Outpatient Spine Surgery: Defining the Outcomes, Value, and Barriers to Implementation

Arjun Vivek Pendharkar, MD; Maryam Nour Shahin, BS; Allen Lin Ho, MD; Eric Scott Sussman, MD; David Arnold Purger, MD, PhD; Anand Veeravagu, MD; John Kevin Ratliff, MD; Atman Mukesh Desai, MD


Neurosurg Focus. 2018;44(5):e11 

In This Article

Patient Selection and Discharge Criteria

If the outcomes of ambulatory spine surgery are deemed acceptable, the next critical step will be to create protocols and standardize patient selection and postoperative care. As seen in the previously described outcome studies, there is an inherent selection bias toward younger and healthier patients undergoing outpatient spine surgery.[44] Age alone has been shown to be an independent risk factor for 30-day complications after ACDF.[9] Chin et al. analyzed the overall eligibility of patients meeting predetermined outpatient criteria in their practice, including a body mass index less than 42, a low to moderate surgical risk, and the absence of medical comorbidities.[13] Interestingly, they did not include patient age but added local caregiver and close to the hospital in their protocol. Overall, in their private practice group, 79% of patients met these criteria. Along the same lines, multiple groups have discussed the need for discharge criteria. Outpatient ACDF carries the feared complication of delayed neck hematoma, and there may be an optimal postoperative observation period to prevent any delayed complications. Lied et al. studied the timing in detecting a postoperative complication after ACDF.[27] Thirty-seven patients (9%) among 390 consecutive surgeries experienced any surgical complication. When stratified by the timing of presentation—immediate (within 6 hours), early (6–72 hours), and late (greater than 72 hours)—all 5 patients (1.2%) who developed a neck hematoma had been diagnosed and undergone evacuation within 6 hours.

Similarly, several groups have created protocols and discharge criteria for outpatient surgery.[15,18,25,31] This includes the empowerment of anesthesia colleagues and nursing staff to improve efficiency and implement safety checkpoints.[41] Furthermore, the utilization of a next-day clinic visit or follow-up telephone call can maintain patient satisfaction as well as preserve safety and outcomes.[20,26,37]