inpatient (2 or more nights). Surgery time, blood loss, return to work, adverse events (AEs), and subsequent surgeries were compared. Results The sample consisted of 145 ASC patients, 348 hospital outpatients, and 65 hospital inpatients. A greater proportion of 2-level surgeries were performed in hospital than ASC. Surgery times were significantly shorter in ASCs than outpatient or inpatient 1-level (63.6 ± 21.6, 86.5 ± 35.8, and 116.7 ± 48.4 minutes, respectively) and 2-level (92.4 ± 37.3, 126.7 ± 43.8, and 140.3 ± 54.5 minutes, respectively) surgeries. Estimated blood loss was also significantly less in ASC than outpatient and inpatient 1-level (18.5 ± 30.6, 43.7 ± 35.9, and 85.7 ± 98.0 mL, respectively) and 2-level (21.1 ± 12.3, 67.8 ± 94.9, and 64.9 ± 66.1 mL). There were no hospital admissions and no subsequent surgeries among ASC patients. ASC patients had 1 AE (0.7%) and hospital patients had 10 AEs (2.4%). Working patients returned to work after a similar number of days off, but fewer ASC patients had returned to work by the end of the 90-day period. Conclusions Both 1- and 2-level CDA may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs.
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Affiliation(s)
| | | | | | | | | | - Richard Kube
- Prairie Spine and Pain Institute, Peoria, Illinois
| | - J Rafe Sales
- Northwest Spine & Laser Center, LLC, Portland, Oregon
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Wan Q, Zhang D, Li S, Liu W, Wu X, Ji Z, Ru B, Cai W. Posterior percutaneous full-endoscopic cervical discectomy under local anesthesia for cervical radiculopathy due to soft-disc herniation: a preliminary clinical study. J Neurosurg Spine 2018; 29:351-357. [DOI: 10.3171/2018.1.spine17795] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVETo the authors’ knowledge, posterior percutaneous full-endoscopic cervical discectomy (PPFECD) has not been reported before as a procedure performed with patients under local anesthesia (LA). In this study, the authors report the outcomes of 25 patients treated by this technique, the surgical steps, and the procedure’s potential advantages.METHODSTwenty-five patients diagnosed with cervical radiculopathy due to soft-disc herniation (SDH) were treated by PPFECD. The intensities of arm and neck pain were measured using the visual analog scale (VAS) and the functional status was assessed using the Neck Disability Index (NDI) preoperatively and at 1, 3, 6, and 12 months postoperatively. Global outcome was also assessed using modified Macnab criteria, and outcomes were grouped as clinical success (excellent or good) and clinical failure (fair or poor). Complications were also recorded.RESULTSNo patient was lost to the follow-up. Significant and durable pain relief and cervical functional improvement were achieved postoperatively. Clinical success was achieved in 24 patients (96%), including 22 excellent and 2 good outcomes at the last follow-up. No serious complications occurred.CONCLUSIONSThe authors’ preliminary experience indicates that PPFECD under LA is a feasible and promising alternative for selected cases of cervical radiculopathy due to SDH, though the procedure’s effectiveness and safety still need confirmation from further studies.
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Affiliation(s)
- Quan Wan
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
| | - Daying Zhang
- 2Department of Pain, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi; and
| | - Shun Li
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
| | - Wenlong Liu
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
| | - Xiang Wu
- 3Department of Anesthesiology, The Affiliated Hospital of School of Medicine of Ningbo University, Ningbo, Zhejiang, China
| | - Zhongwei Ji
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
| | - Bin Ru
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
| | - Wenjun Cai
- 1Department of Pain, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang
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Bennitz JD, Manninen P. Anesthesia for Day Care Neurosurgery. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gennari A, Mazas S, Coudert P, Gille O, Vital JM. Outpatient anterior cervical discectomy: A French study and literature review. Orthop Traumatol Surg Res 2018; 104:581-584. [PMID: 29902639 DOI: 10.1016/j.otsr.2018.