Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs. Hospital Settings

Are There Still Any Benefits to Drainage for Anterior Cervical Arthrodesis/Arthroplasty by Cervicotomy?

STUDY DESIGN

A retrospective single-center study between January 2019 and January 2023.

OBJECTIVE

The role and contribution of drainage in the anterior approach to the cervical spine (cervicotomy) is much debated, motivated primarily by the prevention of retropharyngeal hematoma, so are there still any benefits to drainage?

BACKGROUND

The anterior approach to the cervical spine is a widespread and common procedure performed in almost all spine surgery departments for the replacement of cervical intervertebral discs and medullar or radicular decompression. The primary endpoint was the occurrence of symptomatic postoperative cervical hematoma.

PATIENTS AND METHODS

Four hundred thirty-one patients who had undergone cervical spine surgery by anterior cervicotomy for cervicarthrosis or cervical disc herniation (anterior cervical discectomy and fusion and anterior cervical disc replacement) were consecutively included. Patients were separated into 2 groups: (1) Group A, 140 patients (with postoperative drainage) and (2) Group B, 291 patients (without drainage).

RESULTS

The mean follow-up was 2.8 months. The 2 groups were comparable on all criteria, but there was a predominance of arthroplasty ( P < 0.0001), use of anticoagulants/antiaggregants ( P < 0.0001) and a greater number of stages ( P < 0.0001) in group A. There were a total of 4/431 symptomatic postoperative hematomas (0.92%) in this study. Two hematomas occurred in group A (2/140, 1.4%) and 2 in group B (2/291, 0.68%; P < 0.0001). One patient in group A (0.71%) required surgical drainage for cavity hematoma revealed by marked dyspnea, swallowing, and neurological disorders. One case of hematoma diagnosed by dysphonia and neurological deficit was reported in group B (0.34%; P < 0.0001).

CONCLUSIONS

The placement of a drain during anterior cervicotomy (anterior cervical discectomy and fusion/anterior cervical disc replacement) did not limit the occurrence of symptomatic postoperative hematoma.

Safety and Efficacy of Outpatient Anterior Cervical Disk Replacement (ACDR) in an Ambulatory Surgery Center Versus Hospital Setting: A 2-year Retrospective Analysis

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To compare clinical outcomes of outpatient anterior cervical disk replacements (ACDR) performed in free-standing private ambulatory surgery centers versus tertiary hospital centers.

SUMMARY OF BACKGROUND DATA

ACDR is an increasingly popular technique for treating various degenerative pathologies of the cervical spine. There has been an increase in the utilization of ambulatory surgery centers (ASCs) for outpatient cervical procedures due to economic and convenience benefits; however, a paucity of literature exists in evaluating long-term safety and efficacy of ACDRs performed in ASCs versus outpatient hospital centers.

METHODS

A retrospective cohort review of all patients undergoing 1- or 2-level ACDRs at 2 outpatient ASCs and 4 tertiary care medical centers from 2012 to 2020, with a minimum follow-up of 24 months, was performed. Approval by each patient's insurance and patient preference determined distribution into an ASC or non-ASC. Demographics, perioperative data, length of follow-up, complications, and revision rates were analyzed. Functional outcomes were assessed using VAS and NDI at follow-up visits.

RESULTS

One hundred seventeen patients were included (65 non-ASC and 52 ASC). There were no significant differences in demographics or length of follow-up between the cohorts. ASC patients had significantly lower operative times (ASC: 89.5 minutes vs. non-ASC: 110.5 minutes, P<0.001) and mean blood loss (ASC: 17.5 mL vs. non-ASC: 25.3 mL, P<0.001). No significant differences were observed in rates of dysphagia (ASC: 21.2% vs. non-ASC: 15.6%, P<0.001), infection (ASC: 0.0% vs. non-ASC: 1.6%, P=0.202), ASD (ASC: 1.9% vs. non-ASC: 1.6%, P=0.202), or revision (ASC: 1.9% vs. non-ASC: 0.0%, P=0.262). Both groups demonstrated significant improvements in VAS and NDI scores (P<0.001), but no significant differences in the degree of improvement were observed.

