Cervical spine surgery performed in ambulatory surgical centers: Are patients being put at increased risk?

Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities

Background:

This is an updated analysis of the morbidity and mortality of cervical surgery performed in outpatient/same day (OSD) (Postoperative care unit [PACU] observation 4–6 h), and ambulatory surgicenters (ASC: PACU 23 h) versus inpatient facilities (IF).

Methods:

We analyzed 19 predominantly level III (retrospective) and IV (case series) studies regarding the morbidity/mortality of cervical surgery performed in OSC/ASC versus IF.

Results:

A “selection bias” clearly favored operating on younger/healthier patients to undergo cervical surgery in OSD/ASC centers resulting in better outcomes. Alternatively, those selected for cervical procedures to be performed in IF classically demonstrated multiple major comorbidities (i.e. advanced age, diabetes, high body mass index, severe myelopathy, smoking, 3–4 level disease, and other comorbidities) and had poorer outcomes. Further, within the typical 4–6 h. PACU “observation window,” OSD facilities “picked up” most major postoperative complications, and typically showed 0% mortality rates. Nevertheless, the author’s review of 2 wrongful death suits (i.e. prior to 2018) arising from OSD ACDF cervical surgery demonstrated that there are probably many more mortalities occurring following discharges from OSD where cervical operations are being performed that are going underreported/unreported.

Conclusion:

“Selection bias” favors choosing younger/healthier patients to undergoing cervical surgery in OSD/ ASC facilities resulting in better outcomes. Atlernatively, choosing older patients with greater comorbidities for IF surgery correlated with poorer results. Although most OSD cervical series report 0% mortality rates, a review of 2 wrongful death suits by just one neurosurgeon prior to 2018 showed there are probably many more mortalities resulting from OSD cervical surgery than have been reported.

Safety profile of outpatient vs inpatient ACDF: An analysis of 33,807 outpatient ACDFs

INTRODUCTION

Anterior cervical discectomy and fusion (ACDF) is commonly performed to treat symptomatic cervical spondylolysis. Recently, many spine surgeons have begun performing ACDF in the outpatient setting. However, as this is a relatively new trend, many studies are either outdated or have small sample populations. The aim of this study was to evaluate outcomes following elective outpatient ACDF in comparison to those performed in the inpatient setting.

METHODS

Patients in Mariner Claims Database (2011-2017) undergoing outpatient elective ACDF were propensity score matched using age, gender and comorbidity burden. Chronic and peri-operative complications were assigned based on medical claims codes. All outcomes of interest were analyzed using multivariate logistic regression and compared to those undergoing inpatient ACDF. Significance was defined as p < 0.05 and adjusted with Bonferroni correction.

RESULTS

Outpatient surgery had significantly lower risk of dysphagia within 24 h in both single (OR 0.44, p < 0.001) and multilevel ACDF (OR 0.48, p < 0.001). Patients undergoing outpatient procedures also have lower risk of 90-day minor (Single OR 0.64, p < 0.001; Multilevel OR 0.52, p < 0.001) and major (Single OR 0.48, p < 0.001; Multilevel OR 0.57, p < 0.001) medical complications. Outpatient procedures were also associated with decreased hospital resource utilization with a noted lower risk of subsequent hospital readmission (Single OR 0.71, p < 0.001; Multilevel OR 0.60, p < 0.001) and ER visits (Single OR 0.84, p < 0.001; Multilevel OR 0.87, p < 0.001).

CONCLUSION

Outpatient single and multilevel ACDF may be performed safely in properly selected patients. Since there are relatively low rates of readmission and significant complications within the days following outpatient ACDF, many surgeons should consider transitioning carefully selected patients to an outpatient setting.

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

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.

Emergent reintubation following elective cervical surgery: A case series

AIM

To review cases of emergent reintubation after cervical surgery.

METHODS

Patients who were emergently intubated in the post-operative period following cervical surgery were identified. The patients’ prospectively documented demographic parameters, medical history and clinical symptoms were ascertained. Pre-operative radiographs were examined for the extent of their pathology. The details of the operative procedure were discerned.

RESULTS

Eight hundred and eighty patients received anterior- or combined anterior-posterior cervical surgery from 2008-2013. Nine patients (1.02%) required emergent reintubation. The interval between extubation to reintubation was 6.2 h [1-12]. Patients were kept intubated after reintubation for 2.3 d [2-3]. Seven patients displayed moderate postoperative edema. One patient was diagnosed with a compressive hematoma which was subsequently evacuated in the OR. Another patient was diagnosed with a pulmonary effusion and treated with diuretics. One patient received a late debridement for an infected hematoma. Six patients reported residual symptoms and three patients made a complete recovery.

CONCLUSION

Respiratory compromise is a rare but potentially life threatening complication following cervical surgery. Patients at increased risk should be monitored closely for extended periods of time post-operatively. If the airway is restored adequately in a timely manner through emergent re-intubation, the outcome of the patients is generally favorable.