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 04/03/2018] [Accepted: 04/16/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In France, surgery for lumbar disc herniation is now being done in the outpatient ambulatory setting at select facilities. However, surgery for the cervical spine in this setting is controversial because of the dangers of neck hematoma. We wanted to share our experience with performing ambulatory anterior cervical discectomy in 30 patients at our facility. RESULTS Since 2014, 30 patients (16 men, 14 women; mean age of 47.2 years) with cervical radiculopathy due to single-level cervical disc disease (19 at C5-C6 and 11 at C6-C7) were operated at our ambulatory surgery center. After anterior cervical discectomy, cervical disc replacement was performed in 13 patients and fusion in 17 patients. The mean operative time was 38minutes and the mean duration of postoperative monitoring was 7hours 30minutes. The patients stayed at the healthcare facility for an average of 10hours 10minutes. One female patient (3%) was transferred to a standard hospital unit due to a neurological deficit requiring surgical revision with no cause identified. Two patients (7%) were rehospitalized on Day 1 due to dysphagia that resolved spontaneously. Thus the "ambulatory success rate" was 90% (27/30). There were no other complications and the overall satisfaction rate was excellent (9.6/10). DISCUSSION Outpatient anterior cervical discectomy is now widely performed in the United States. Ours is the first study of French patients undergoing this procedure. The complication rate was very low (<2%) and even lower than patients treated in an inpatient hospital setting in comparative studies. Note that our patients were carefully selected for outpatient surgery as certain risk factors for complications have previously been identified (age, 3+levels, comorbidities/ASA>2). No deaths in the first 30 days postoperative have been reported in the literature. Wound hematoma leading to airway compromise is rare in the ambulatory setting (0.2%). The few cases that occurred were detected early and the hematoma drained before the patient was discharged. Dysphagia is actually the most common complication (8 to 30%). CONCLUSION Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. Our criteria are patients less than 65 years of age, single-level disease, ASA<2, and standard cervical morphology. The complication and readmission rates are low. Careful hemostasis combined with close postoperative monitoring for at least 6hours helps to reduce the risk of neck hematoma. Prevention of postoperative dysphagia must be a focus of the care provided.
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Affiliation(s)
- Antoine Gennari
- Service d'orthopédie, unité rachis 1, CHU de Pellegrin, 33000 Bordeaux, France.
| | - Simon Mazas
- Service d'orthopédie, unité rachis 1, CHU de Pellegrin, 33000 Bordeaux, France
| | - Pierre Coudert
- Service d'orthopédie, unité rachis 1, CHU de Pellegrin, 33000 Bordeaux, France
| | - Olivier Gille
- Service d'orthopédie, unité rachis 1, CHU de Pellegrin, 33000 Bordeaux, France
| | - Jean-Marc Vital
- Service d'orthopédie, unité rachis 1, CHU de Pellegrin, 33000 Bordeaux, France
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Chin KR, Pencle FJR, Mustafa LM, Mustafa MM, Benny A, Seale JA. Sentinel sign in standalone anterior cervical fusion: Outcomes and fusion rate. J Orthop 2018; 15:935-939. [PMID: 30190635 DOI: 10.1016/j.jor.2018.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background The authors aim to demonstrate the feasibility, outcomes and fusion rate of a standalone PEEK cage in the outpatient setting. Methods 48 consecutive patients undergoing standalone ACDF (S-ACDF) (Group 1) were compared to control group of 49 patients who had ACDF with ACP (Group 2). Results Analysis of follow-up at the one year period postoperative outcomes between groups 1 and 2 demonstrated no intergroup statistical significant difference in VAS neck, arm and NDI scores p = 0.414, 0.06 and p = 0.328 respectively. Conclusion We conclude that S-ACDF can be safely done in an ambulatory surgery center with satisfactory clinical and patient-reported outcomes.
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Affiliation(s)
- Kingsley R Chin
- Less Exposure Surgery Specialists Institute (LESS Institute), USA.,Herbert Wertheim College of Medicine at Florida International University, USA.,Charles E. Schmidt College of Medicine at Florida Atlantic University, USA.,University of Technology, Jamaica
| | | | - Luai M Mustafa
- Herbert Wertheim College of Medicine at Florida International University, USA
| | - Moawiah M Mustafa
- Herbert Wertheim College of Medicine at Florida International University, USA
| | - Amala Benny
- Less Exposure Surgery Specialists Institute (LESS Institute), USA.,Less Exposure Surgery (LES) Society, USA
| | - Jason A Seale
- Less Exposure Surgery Specialists Institute (LESS Institute), USA.,Less Exposure Surgery (LES) Society, USA
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Arshi A, Wang C, Park HY, Blumstein GW, Buser Z, Wang JC, Shamie AN, Park DY. Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database. Spine J 2018; 18:1180-1187. [PMID: 29155340 PMCID: PMC6291305 DOI: 10.1016/j.spinee.2017.11.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/02/2017] [Accepted: 11/07/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population. PURPOSE The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF. STUDY DESIGN/SETTING This is a large-scale retrospective case control study. PATIENT SAMPLE The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery. MATERIALS AND METHODS A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF. RESULTS Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable. CONCLUSIONS Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.
