Authors & Year |
Study Information |
Type of Surgery |
Observations/Conclusions |
Outcomes |
Silvers et al., 1996 |
Single institution, study dates May–Dec 1994, 50 prospectively analyzed outpatients, 53 retrospectively analyzed inpatient controls |
1- to 2-level ACDF |
No statistically significant difference btwn inpatient & outpatient groups on any parameters; ambulatory surgery does not compromise safety or efficacy of ACDF |
Mortality: 0%, complication rate for each group: 2%; outpatients: dysphagia (partially recovered) & vocal cord paralysis (not fully resolved at >1 yr): 1 (2%); inpatients: superficial wound infection: 1 (1.9%) |
Trahan et al., 2011 |
One physician's practice, study dates Nov 2005–Apr 2009, 59 outpatients, 58 inpatients |
1- to 2-level ACDF: 1-level 68, 2-level 49 |
1- to 2-level ACDF can be done on an outpatient basis; complication rates low, critical postop complications including respiratory compromise occur very infrequently & in the immediate postop period |
Outpatients: any complication 1 (1.4%), neck swelling & difficulty breathing & anxiety requiring readmission 1 (1.4%) |
Stieber et al., 2005 |
Two senior authors, freestanding ASC, study dates 1998–2002, 30 ASC, 60 inpatients |
1- to 2-level ACDF+P at C4–5 or below as adjunct to autogenous iliac crest bone graft or structural allograft: 1-level: 40, 2-level: 50 |
Outpatient group had lower complication rate than controls (likely due to selection bias); transient dysphagia most common complication in outpatients |
ASC: any complication 3 (10%), dysphagia 3 (10%), readmission 0 (0%); inpatients: any complication 7 (13%), transient dysphagia 3 (5%), graft donor site pain 4 (14%), increased LOS due to complication 4 (7%), readmitted for early complication 4 (7%) |
Lied et al., 2008 |
Single institution, 390 outpatients |
ACDF: 278 fused w/autologous iliac crest, 112 fused w/PEEK graft |
6-hr postop observation, then discharge is safe |
Mortality: 0 (0%); any complication: 37 (9%), immediate complication (0–6 hrs): 17, early complication (6–72 hrs): 1, late complication (>72 hrs): 19; all life-threatening neck hematomas detected w/in first 6 hrs |
Villavicencio et al., 2007 |
Single institution, study dates Apr 2003–Apr 2005, 103 outpatients, d/c <15 hrs postop: 99 (96.1%), d/c after 23 hrs observation after 3-level ACDF: 4 (3.9%) |
1- to 3-level ACDF |
ACDF w/instrumentation as outpatient is safe & feasible & not associated w/increased complications |
Overall complication rate: 4 (3.8%), major complications (vertebral fracture & dehydration resulting in readmission): 2 (1.9%), minor complications (allergic reaction to medications that did not require hospitalization, transient [≤3 mos] neurological deficit): 2 (1.9%) |
Garringer & Sasso, 2010 |
Single surgeon, prospective, study dates Nov 1993–May 2006, 645 outpatients |
1-level ACDF |
1-level ACDF safe in outpatient setting w/4-hr observation; using postop drain is questionable |
Mortality: 0 (0%), any complication: 2 (0.3%), both epidural hematomas, both occurred w/in 4-hr observation period, both resolved w/o permanent deficit; unplanned admission: 24 (6%), >80% due to pain or nausea |
Sheperd & Young, 2012 |
ASC dedicated to spine surgery, study dates 2007–2009, 152 ASC |
1- to 2-level ACDF |
75 patients completed self-reported survey w/in 6 mos, reporting 100% satisfaction rate; ACDF safe in selected patients as outpatient procedure w/high patient satisfaction |
ED visit 6 (3.9%): neck pain 2 (1.3%), dysphagia 1 (0.7%), vocal cord paralysis & dysphagia 1 (0.7%), nausea 1 (0.7%), cervical swelling 1 (0.7%); required readmission: 1 (0.7%); long-term sequelae: 0 (0%); complication rate: 3.9% |
Wohns, 2010 |
Single institution, study dates Feb 2009–May 2010, 14 ASC, 12 hospital-based outpatients |
