Outpatient Surgery Reduces Short-term Complications in Lumbar Discectomy

An Analysis of 4310 Patients From the ACS-NSQIP Database

Andrew J. Pugely, MD; Christopher T. Martin, MD; Yubo Gao, PhD; Sergio A. Mendoza-Lattes, MD

Disclosures

Spine. 2013;38(3):264-271. 

In This Article

Abstract and Introduction

Abstract

Study Design. Propensity score–adjusted prospective cohort study.
Objective. To compare the incidence of complications in patients undergoing single-level lumbar discectomy between the inpatient and outpatient settings, to determine baseline 30-day complication rates for lumbar discectomy, and to identify independent risk factors for complications.
Summary of Background Data. Lumbar discectomy is the most common spinal procedure performed and can be done on an outpatient basis. Lower costs, greater patient satisfaction, and equivalent safety have been reported with outpatient surgery.
Methods. Patients undergoing lumbar discectomy between 2005 and 2010 were selected from The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patient selection was based on a single primary current procedural terminology code. To ensure comparable inpatient and outpatient cohorts, patients with multilevel procedures were excluded. Thirty-day postoperative complications and preoperative patient characteristics were identified and compared. Propensity score matching and multivariate logistic regression analysis were used to adjust for selection bias and identify predictors of 30-day morbidity.
Results. Of the 4310 lumbar discectomy cases, 2658 (61.7%) underwent an inpatient hospital stay after surgery, whereas 1652 (38.3%) patients had outpatient surgery. Unadjusted overall complication rates (6.5% vs. 3.5%, P < 0. 0001) were higher in those undergoing inpatient surgery. After propensity score matching, overall complication rate was still higher with the inpatient cohort (5.4% vs. 3.5%, P = 0.0068). Adjusted comparison using multivariate logistic regression also demonstrated a significantly higher rate of complication for inpatients (odds ratio, 1.521; 95% confidence interval, 1.048–2.206). Age, diabetes, presence of preoperative wound infection, blood transfusion, operative time, and an inpatient hospital stay were all independent risk factors of short-term complication after lumbar discectomy.
Conclusion. After adjusting for confounders using propensity score matching and multivariate logistic regression analysis, patients undergoing outpatient lumbar discectomy had lower overall complication rates than those treated as inpatients. Surgeons should consider outpatient surgery for lumbar discectomy in appropriate candidates.

Introduction

Lumbar discectomy is the most common spinal surgical procedure, with more than 300,000 performed annually.[1,2] The procedure involves a hemilaminectomy or laminotomy followed by removal of herniated disc material, usually for the treatment of radiculopathy. Long-term outcomes of the procedure are favorable, with high patient satisfaction.[3,4]

Traditionally, the procedure has necessitated a 1- to 2-day inpatient hospital stay.[1,5] The primary benefit of an inpatient stay is close monitoring of the surgical wound for signs of infection or hematoma formation and for signs of neurological deficit which might require urgent intervention. In contrast, outpatients avoid the nosocomial risks of hospitalization, and outpatient discectomies have been performed since at least 1985.[6] Since that time, several studies have reported low complication rates in an outpatient setting, with satisfaction rates similar to that reported with inpatient hospitalization.[1,6–8] Furthermore, other surgical subspecialties have reported lower complication rates in outpatients than in inpatients undergoing the same procedure, presumably due to the decreased nosocomial risks.[1,5–8,28,30–32] However, to the best of our knowledge, no large prospective study has ever directly compared the incidence of complications between inpatient and outpatients undergoing discectomy, and thus the relative safety of the outpatient protocol remains unknown in this patient population.

The purpose of this study was to compare the incidence of complications in patients undergoing single-level lumbar discectomy between the inpatient and outpatient settings, to determine baseline 30-day complication rates for lumbar discectomy, and to identify independent risk factors for complications. We queried a database prospectively maintained by The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)[9] to identify all lumbar discectomy cases performed between 2005 and 2010 and hypothesized that because of inherent exposure and care process differences, significant differences may exist between patients who underwent outpatient procedures and those with inpatient hospitalization.

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