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Affiliation(s)
- Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Christopher Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Howard Y. Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Gideon W. Blumstein
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Arya N. Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Don Y. Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404,Corresponding author. Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St. Suite 3142, Santa Monica, CA 90404. Tel.: (424) 259-9829., (D.Y. Park)
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Pendharkar AV, Shahin MN, Ho AL, Sussman ES, Purger DA, Veeravagu A, Ratliff JK, Desai AM. Outpatient spine surgery: defining the outcomes, value, and barriers to implementation. Neurosurg Focus 2018; 44:E11. [DOI: 10.3171/2018.2.focus17790] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.
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Du Q, Wang X, Qin JP, Friis T, Kong WJ, Cai YQ, Ao J, Xu H, Liao WB. Percutaneous Full-Endoscopic Anterior Transcorporeal Procedure for Cervical Disc Herniation: A Novel Procedure and Early Follow-Up Study. World Neurosurg 2018; 112:e23-e30. [DOI: 10.1016/j.wneu.2017.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/29/2017] [Accepted: 12/01/2017] [Indexed: 11/30/2022]
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Mullins J, Pojskić M, Boop FA, Arnautović KI. Retrospective single-surgeon study of 1123 consecutive cases of anterior cervical discectomy and fusion: a comparison of clinical outcome parameters, complication rates, and costs between outpatient and inpatient surgery groups, with a literature review. J Neurosurg Spine 2018; 28:630-641. [PMID: 29600910 DOI: 10.3171/2017.10.spine17938] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Outpatient anterior cervical discectomy and fusion (ACDF) is becoming more common and has been reported to offer advantages over inpatient procedures, including reducing nosocomial infections and costs, as well as improving patient satisfaction. The goal of this retrospective study was to evaluate and compare outcome parameters, complication rates, and costs between inpatient and outpatient ACDF cases performed by 1 surgeon at a single institution. METHODS In a retrospective study, the records of all patients who had undergone first-time ACDF performed by a single surgeon in the period from June 1, 2003, to January 31, 2016, were reviewed. Patients were categorized into 2 groups: those who had undergone ACDF as outpatients in a same-day surgical center and those who had undergone surgery in the hospital with a minimum 1-night stay. Outcomes for all patients were evaluated with respect to the following parameters: age, sex, length of stay, preoperative and postoperative pain (self-reported questionnaires), number of levels fused, fusion, and complications, as well as the presence of risk factors, such as an increased body mass index, smoking, and diabetes mellitus. RESULTS In total, 1123 patients were operated on, 485 (43%) men and 638 (57%) women, whose mean age was 50 years. The mean follow-up time was 25 months. Overall, 40.5% underwent 1-level surgery, 34.3% 2-level, 21.9% 3-level, and 3.2% 4-level. Only 5 patients had nonunion of vertebrae; thus, the fusion rate was 99.6%. Complications occurred in 40 patients (3.6%), with 9 having significant complications (0.8%). Five hundred sixty patients (49.9%) had same-day surgery, and 563 patients (50.1%) stayed overnight in the hospital. The inpatients were older, were more commonly male, and had a higher rate of diabetes. Smoking status did not influence the length of stay. Both groups had a statistically significant reduction in pain (expressed as a visual analog scale score) postoperatively with no significant difference between the groups. One- and 2-level surgeries were done significantly more often in the outpatient setting (p < 0.001). The complication rate was 4.1% in the outpatient group and 3.0% in the inpatient group; there was no statistically significant difference between the 2 groups (p = 0.339). Significantly more complications occurred with 3- and 4-level surgeries than with 1- and 2-level procedures (p < 0.001, chi-square test). The overall average inpatient cost for commercial insurance carriers was 26% higher than those for outpatient surgery. CONCLUSIONS Anterior cervical discectomy and fusion is safe for patients undergoing 1- or 2-level surgery, with a very significant rate of pain reduction and fusion and a low complication rate in both clinical settings. Outpatient and inpatient groups undergoing 3- or 4-level surgery had an increased risk of complications (compared with those undergoing 1- or 2-level surgery), with a negligible difference between the 2 groups. This finding suggests that these procedures can also be included as standard outpatient surgery. Comparable outcome parameters and the same complication rates between inpatient and outpatient groups support both operative environments.