Cervical disc arthroplasty |
100% patients reported improvement; outpatient cervical disc arthroplasty costs: 62% < 1-level outpatient ACDF, 84% < 1-level inpatient cervical disc arthroplasty; outpatient: 1-level cervical disc arthroplasty: $11,144.83, 1-level ACDF: $29,313.43; inpatient: 1-level cervical disc arthroplasty: $68,000, 1-level ACDF: $61,095.49 |
No mortality, complications, cases requiring hospital transfer, postop ED visit |
Walid et al., 2010 |
Reviewed patients who went through common process of surgery venue selection, 97 outpatients, 578 inpatients |
ACDF (levels unspecified), lumbar microdiscectomy, lumbar decompression w/or w/o fusion |
Mean age older in inpatients (p <0.001); prevalence of DM, CHF, heart disease, CABG/stent/balloon angioplasty, knee problems, & depression higher in inpatients (p <0.05); prevalence of COPD & history of stroke higher in outpatient cervical surgery cohort (p <0.05) |
Outpatients: any complication 1 (1.0%), postop infection 1 (1.0%); inpatients: any complication 16 (2.8%), postop infection 16 (2.8%); all patients w/complications obese |
Lied et al., 2013 |
Single institution, 96 outpatients |
1- or 2-level ACDF: 1-level: 60, 2-level: 36 |
91% patient satisfaction using NASSQ; ACDF in select patients w/cervical disc degeneration appears safe as outpatient procedure w/sufficient postop observation; clinical outcomes & patient satisfaction comparable w/those for inpatient procedure |
Mortality: 0%; surgical morbidity: 5.2%, hematoma 2 (2.1%), dysphagia 2 (2.1%), neurological deterioration 1 (1%) |
Baird et al., 2014 |
US HCUP SID & SASD for CA, NY, FL, & MD; study dates 2005–2009 |
Cervical spine surgery in outpatient setting |
Increase in cervical spine surgeries in ambulatory setting during study period: ACDF 68%, pst decompression 21%; majority (>99%) d/c home after ambulatory surgery |
|
Martin et al., 2008 |
NSQIP, 597 outpatients, 2317 inpatients |
1-level ACDF |
Age >65 yrs, ASA score III or IV, current dialysis, current steroid use, recent sepsis, & op times >120 mins all independent risk factors for complications; no significant differences in complication rate btwn groups; reasonable to consider inpatient 1-level ACDF in patients w/aforementioned risk factors |
Mortality: 5 (0.2%), any complication: 92 (3.2%), reoperation: 34 (1.2%); outpatients: mortality 1 (0.2%), any complication (1.3%), reoperation (0.2%); inpatients: mortality 4 (0.2%), any complication (3.6%), reoperation (1.4%) |
Best et al., 2015 |
National Survey of Ambulatory Surgery |
Discectomy, laminectomy, fusion |
Ambulatory surgeries for intervertebral disc disorders & spinal stenosis increased btwn 1994 & 2006 |
|
Helseth et al., 2015 |
Private clinic, single institution, prospectively recorded complications, study dates 2008–2013, 1449 outpatients |
Microsurgical decompression: lumbar 1073, cervical 376 |
In favor of outpatient spinal surgery for properly selected patients |
Surgical mortality: 0 (0%), any complication: 51 (3.5%), same-day admission: 3 (0.2%), admission w/in 3 mos: 22 (1.5%), hematoma: 9 (0.6%), neurological deterioration: 4 (0.3%), deep wound infection 13 (0.9%), dural lesion & CSF leakage: 15 (1.0%), persistent dysphagia: 2 (0.1%), persistent hoarseness: 2 (0.1%), severe pain/headache: 6 (0.4%), reoperation: 67 (4.6%); all life-threatening hematomas detected w/in hrs after cervical (6 hrs) & lumbar (3 hrs) surgery |
McGirt et al., 2015 |
NSQIP, study dates 2005–2011, 1168 outpatients, 6120 inpatients |
1- to 2-level ACDF |
Return to OR w/in 30 days & major morbidity lower in outpatients |
Outpatients: major morbidity 0.94%, return to OR w/in 30 days 1.4%; inpatients: major morbidity 4.5%, return to OR w/in 30 days 2% |
Adamson et al., 2016 |
Single institution, ASC, study dates 2006–2013, 1000 ASC, 484 inpatients |
