Safety of Outpatient Single-Level Cervical Total Disc Replacement

A Propensity-Matched Multi-Institutional Study

Patawut Bovonratwet, BS; Michael C. Fu, MD, MHS; Vineet Tyagi, MD; Nathaniel T. Ondeck, MD, MHS; Todd J. Albert, MD; Jonathan N. Grauer, MD

Disclosures

Spine. 2019;44(9):E530-E538. 

In This Article

Abstract and Introduction

Abstract

Study Design: A retrospective cohort comparison study.

Objective: The aim of this study was to investigate the perioperative adverse event profile of cervical total disc replacement (CTDR) performed as an outpatient relative to inpatient procedure.

Summary of Background Data: Recent reimbursement changes and a push for safe reductions in hospital stay have resulted in increased interest in performing CTDRs in the outpatient setting. However, there has been a paucity of studies investigating the safety of outpatient CTDR procedures, despite increasing frequency.

Methods: Patients who underwent single-level CTDR were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Outpatient versus inpatient procedure status was defined by length of stay, with outpatient being less than 1 day. Patient baseline characteristics and comorbidities were compared between the two groups. Propensity score matched comparisons were then performed for 30-day perioperative complications and readmissions between the two cohorts. In addition, perioperative outcomes of outpatient single-level CTDR versus matched outpatient single-level anterior cervical discectomy and fusion (ACDF) cases were compared.

Results: In total, 373 outpatient and 1612 inpatient single-level CTDR procedures were identified. After propensity score matching was performed to control for potential confounders, statistical analysis revealed no significant difference in perioperative complications between outpatient versus matched inpatient CTDR. Notably, the rate of readmissions was not different between the two groups. In addition, there was no difference in rates of perioperative adverse events between outpatient single-level CTDR versus matched outpatient single-level ACDF.

Conclusion: The perioperative outcomes evaluated in the current study support the conclusion that, for appropriately selected patients, single-level CTDR can be safely performed in the outpatient setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient CTDR or outpatient single-level ACDF.

Level of Evidence: 3

Introduction

Cervical total disc replacement (CTDR) and anterior cervical discectomy and fusion (ACDF) are both common treatments of degenerative cervical conditions. Compared with ACDF, which has been the standard of care,[1] CTDR allows for reconstruction with a motion-preserving procedure.[2] In addition, data from some studies suggest that CTDR may limit stresses on adjacent discs and thus potentially reduce the incidence of adjacent segment disease.[3,4] Although CTDR is most commonly performed in the inpatient setting, efforts to maximize patient satisfaction and a push for safe reductions in hospital stay have resulted in increased interest in performing CTDRs in the outpatient setting.[1,5,6]

Studies looking at the feasibility of same-day discharge CTDR have shown promising initial results. Wohns[5] reported positive outcomes in a retrospective review of 26 consecutive outpatient single-level CTDR cases. None of the patients required transfer to the hospital, had any perioperative complications, or required emergency room admissions in the perioperative period. The study also found that the reduction in cost when compared with inpatient single-level CTDR was 84%.[5] Of note, the number of patients in this study was relatively small.

A different study by Chin et al[1] compared 55 consecutive patients undergoing outpatient single-level CTDR with those undergoing outpatient single-level ACDF. Their single-center retrospective analysis found no difference in 2-year Visual Analogue Scale neck, arm, and Neck Disability Index scores. The most common perioperative complaint for both groups was dysphagia, but there were no statistical differences between the two groups.[1] In addition, there were no reports of hematoma or worsening perioperative pain in both groups.[1]

Despite a growing trend to perform CTDR in the ambulatory setting, there are limited data establishing the safety of preforming these procedures as outpatients with sample sizes of 55 or less patients.[1,5] Therefore, the primary purpose of the current study was to use the multi-institutional National Surgical Quality Improvement Program (NSQIP) database to assess the 30-day perioperative complications and readmissions of outpatient relative to inpatient single-level CTDR. A secondary purpose of the current study was to compare the 30-day perioperative complications and readmissions of outpatient single-level CTDR to those associated with outpatient single-level ACDF.

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