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Affiliation(s)
- Jack Mullins
- 1College of William & Mary, Williamsburg, Virginia
| | - Mirza Pojskić
- 2Department of Neurosurgery, University of Marburg, Germany
| | - Frederick A Boop
- 3Semmes Murphey Neurologic & Spine Institute; and.,4Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kenan I Arnautović
- 3Semmes Murphey Neurologic & Spine Institute; and.,4Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Sivaganesan A, Hirsch B, Phillips FM, McGirt MJ. Spine Surgery in the Ambulatory Surgery Center Setting: Value-Based Advancement or Safety Liability? Neurosurgery 2018. [DOI: 10.1093/neuros/nyy057] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Here, we systematically review clinical studies that report morbidity and outcomes data for cervical and lumbar surgeries performed in ambulatory surgery centers (ASCs). We focus on anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, cervical arthroplasty, lumbar microdiscectomy, lumbar laminectomy, and minimally invasive transforaminal interbody fusion (TLIF) and lateral lumbar interbody fusion, as these are prevalent and surgical spine procedures that are becoming more commonly performed in ASC settings.
A systematic search of PubMed was conducted, using combinations of the following phrases: “outpatient,” “ambulatory,” or “ASC” with “anterior cervical discectomy fusion,” “ACDF,” “cervical arthroplasty,” “lumbar,” “microdiscectomy,” “laminectomy,” “transforaminal lumbar interbody fusion,” “spine surgery,” or “TLIF.”
In reviewing the available literature to date, there is ample level 3 (retrospective comparisons) and level 4 (case series) evidence to support both the safety and effectiveness of outpatient cervical and lumbar surgery. While no level 1 or 2 (randomized clinical trials) evidence currently exists, the plethora of real-world clinical data creates a formidable argument for serious investments in ASCs for multiple spine procedures.
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Affiliation(s)
- Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon Hirsch
- Department of Orthopedics Surgery, Rush University Medical Center, Chicago, Illinois
| | - Frank M Phillips
- Department of Orthopedics Surgery, Rush University Medical Center, Chicago, Illinois
| | - Matthew J McGirt
- Depart-ment of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
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Discrepancies in the Definition of "Outpatient" Surgeries and Their Effect on Study Outcomes Related to ACDF and Lumbar Discectomy Procedures: A Retrospective Analysis of 45,204 Cases. Clin Spine Surg 2018; 31:E152-E159. [PMID: 29351096 DOI: 10.1097/bsd.0000000000000615] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective study. OBJECTIVE To study the differences in definition of "inpatient" and "outpatient" [stated status vs. actual length of stay (LOS)], and the effect of defining populations based on the different definitions, for anterior cervical discectomy and fusion (ACDF) and lumbar discectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. SUMMARY OF BACKGROUND DATA There has been an overall trend toward performing ACDF and lumbar discectomy in the outpatient setting. However, with the possibility of patients who underwent outpatient surgery staying overnight or longer at the hospital under "observation" status, the distinction of "inpatient" and "outpatient" is not clear. MATERIALS AND METHODS Patients who underwent ACDF or lumbar discectomy in the 2005-2014 ACS-NSQIP database were identified. Outpatient procedures were defined in 1 of 2 ways: either as being termed "outpatient" or hospital LOS=0. Differences in definitions were studied. Further, to evaluate the effect of the different definitions, 30-day outcomes were compared between "inpatient" and "outpatient" and between LOS>0 and LOS=0 for ACDF patients. RESULTS Of the 4123 "outpatient" ACDF patients, 919 had LOS=0, whereas 3204 had LOS>0. Of the 13,210 "inpatient" ACDF patients, 337 had LOS=0, whereas 12,873 had LOS>0. Of the 15,166 "outpatient" lumbar discectomy patients, 8968 had LOS=0, whereas 6198 had LOS>0. Of the 12,705 "inpatient" lumbar discectomy patients, 814 had LOS=0, whereas 11,891 had LOS>0. On multivariate analysis of ACDF patients, when comparing "inpatient" with "outpatient" and "LOS>0" with "LOS=0" there were differences in risks for adverse outcomes based on the definition of outpatient status. CONCLUSIONS When evaluating the ACS-NSQIP population, ACDF and lumbar discectomy procedures recorded as "outpatient" can be misleading and often did not correlate with same day discharge. These findings have significant impact on the interpretation of existing studies and define an area that needs clarification for future studies. LEVEL OF EVIDENCE Level 3.