CONCLUSIONS

Our 2-year results demonstrate that ACDRs performed in ASCs may offer the advantages of reduced operative time and blood loss without an increased risk of postoperative complications.

Impact of Preoperative 12-item Short Form Mental Composite Scores on Clinical Outcomes in Cervical Disc Replacement

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aim to examine the effects of preoperative mental health status on demographic, perioperative characteristics, and postoperative outcomes in patients undergoing cervical disc replacement (CDR).

SUMMARY OF BACKGROUND DATA

The effect of preoperative mental health status has not been widely studied in CDR.

METHODS

Patients undergoing primary CDR were retrospectively collected and stratified into 2 cohorts by 12-item Short Form Survey Mental Composite Score (SF-12 MCS) ≥48.9. Patients without preoperative SF-12 MCS scores or diagnosis of infection, malignancy, or trauma were excluded. Demographic information, perioperative characteristic, and patient reported outcome measures (PROMs) were collected. Patient reported outcome measurement information system physical function (PROMIS-PF)/SF-12 Physical Component Score (PCS)/SF-12 MCS/visual analog scale (VAS) neck/VAS leg/neck disability index (NDI) were collected preoperatively and 6 weeks/12 weeks/6 months/1 year postoperatively.

RESULTS

Eighty-seven patients were included, (47 having SF-12 MCS≥48.9). For PROMs, both cohorts had significant improvement from preoperative baseline, besides SF-12 PCS/MCS at 1 year for the depressed cohort and SF-12 MCS at all time points. The non-depressed cohort demonstrated significantly higher PROMIS-PF preoperatively and at 12 weeks, SF-12 PCS at 12 weeks, SF-12 MCS at all time points, decreased VAS neck at 12 weeks and NDI preoperatively and at 12 weeks, overall minimal clinically important difference (MCID) in most patients in all PROMs besides SF-12 MCS, and higher MCID for PROMIS-PF at 12 weeks. The depressed cohort demonstrated overall MCID in most patients with PROMIS-PF/SF-12 MCS/VAS neck/NDI, and a higher MCID for 6 weeks/12 weeks/6 months postoperatively and overall SF-12 PCS.

CONCLUSION

Whereas both cohorts demonstrated significantly improved PROMs from baseline, the non-depressed cohort demonstrated better physical function, mental health, decreased pain, and disability at various time points, whereas the depressed cohort demonstrated higher mental health MCID achievement at every time point except 1 year. These findings may be useful in managing expectations for patients undergoing cervical surgery.

Observational, Multicenter Study of the Efficacy and Safety of Cervical Disk Arthroplasty With Mobi-C in the Treatment of Cervical Degenerative Disk Disease. Results at 10 years Follow-Up

BACKGROUND

Cervical disk arthroplasty replacement (CDA) was developed to avoid specific disadvantages of cervical fusion. The purpose of this paper is to provide 10-year follow-up results of an ongoing prospective study after CDA.

METHODS

Three hundred eighty-four patients treated using the Mobi-C (ZimVie, Troyes, France) were included in a prospective multicenter study. Routine clinical and radiologic examinations were reported preoperatively and postoperatively with up to 10-year follow-up. Complications and revision surgeries were also documented.

RESULTS

At 10 years showed significant improvement in all clinical outcomes [Neck Disability Index, visual analog scale (VAS) for arm and neck pain, physical component summary of SF36, and mental component summary of SF36). Motion at the index level increased significantly over baseline (mean range of motion=7.6 vs. 8 degrees at five years and 6.0 degrees preoperatively; P <0.001) and 71.3% of the implanted segments remained mobile (range of motion>3 degrees). Adjacent disks were also mobile at 10 years with the same mobility as preoperatively. At 10 years, 20.9% of the implanted segments demonstrated no heterotopic ossification. Thirty-four patients (8.9%) experienced 41 adverse events, with or without reoperation during the first five years. We found only two additional surgeries after five years. We observed an increased percentage of working patients and a decrease in medication consumption. Regarding the overall outcome, 94% of patients were satisfied.

