The safety of instrumented outpatient anterior cervical discectomy and fusion

Abstract

Background context Reported hospitalization times after an anterior cervical discectomy and fusion (ACDF) procedure range between 20 hours to 4 days. Reasons for this wide variation are manifold, but the safety of an instrumented ACDF in the setting of a hostile medical-legal climate is most likely the primary concern influencing such a discrepancy. Purpose The purpose of this study was to evaluate the safety and feasibility of performing single, two- and three-level ACDF with instrumentation on an outpatient or 23-hour observation period basis in order to potentially diminish the additional cost of hardware without compromising the purported benefits of surgery. Study design/setting A retrospective chart review of patients undergoing instrumented ACDF on an outpatient basis was performed. Patient sample A total of 103 patients with neck pain and/or radiculopathy undergoing ACDF were enrolled into this study. Outcome measures Included the evaluation of intraoperative and perioperative complications, which were reported for a total of 6 months after surgery. Clinical examination and radiographical assessment, including plain radiographs and computed tomography and magnetic resonance imaging (when required), were performed to assess complications. Methods Complications were divided into two groups: major and minor. Major complications included vertebral fracture and dehydration resulting in readmission. Minor complications included allergic reactions to medications that did not require hospitalization, and transient (≤3 months) neurologic deficit. A comprehensive literature search and meta-analysis was performed to generate a large comparison group in order to compare the complication rates in our outpatient series to those reported in the literature. Results A total of 99 patients (96.1%) undergoing single and two-level ACDF were discharged less than 15 hours after their surgeries (median time: 8 hours; range: 2–15 hours), and 4 patients (3.9%) were discharged after a 23-hour observation period following three-level ACDF. The overall complication rate in our outpatient series was 3.8% (n=4), including 1.9% (n=2) major and 1.9% (n=2) minor complications. The overall complication rate in the 633 patient meta-analysis derived comparison group was 0.95% (n=6). The difference between overall complication rates was not found to be significantly different (p=.12). The hardware-related complication rate in the meta-analysis comparison group was 0.5% (n=3), and was not found to be significantly different from our rate of 0% (p≤1). Conclusion Performing ACDF with instrumentation on an outpatient basis is feasible, and it is not associated with higher overall or hardware-related complication rates as compared with complication rates reported in the literature, suggesting that this procedure is safe to perform on an outpatient basis.