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Modified posterior percutaneous endoscopic cervical discectomy for lateral cervical disc herniation: the vertical anchoring technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1460-1468. [PMID: 29478117 DOI: 10.1007/s00586-018-5527-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/14/2018] [Accepted: 02/14/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE During the long-term practice of percutaneous endoscopic cervical discectomy (PECD) at our institution, we have modified the protocol to include the vertical anchoring technique (VAT), which we will describe in detail in this article. The objective of this study was to compare the clinical outcomes associated with the conventional posterior PECD technique with that associated with the modified technique to determine the safety and efficacy of the latter technique. METHODS From December 2014 to January 2016, a total of 44 patients with single cervical disc herniation were randomly divided into two groups. One group underwent conventional posterior PECD, and the other group underwent posterior PECD combined with VAT. The operative time, fluoroscopy times and perioperative complications were recorded. The visual analog scale (VAS) for neck and arm pain and the modified MacNab criteria at 1 day, 3, 6, and 12 months after surgery were used to evaluate the postoperative outcomes. RESULTS All patients underwent surgery successfully without severe complications. The operative time and intraoperative fluoroscopy times were significantly less in patients treated with VAT than in those who underwent conventional posterior PECD (P < 0.05). Both types of surgery significantly improved the symptoms of patients. According to the results of the follow-up period, there were no significant differences in VAS scores for neck and arm pain or the modified MacNab criteria between the two groups (P > 0.05). There was no recurrence in either group during the follow-up period. CONCLUSIONS Although the clinical outcomes of the two surgical techniques were similar, the VAT decreased the operative time and intraoperative fluoroscopy times in posterior PECD surgery. The learning curve for posterior PECD could be shortened by using the VAT. These slides can be retrieved under Electronic Supplementary Material.
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Oezdemir S, Komp M, Hahn P, Ruetten S. Decompression for cervical disc herniation using the full-endoscopic anterior technique. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:1-10. [PMID: 29392340 DOI: 10.1007/s00064-018-0531-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/30/2017] [Accepted: 02/27/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Resection of a cervical disc herniation using a full-endoscopic technique with an anterior approach. INDICATION Fresh disc herniation with monoradicular symptoms in the upper extremity. CONTRAINDICATIONS Pure neck pain, cervical myelopathy, older and calcified disc herniations, higher grade of instability and deformity. SURGICAL TECHNIQUE Introduction of a guidewire and dilatator to a cervical disc using an anterior approach. Under full-endoscopic view, preparation of the posterior parts of the annulus, opening of the annulus and posterior longitudinal ligament and resection of the herniated fragment from the epidural space. POSTOPERATIVE MANAGEMENT Immediate mobilisation, isometric/coordinative exercises, functional exercises from week 3, building up strength from week 6. RESULTS A total of 120 patients were operated using the full-endoscopic or microsurgically assisted technique and were followed up for 24 months. Significant improvement was achieved in both groups. The group of full-endoscopic operated patients returned to work significantly earlier and 89% of all patients would undergo the operation again.
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Affiliation(s)
- S Oezdemir
- Zentrum für Wirbelsäulenchirurgie und Schmerztherapie, Zentrum für Orthopädie und Unfallchirurgie, St. Elisabeth Gruppe-Katholische Kliniken Rhein-Ruhr, St. Anna Hospital Herne, Hospitalstraße 19, 44649, Herne, Germany.
| | - M Komp
- Zentrum für Wirbelsäulenchirurgie und Schmerztherapie, Zentrum für Orthopädie und Unfallchirurgie, St. Elisabeth Gruppe-Katholische Kliniken Rhein-Ruhr, St. Anna Hospital Herne, Hospitalstraße 19, 44649, Herne, Germany
| | - P Hahn
- Zentrum für Wirbelsäulenchirurgie und Schmerztherapie, Zentrum für Orthopädie und Unfallchirurgie, St. Elisabeth Gruppe-Katholische Kliniken Rhein-Ruhr, St. Anna Hospital Herne, Hospitalstraße 19, 44649, Herne, Germany
| | - S Ruetten
- Zentrum für Wirbelsäulenchirurgie und Schmerztherapie, Zentrum für Orthopädie und Unfallchirurgie, St. Elisabeth Gruppe-Katholische Kliniken Rhein-Ruhr, St. Anna Hospital Herne, Hospitalstraße 19, 44649, Herne, Germany
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Laratta JL, Shillingford JN, Saifi C, Riew KD. Cervical Disc Arthroplasty: A Comprehensive Review of Single-Level, Multilevel, and Hybrid Procedures. Global Spine J 2018; 8:78-83. [PMID: 29456918 PMCID: PMC5810892 DOI: 10.1177/2192568217701095] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Degenerative disc disease and spondylosis resulting in radiculopathy and retrodiscal myelopathy are among the most frequently encountered cervical spinal disorders. Traditionally, anterior cervical discectomy and fusion (ACDF) has successfully achieved neural decompression and restored intradiscal height in these conditions. Unfortunately, nonunion and iatrogenic adjacent segment pathology associated with fusion procedures in the cervical spine has led to an interest in motion-preserving procedures. Cervical disc arthroplasty (CDA) was developed in hopes of preserving cervical biomechanics while mitigating the complications associated with ACDF. Through a systematic review of both published and ongoing studies on single- and multilevel CDA, and hybrid surgeries, we aim to provide evidence for their safety and efficacy in the treatment of various cervical pathologies. METHODS A systematic search of several large databases, including Cochrane Central, PubMed, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry was conducted to identify published studies and ongoing clinical trials on CDA and hybrid surgery. RESULTS Among the relevant studies reviewed, 3 were randomized controlled trials, 2 systematic reviews, as well as multiple prospective case series, biomechanical studies, and meta-analyses. CONCLUSION Over the past decade, multiple high-quality studies have shown that single-level CDA can offer equivalent clinical outcomes with a reduction in secondary procedures and total cost when compared to ACDF. However, more recently there has been an increasing prevalence of 2-level CDA and hybrid surgery. Although the data regarding these multilevel procedures is less robust, it appears that they may be as effective as their single-level counterparts.