CONCLUSIONS

Our 10-year results showed significant improvement in all clinical outcomes, with low rates of revision or failure. This experience in patients with long-term follow-up after CDA endorses durable, favorable outcomes in properly selected patients.

Differences in patient outcomes after outpatient GI endoscopy across settings: a statewide matched cohort study

BACKGROUND AND AIMS

Outpatient GI endoscopy has been shifting from hospital outpatient departments (HOPDs) to ambulatory surgery centers (ASCs) in recent years. However, evidence on whether patient outcomes after endoscopic procedures are comparable across settings is limited. This study compares the incidence of unplanned hospital visits after GI endoscopy performed in ASCs versus HOPDs.

METHODS

We conducted a retrospective cohort study examining unplanned hospital visits after outpatient GI endoscopy performed in Massachusetts during 2014 to 2017 using Massachusetts All-Payer Claims Database and Medicare fee-for-service claims. We identified screening colonoscopy, nonscreening colonoscopy, and esophagogastroduodenoscopies (EGDs) performed in ASCs or HOPDs and estimated unplanned hospital visit rates within 7 and 30 days after these procedures. To compare rates between ASCs and HOPDs, we constructed procedure-specific, propensity score-matched samples and used multilevel logistic regressions adjusting for patient, procedure, and facility characteristics.

RESULTS

Seven-day unplanned hospital visit rates were 10.6, 18.3, and 38.9 per 1000 procedures for screening colonoscopy, nonscreening colonoscopy, and EGD, respectively, with significant variation across facilities. ASC patients consistently had fewer postprocedure hospital encounters. The relative risk of having 7-day hospital visits after screening colonoscopy performed in ASCs was .88 (95% confidence interval [CI], .79-.98) compared with HOPDs. The estimates were .84 (95% CI, .75-.94) for nonscreening colonoscopy and .57 (95% CI, .50-.65) for EGD. Thirty-day visits showed similar patterns.

CONCLUSIONS

Unplanned hospital visits after outpatient GI endoscopy were not uncommon. However, ASC patients consistently had less frequent hospital-based acute care encounters, indicating that GI endoscopy could be performed safely in ASCs for select patients.

Safety of Anterior Cervical Disc Arthroplasty in the Ambulatory Setting: an Eastern European Experience

Aim: Spine surgery has been gradually transitioning from the inpatient setting into ambulatory surgery centers (ASC) and as such, the safety of treating patients on an outpatient basis needs to be validated. Objective:In this study, we aimed to evaluate the safety of anterior cervical disc arthroplasty (CDA) performed in an ambulatory setting in an Eastern European population. All existing studies evaluating safety and efficiency of outpatient CDA have originated from high-volume ASCs from the USA. Methods:We retrospectively reviewed 103 consecutive patients who underwent outpatient CDA between January 2018 and February 2020 in order to assess the safety of outpatient single- and multi-level CDA procedures. Various operative data was collected, including adverse events. Results:One patient required reintervention for reposition of the implant, resulting in a reoperation rate of 0.97%. Of the total 149 levels treated, the risk of readmission per level treated was 0.67%. Other AEs included prolonged postoperative hoarseness (laryngeal nerve dysfunction) in two (1.94%) patients, which for one patient resolved within one year. There were no other cases of reintervention, hospital readmission, or postoperative emergency visits. Conclusion:To our knowledge, this is the first study to evaluate the safety of CDA in the ambulatory setting in an Eastern European population. Our data suggests that CDA may be considered safe in the outpatient setting in appropriately selected patients. The 30-day reintervention rate was 0.97%, while AE rate was 1.94%. The reoperation and AE rates were similar to or lower than the complication rates reported by large US outcome studies.