1-, 2-, >2-level ACDF; ASC: 1-level 629, 2-level 365, >2-level 6; inpatient: 1-level 274, 2-level 210 |
Surgical complications low & can be diagnosed in 4-hr ASC PACU window; similar results compared to those for inpatient ACDF; can perform ACDF safely as outpatient ASC procedure; 90-day morbidity similar btwn cohorts for 1- & 2-level ACDF |
Transfer from ASC to inpatient: 8 (0.8%), pain control: 3, chest pain & EEG changes: 2, intraop CSF leak: 1, postop hematoma: 1, profound postop weakness & surgical re-exploration: 1; mortality: 0%; 30-day hospital readmission: 2.2% |
Arshi et al., 2017 |
Humana-insured patients, study dates 2011–2016, 1215 outpatients, 10,964 inpatient |
1- to 2-level ACDF |
Adjusting for age, sex, & comorbidities: outpatients more likely to undergo revision surgery for pst fusion at 6 mos & 1 yr, ant fusion at 1 yr; outpatient more likely to have postop acute renal failure |
Outpatients: acute renal failure 15 (1.23%), respiratory failure 16 (1.32%), CVA 12 (0.99%); inpatients: acute renal failure 164 (1.50%), respiratory failure 313 (2.85%), CVA 132 (1.20) |
Chin et al., 201714 |
Single center, ASC |
TDR: 55; 1-level ACDF: 55 |
1-level TDR safe in ASC w/satisfactory clinical & patient-reported outcomes; comparable w/ACDF in outpatient setting |
Dysphagia most common postop complaint in both groups (6 total), no intergroup significant differences |
Chin et al., 201713 |
Single surgeon, ASC, study dates 2008–2014, 557 ASC, 210 inpatients |
Inpatient: decompression 71, fusion 138; outpatient: decompression 150, fusion/disc replacement 197 |
Majority of spine surgery can be done as outpatient procedure after meeting certain eligibility criteria |
Overall revision surgery 14%, overall complication rate 5% |
Idowu et al., 2017 |
Truven Health Marketscan Research Databases, study dates 2003–2014, inpatient hospital, outpatient hospital, ASC |
Lumbar fusion, lumbar decompression, ant cervical fusion, pst cervical decompression, pst cervical fusion |
True ambulatory surgery (defined as at ASC) not increasing at same rate as outpatient procedures |
|
Fu et al., 2017 |
NSQIP database, study dates 2011–2014, 4759 outpatients, 17,211 inpatients |
1- to 2-level ACDF: 2-level 6890 (20.7% outpatient) |
Greater comorbidity burden (CCI), higher ASA class, chronic steroid use, HTN, & male sex independent risk factors for post-d/c complications; outpatient 2-level ACDF not associated w/increased postop morbidity relative to inpatient procedure |
2-level ACDF complications: 1.47% outpatient, 3.94% inpatient (p<0.001) |
Khanna et al., 2018 |
NSQIP, study dates 2011–2013, 1778 (25.6%) outpatients, 5162 (74.4%) inpatients |
1-level ACDF 6940 |
Complication rate higher in inpatient group (p=0.003); outpatient surgery for 1-level ACDF safe & favorable for select patients |
Overall complication rate: 4.2%; outpatient: complication rate 1.2%, 30-day readmission 1.8%, mortality 0.1%; inpatient: complication rate 2.5%, 30-day readmission 2.2%, mortality 0.1% |
Purger et al., 2017 |
CA, FL, NY SID & SASD, 3135 ambulatory, 46,966 inpatients |
ACDF |
Ambulatory younger (48.0 vs 53.1 yrs), more likely white; higher CCI, increased rate of ED visits, & readmission in both groups; overall charges lower for ambulatory $33,362.51 vs inpatient $74,667.04 |
Ambulatory: mortality 0%, ED w/in 30 days 168 (5.4%), readmitted 51 (1.6%), reoperation 200 (0.4%); infection, hematoma, disruption of surgical site or complication from implant: 20, neck pain or injury, radiculopathy, DD: 52, laryngeal/airway: 0, dysphagia/esophageal: 7, other: 172; inpatient: infection, hematoma, disruption of surgical site or complication from implant: 397, neck pain or injury, radiculopathy, DD: 630, laryngeal/airway: 7, dysphagia/esophageal: 118, other: 3792 |