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Affiliation(s)
- Joseph L. Laratta
- The Spine Hospital, New York–Presbyterian Healthcare System, Columbia University Medical Center, New York, NY, USA
| | - Jamal N. Shillingford
- The Spine Hospital, New York–Presbyterian Healthcare System, Columbia University Medical Center, New York, NY, USA,Jamal N. Shillingford, Department of Orthopaedic Surgery, The Spine Hospital, New York–Presbyterian Healthcare System, Columbia University Medical Center, 5141 Broadway, 3 Field West, New York, NY 10034, USA.
| | - Comron Saifi
- The Spine Hospital, New York–Presbyterian Healthcare System, Columbia University Medical Center, New York, NY, USA
| | - K. Daniel Riew
- The Spine Hospital, New York–Presbyterian Healthcare System, Columbia University Medical Center, New York, NY, USA
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[Decompression for cervical disc herniation using the full-endoscopic anterior technique - German version]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:25-35. [PMID: 29318336 DOI: 10.1007/s00064-017-0528-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/30/2017] [Accepted: 02/27/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Resection of a cervical disc herniation using a full-endoscopic technique with an anterior approach. INDICATION Fresh disc herniation with monoradicular symptoms in the upper extremity. CONTRAINDICATIONS Pure neck pain, cervical myelopathy, older and calcified disc herniations, higher grade of instability and deformity. SURGICAL TECHNIQUE Introduction of a guidewire and dilatator to a cervical disc using an anterior approach. Under full-endoscopic view, preparation of the posterior parts of the annulus, opening of the annulus and posterior longitudinal ligament and resection of the herniated fragment from the epidural space. POSTOPERATIVE MANAGEMENT Immediate mobilisation, isometric/coordinative exercises, functional exercises from week 3, building up strength from week 6. RESULTS A total of 120 patients were operated using the full-endoscopic or microsurgically assisted technique and were followed up for 24 months. Significant improvement was achieved in both groups. The group of full-endoscopic operated patients returned to work significantly earlier and 89% of all patients would undergo the operation again.
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Wang Z, Zhao H, Liu JM, Chao R, Chen TB, Tan LW, Zhu F, Zhao JH, Liu P. Biomechanics of anterior plating failure in treating distractive flexion injury in the caudal subaxial cervical spine. Clin Biomech (Bristol, Avon) 2017; 50:130-138. [PMID: 29100186 DOI: 10.1016/j.clinbiomech.2017.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 10/16/2017] [Accepted: 10/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Operative level is a potential biomechanical risk factor for construct failure during anterior fixation for distractive flexion injury. No biomechanical study of this concept has been reported, although it is important in clinical management. METHODS To explore the mechanism of this concept, a previously validated three-dimensional C2-T1 finite element model was modified to simulate surgical procedure via the anterior approach for treating single-level distractive flexion injury, from C2-C3 to C7-T1. Four loading conditions were used including no-compression, follower load, axial load, and combined load. Construct stability at the operative level was assessed. FINDINGS Under these loading conditions with the head's weight simulated, segmental stability decreases when the operative level shifts cephalocaudally, especially at C6-C7 and C7-T1, the stress of screw-bone interface increases cephalocaudally, and in the same operative level, the caudal screws always carries more load than the cephalad ones. All these predicted results are consistent with failure patterns observed in clinical reports. In the contrast, under other loading conditions without the weight of head, no obvious segmental divergence was predicted. INTERPRETATION This study supports that the biomechanical mechanism of this phenomenon includes eccentric load from head weight during sagittal movements and difference of moment arms. Our study suggests that anterior fixation is not recommended for treating distractive flexion injury at the caudal segments of the subaxial cervical spine, especially at C6-C7 and C7-T1, because of the intrinsic instability in these segments. Combined posterior rigid fixation with anterior fixation should be considered for these segments.