Comparison of the Safety of Outpatient Cervical Disc Replacement With Inpatient Cervical Disc Replacement: A Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVES

Outpatient cervical disc replacement (CDR) has been performed with an increasing trend in recent years. However, the safety profile surrounding outpatient CDR remains insufficient. The present study systematically reviewed the current studies about outpatient CDR and performed a meta-analysis to evaluate the current evidence on the safety of outpatient CDR as a comparison with the inpatient CDR.

METHODS

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases comprehensively up to April 2020. Patient demographic data, overall complication, readmission, returning to the operation room, operating time were analyzed with the Stata 14 software and R 3.4.4 software.

RESULTS

Nine retrospective studies were included. Patients underwent outpatient CDR were significantly younger (mean difference [MD] = -1.97; 95% CI -3.80 to -0.15; P = .034) and had lower prevalence of hypertension (OR = 0.68; 95% CI 0.53-0.87; P = .002) compared with inpatient CDR. The pooled prevalence of overall complication was 0.51% (95% CI 0.10% to 1.13%) for outpatient CDR. Outpatient CDR had a 59% reduction in risk of developing complications (OR = 0.41; 95% CI 0.18-0.95; P = .037). Outpatient CDR showed significantly shorter operating time (MD = -18.37; 95% CI -25.96 to -10.77; P < .001). The readmission and reoperation rate were similar between the 2 groups.

CONCLUSIONS

There is a lack of prospective studies on the safety of outpatient CDR. However, current evidence shows outpatient CDR can be safely performed under careful patient selection. High-quality, large prospective studies are needed to demonstrate the generalizability of this study.

Utilization of a Standardized Care Pathway to Decrease Costs of Ankle Fracture Management

INTRODUCTION

Ankle fractures are the most common fracture of the foot and ankle treated at trauma hospitals in the United States, costing millions of dollars yearly. The purpose of this study was to determine whether a standardized care pathway led to a difference in the direct and indirect costs of surgical fixation of ankle fractures at one Level I Trauma Center and tertiary care medical center.

METHODS

We analyzed cost, volume, length of stay, and collections for surgical treatment of ankle fractures in inpatient and outpatient settings by the orthopaedics and podiatry departments during fiscal years 2016 to 2018. Based on these data, we compared projected costs and collections across a 5-year period with the procedure being done by a single department (orthopaedics only and podiatry only).

RESULTS

Total costs per case fell by 18% in the orthopaedics department and 8% in the podiatry department over the 3-year period. The podiatry department spent an average of $1,296 (46%) more per case than the orthopaedics department, driven by increased average supply costs. Both departments had significantly decreased direct costs (P = 0.0039 orthopaedics and P = 0.033 podiatry) in the outpatient setting. The orthopaedics department also had significantly lower average supply costs than the podiatry department (P = 0.045) and significantly decreased total costs in the outpatient setting (P = 0.0084).

DISCUSSION

The orthopaedics department performed a higher volume of cases at a lower cost per case than the podiatry department. These savings were driven by a standardized ankle fracture treatment pathway that we propose decreased direct and supply costs. Our results suggest that surgical treatment of ankle fracture cases using a standardized care pathway is economically advantageous because of limiting variations in care and creating manageable workflows.

Identifying the Most Appropriate ACDF Patients for an Ambulatory Surgery Center: A Pilot Study Using Inpatient and Outpatient Hospital Data

STUDY DESIGN

Retrospective cohort analysis of prospectively collected data.

OBJECTIVES

Using a national cohort of patients undergoing elective anterior cervical discectomy and fusion (ACDF) in an inpatient/outpatient setting, the current objectives were to: (1) outline preoperative factors that were associated with complications, and (2) describe potentially catastrophic complications so that this data can help stratify the best suited patients for an ambulatory surgery center (ASC) compared with a hospital setting.