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Affiliation(s)
- Zhong Wang
- Department of Spine Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Hui Zhao
- Chongqing Key Laboratory of Vehicle Crash/Bio-Impact and Traffic Safety, Department 4, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ji-Ming Liu
- Shandong Weigao Orthopedic Device Company LIMITED, No 26 Xiangjiang Road, Tourist Resorts, Weihai City, Shandong Province, China
| | - Rui Chao
- Department of Spine Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China; Department of Orthopaedic Surgery, Chongqing Emergency Medical Center, The Fourth People's Hospital of Chongqing, Chongqing, China
| | - Tai-Bang Chen
- Department of Orthopaedic surgery, Kunming General Hospital, Yunnan, China
| | - Li-Wen Tan
- Institute of Digital Medicine, Third Military Medical University, Chongqing, China
| | - Feng Zhu
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Jian-Hua Zhao
- Department of Spine Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China.
| | - Peng Liu
- Department of Spine Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China.
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Chin KR, Pencle FJR, Seale JA, Valdivia JM. Soft tissue swelling incidence using demineralized bone matrix in the outpatient setting. World J Orthop 2017; 8:770-776. [PMID: 29094007 PMCID: PMC5656492 DOI: 10.5312/wjo.v8.i10.770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/11/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess use of demineralized bone matrix (DBM) use in anterior cervical discectomy and fusion (ACDF) in outpatient setting.
METHODS One hundred and forty-five patients with prospectively collected data undergoing single and two level ACDF with DBM packed within and anterior to polyetheretherketone (PEEK) cages. Two groups created, Group 1 (75) outpatients and control Group 2 (70) hospital patients. Prevertebral soft tissue swelling (PVSTS) was measured anterior to C2 and C6 on plain lateral cervical radiographs preoperatively and one week postoperatively and fusion assessed at two years.
RESULTS There was no intergroup significance between preoperative and postoperative visual analogue scales (VAS) and neck disability index (NDI) scores between Group 1 and 2. Mean preoperative PVSTS in Group 1 was 4.7 ± 0.2 mm at C2 level and 11.1 ± 0.5 at C6 level compared to Group 2 mean PVSTS of 4.5 ± 0.5 mm and 12.8 ± 0.5, P = 0.172 and 0.127 respectively. There was no radiographic or clinical evidence of adverse reaction noted. In Group 1 mean postoperative PVSTS was 5.5 ± 0.4 mm at C2 and 14.9 ± 0.6 mm at C6 compared Group 2 mean PVSTS was 4.9 ± 0.3 mm at C2 and 14.8 ± 0.5 mm at C6, P = 0.212 and 0.946 respectively. No significant increase in prevertebral soft tissue space at C2 and C6 level demonstrated.
CONCLUSION ACDF with adjunct DBM packed PEEK cages showed a statistical significant intragroup improvement in VAS neck pain scores and NDI scores (P = 0.001). There were no reported serious patient complications; post-operative radiographs demonstrated no significant difference in prevertebral space. We conclude that ACDF with DBM-packed PEEK cages can be safely done in an ASC with satisfactory outcomes.
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Affiliation(s)
- Kingsley R Chin
- Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL 33431, United States
- Less Exposure Surgery Specialists Institute, Fort Lauderdale, FL 33311, United States
- Herbert Wertheim College of Medicine at Florida International University, Miami, FL 33199, United States
| | | | - Jason A Seale
- Less Exposure Surgery Specialists Institute, Fort Lauderdale, FL 33311, United States
- Less Exposure Surgery Society, Malden, MA 02148, United States
| | - Juan M Valdivia
- Less Exposure Surgery Specialists Institute, Fort Lauderdale, FL 33311, United States
- Less Exposure Surgery Society, Malden, MA 02148, United States
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47
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Overley SC, Merrill RK, Leven DM, Meaike JJ, Kumar A, Qureshi SA. A Matched Cohort Analysis Comparing Stand-Alone Cages and Anterior Cervical Plates Used for Anterior Cervical Discectomy and Fusion. Global Spine J 2017; 7:394-399. [PMID: 28811982 PMCID: PMC5544154 DOI: 10.1177/2192568217699211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare perioperative characteristics of stand-alone cages and anterior cervical plates used for anterior cervical discectomy and fusion (ACDF). METHODS We reviewed 40 adult patients who received a stand-alone cage for elective ACDF and matched them with 40 patients who received an anterior cervical plate. We statistically compared operative time, length of stay, proportion of ambulatory cases, overall complications necessitating a trip to the ED, readmission, or reoperation related to index procedure. RESULTS There were 21 women and 19 men in the plate cohort with average ages of 53 years ± 12 and 20 women and 20 men in the stand-alone group with an average age of 52 years ± 11. With no statistical difference in total number, the plate group experienced 4 short-term (within 90 days of discharge) complications, including 3 patients who visited the emergency department for dysphagia and 1 who visited the emergency department for severe back pain, while the stand-alone group experienced 0 complications. There was no significant difference in operative time between the stand-alone group (75.35 min) and the plate group (81.35 min; P = .37). There was a significant difference between the proportion of ambulatory cases in the stand-alone group (25) and the plate group (6; P < .0001). CONCLUSION Our results demonstrate that stand-alone cages have fewer complications compared to anterior plating, with a lower trend of incidence of postoperative dysphagia. Stand-alone cages may offer the advantage of sending patients home ambulatory after ACDF surgery.
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Affiliation(s)
| | | | - Dante M. Leven
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Abhishek Kumar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sheeraz A. Qureshi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Sheeraz A. Qureshi, 5 East 98th St, 4th Floor, New York, NY 10029, USA.
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48
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Abstract
STUDY DESIGN Delphi Panel expert panel consensus and narrative literature review. OBJECTIVE To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)). SUMMARY OF BACKGROUND DATA Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings are lacking. METHODS A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Predetermined consensus was set at 70% for each best-practice statement. RESULTS A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and subcategories) achieved consensus, including preoperative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6). CONCLUSION This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment. LEVEL OF EVIDENCE 4.
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49
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Clinical Outcomes of Outpatient Cervical Total Disc Replacement Compared With Outpatient Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2017; 42:E567-E574. [PMID: 27755491 DOI: 10.1097/brs.0000000000001936] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A single-center, retrospective study. OBJECTIVE The aim of this study was to determine the safety and outcomes of total disc replacement (TDR) as an outpatient procedure in the ambulatory surgery center (ASC). SUMMARY OF BACKGROUND DATA Anterior cervical discectomy and fusion (ACDF) has been demonstrated to be safe in the outpatient setting, as the awareness of same-day surgery procedures is on the rise due to better outcome and shorter recovery time. There is a need for motion preservation in a subset of patients TDR provides a solution. Transitioning spine surgery to the outpatient setting including cervical TDR is the next logical step. METHODS The medical records of 55 consecutive patients undergoing single level TDR (Group 1) were compared with our control group of 55 patients who had single-level ACDF (Group 2). Outcomes assessed included Visual Analogue Scale (VAS) neck, arm, neck disability index (NDI) scores, and complication rate. RESULTS Fifty-five patients in Group 1 (TDR, 60%) were male with the group's mean age being 42.6 ± 1.4 years and body mass index (BMI) 24.8 ± 1.2 kg/m. Fifty-five patients in Group 2 (ACDF), 57%, were male with the group's mean age being 53 ± 1.0 years and mean BMI 27.9 ± 0.8 kg/m. There was no statistically significant intergroup difference in 2-year VAS neck, arm and NDI scores. Dysphagia was the most common postoperative compliant in both groups (six patients), with no intergroup significance, P = 0.4. CONCLUSION In the ambulatory setting, TDR has shown statistical significant intragroup improvement in VAS neck, arm pain scores, and NDI scores (P < 0.001). In this study, no patients reported serious complications, no incidence of hematoma formation, or worsening postop pain. We conclude that single-level TDR can be safely done in an ASC with satisfactory clinical and patient-reported outcomes. This is comparable to single-level ACDF in the outpatient setting and previous 2-year TDR studies. LEVEL OF EVIDENCE 3.
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50
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Purger DA, Pendharkar AV, Ho AL, Sussman ES, Yang L, Desai M, Veeravagu A, Ratliff JK, Desai A. Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost. Neurosurgery 2017; 82:454-464. [DOI: 10.1093/neuros/nyx215] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 04/07/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission.
OBJECTIVE
To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF.
METHODS
Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.
RESULTS
A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients (P < .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P < .05; inpatient OR 1.289, P < .0001) and readmission (ambulatory OR 1.746, P < .0001; inpatient OR 1.685, P < .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P < .0001).
CONCLUSION
ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.
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Affiliation(s)
- David A Purger
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - Allen L Ho
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Lingyao Yang
- Depart-ment of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Manisha Desai
- Depart-ment of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, California
| | - John K Ratliff
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Atman Desai
- Department of Neurosurgery, Stanford University, Stanford, California
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