SUMMARY OF BACKGROUND DATA

ASCs are increasingly utilized for spinal procedures and represent an enormous opportunity for cost savings. However, ASCs have come under scrutiny for profit-driven motives, lack of adequate safety measures, and inability to handle complications.

METHODS

Adults who underwent ACDF between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure ACDF [Current Procedural Terminology (CPT) 22551, 22552], elective, neurological/orthopedic surgeons, length of stayof 0/1 day, and being discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications.

RESULTS

A total of 12,169 patients underwent elective ACDF with a length of stay of 0/1 day and were discharged directly home. A total of 179 (1.47%) patients experienced a complication. Multivariate logistic regression revealed the following factors were significantly associated with a complication: Charlson Comorbidity Index (CCI) >3, history of transient ischemic attack/cerebrovascular accident, abnormal bilirubin, and operative time of >2 hours. Approximate comorbidity score cutoffs associated with <2% risk of complication were: American Society of Anesthesiologists (ASA)≤2, CCI≤2, modified frailty index (mFI) ≤0.182. A total of 51 (0.4%) patients experienced potentially catastrophic complications.

CONCLUSIONS

The current results represent a preliminary, pilot analysis using inpatient/outpatient data in selecting appropriate patients for an ASC. The incidence of potentially catastrophic complication was 0.4%. These results should be validated in multi-institution studies to further optimize appropriate patient selection for ASCs.

Postoperative Critical Events Associated With Obstructive Sleep Apnea: Results From the Society of Anesthesia and Sleep Medicine Obstructive Sleep Apnea Registry

BACKGROUND

Obstructive sleep apnea (OSA) patients are at increased risk for pulmonary and cardiovascular complications; perioperative mortality risk is unclear. This report analyzes cases submitted to the OSA Death and Near Miss Registry, focusing on factors associated with poor outcomes after an OSA-related event. We hypothesized that more severe outcomes would be associated with OSA severity, less intense monitoring, and higher cumulative opioid doses.

METHODS

Inclusion criteria were age ≥18 years, OSA diagnosed or suspected, event related to OSA, and event occurrence 1992 or later and <30 days postoperatively. Factors associated with death or brain damage versus other critical events were analyzed by tests of association and odds ratios (OR; 95% confidence intervals [CIs]).

RESULTS

Sixty-six cases met inclusion criteria with known OSA diagnosed in 55 (83%). Patients were middle aged (mean = 53, standard deviation [SD] = 15 years), American Society of Anesthesiologists (ASA) III (59%, n = 38), and obese (mean body mass index [BMI] = 38, SD = 9 kg/m); most had inpatient (80%, n = 51) and elective (90%, n = 56) procedures with general anesthesia (88%, n = 58). Most events occurred on the ward (56%, n = 37), and 14 (21%) occurred at home. Most events (76%, n = 50) occurred within 24 hours of anesthesia end. Ninety-seven percent (n = 64) received opioids within the 24 hours before the event, and two-thirds (41 of 62) also received sedatives. Positive airway pressure devices and/or supplemental oxygen were in use at the time of critical events in 7.5% and 52% of cases, respectively. Sixty-five percent (n = 43) of patients died or had brain damage; 35% (n = 23) experienced other critical events. Continuous central respiratory monitoring was in use for 3 of 43 (7%) of cases where death or brain damage resulted. Death or brain damage was (1) less common when the event was witnessed than unwitnessed (OR = 0.036; 95% CI, 0.007-0.181; P < .001); (2) less common with supplemental oxygen in place (OR = 0.227; 95% CI, 0.070-0.740; P = .011); (3) less common with respiratory monitoring versus no monitoring (OR = 0.109; 95% CI, 0.031-0.384; P < .001); and (4) more common in patients who received both opioids and sedatives than opioids alone (OR = 4.133; 95% CI, 1.348-12.672; P = .011). No evidence for an association was observed between outcomes and OSA severity or cumulative opioid dose.

CONCLUSIONS

Death and brain damage were more likely to occur with unwitnessed events, no supplemental oxygen, lack of respiratory monitoring, and coadministration of opioids and sedatives. It is important that efforts be directed at providing more effective monitoring for OSA patients following surgery, and clinicians consider the potentially dangerous effects of opioids and sedatives-especially when combined-when managing OSA patients postoperatively.

Comparison of the safety of outpatient cervical disc replacement with inpatient cervical disc replacement: A protocol for a meta-analysis

BACKGROUND

Cervical disc replacement (CDR) has been widely used as an effective treatment for cervical degenerative disc diseases in recent years. However, the cost of this procedure is very high and may bring a great economic burden to patients and the health care system. It is reported that outpatient procedures can reduce nearly 30% of the costs associated with hospitalization compared with inpatient procedures. However, the safety profile surrounding outpatient CDR remains poorly resolved. This study aims to evaluate the current evidence on the safety of outpatient CDR METHODS:: Four English databases were searched. The inclusion and exclusion criteria were developed according to the PICOS principle. The titles and abstracts of the records will be screened by 2 authors independently. Records that meet the eligibility criteria will be screened for a second time by reading the full text. An extraction form will be established for data extraction. Risk of bias assessment will be performed by 2 authors independently using Cochrane risk of bias tool or Newcastle-Ottawa scale. Data synthesis will be conducted using Stata software. Heterogeneity among studies will be assessed using I test. The funnel plot, Egger regression test, and Begg rank correlation test will be used to examine the publication bias.

RESULTS

The results of this meta-analysis will be published in a peer-review journal.

CONCLUSION

This will be the first meta-analysis that compares the safety of outpatient CDR with inpatient CDR. Our study will help surgeons fully understand the complications and safety profile surrounding outpatient CDR. OSF REGISTRATION NUMBER:: doi.org/10.17605/OSF.IO/3597Z.

The Safety of Single and Multilevel Cervical Total Disc Replacement in Ambulatory Surgery Centers

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Evaluate the safety profile of single- and multilevel cervical artificial disc replacement (ADR) performed in an outpatient setting.

SUMMARY OF BACKGROUND DATA

As healthcare costs rise, attempts are made to perform an increasing proportion of spine surgery in ambulatory surgery centers (ASCs). ASCs are more efficient, economically and functionally. Few studies have published on the safety profile of multilevel cervical ADR.

METHODS

We have performed an analysis of all consecutive cervical ADR surgeries that we performed in an ASC over a 9-month period, including multilevel and revision surgery. The pre-, intra-, and postoperative data recorded included age, sex, body mass index, tobacco use, and diabetes; level and procedure, operating room time, estimated blood loss (EBL), and complications; and discharge site, occurrence of reoperation, hospital admission, or any medical complication or infection over a 90-day period.

RESULTS

A total of 147 patients underwent 231 treated levels: 71 single-level, 76 multilevel: 69 two-level, 6 three-level, and 1 four-level. Average age was 50 ± 10 years; 71 women, 76 men. None of the patients had insulin-dependent diabetes, 4 were current smokers, and 16 were former smokers. Average body mass index was 26.8 ± 4.6 (range 18-40). Average total anesthesia time was 88 minutes (range 39-168 min). Average EBL was 15 mL (range 5-100 mL). Approximately 90.3% of patients were discharged directly home, 9.7% to an aftercare facility. In the 90-day postoperative period there were zero deaths and two hospital admissions (1.4%)-one for medical complication (0.7%) and one for a surgical site infection (0.7%).

CONCLUSION

In this consecutive case series we performed 231 ADRs in 147 patients in the outpatient setting, including multilevel and revision procedures, with 2 minor postoperative complications resulting in hospital unplanned admissions within 90 days. We believe that these procedures are safe to perform in an ASC. An efficient surgical team and careful patient selection criteria are critical in making this possible.

LEVEL OF EVIDENCE

3.

Outcomes and value in elective cervical spine surgery: an introductory and practical narrative review

How we determine a successful clinical outcome and the value of a spine intervention are two major questions surrounding clinical spine research. Patient-reported outcomes (PROs), both LEGACY and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, are becoming ubiquitous throughout the literature. Spine surgeons need a facile understanding of the financial landscape of their environment to influence change. In the current introductory, narrative review on outcomes and value in cervical spine surgery, we aim to: (I) define relevant outcome and cost terminology, (II) review recent cervical spine surgery literature, divided by specific pathology with a focus on LEGACY and PROMIS measures, and (III) discuss value and cost as they pertain to postoperative return to work and ambulatory surgery centers surgeries.

Complication avoidance and management in ambulatory spine surgery

The positive safety profile and potential cost savings associated with ambulatory spine surgery have resulted in an increasing number of spine procedures being performed on an outpatient basis. As indications become more inclusive and the variety and volume of ambulatory procedures grow, the incidence of complications may rise. Limiting adverse events in the outpatient setting starts with patient selection. Surgeons should be aware of the potential complications and associated risk factors for common ambulatory spine procedures and employ strategies to limit and appropriately manage them. Protocols which include patient education, multimodal anesthesia and analgesia, standardized post-operative monitoring, and safe discharge planning are also essential for maximizing safety in the ambulatory setting.

Future endeavors in ambulatory spine surgery

Due to the high societal and financial burden of spinal disorders, spine surgery is thought to be one of the most impactful targets for healthcare cost reduction. One avenue for cost-reduction that is increasingly being explored not just in spine surgery but across specialties is the performance of surgeries in ambulatory surgery centers (ASCs). Despite potential cost-savings, the utilization of ASCs for spine surgery remains largely limited to high-volume centers in the US, and predominantly for single- or two-level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) procedures. Factors most commonly cited for the lack of wider adoption include the risk of life-threatening complications, paucity of guidelines, and limited accessibility of these procedures to various patient populations. Thus, the future growth and adoption of ambulatory spine surgery depends on addressing these concerns by developing evidence-based guidelines for patient- and procedure selection, creating risk-stratification tools, devising appropriate discharge recommendations, and optimizing care protocols to ensure that safety, efficacy and outcomes are maintained. Other avenues that may allow for more widespread use of ASCs include the use of electronic health tools for post-operative monitoring after discharge from the ASC, increasing accessibility of ambulatory procedures to eligible populations, and identifying systemic inefficiencies and implementing process-improvement measures to optimize patient-selection, scheduling and peri-operative management. The success of ambulatory surgery ultimately depends not only on the surgical procedure, but also on its organization upstream and downstream. It provides an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.

Evidence-based use of arthroplasty in cervical degenerative disc disease

INTRODUCTION

Cervical disc arthroplasty (CDA) was developed to decrease the rate of symptomatic adjacent-level disease while preserving motion in the cervical spine.

METHODS

The objectives of this paper are to provide criteria for proper patient selection as well as to present a comprehensive literature review of the current evidence for CDA, including randomized studies, the most recent meta-analysis findings, and long-term follow-up clinical trials as well.

RESULTS

Currently, there are several prospective randomized controlled studies of level I of evidence attesting to the safety and efficacy of CDA in the management of cervical spondylotic disease (CSD) for one- or two-level degenerative diseases. These as well as recent meta-analyses suggest that CDA is potentially similar or even superior to anterior cervical discectomy and fusion (ACDF) when considering several outcomes, including dysphagia and re-operation rate over medium-term follow-up. Less robust studies have also reported satisfactory clinical and radiological outcomes of CDA for hybrid procedures (ACDF combined with CDA), non-contiguous disease, and even for multilevel disease (more than 2 levels).

CONCLUSIONS

Based on this evidence we conclude that CDA is a safe and effective alternative to ACDF in properly selected patients for one- or two-level diseases. Defining superiority of specific implants and detailing optimal surgical indications will require further well-designed long-term studies.