The Safety of Single and Multilevel Cervical Total Disc Replacement in Ambulatory Surgery Centers

Jason M. Cuéllar, MD, PhD; Todd H. Lanman, MD; Alexandre Rasouli, MD


Spine. 2020;45(8):512-521. 

In This Article

Abstract and Introduction


Study Design: Retrospective cohort.

Objective: Evaluate the safety profile of single- and multilevel cervical artificial disc replacement (ADR) performed in an outpatient setting.

Summary of Background Data: As healthcare costs rise, attempts are made to perform an increasing proportion of spine surgery in ambulatory surgery centers (ASCs). ASCs are more efficient, economically and functionally. Few studies have published on the safety profile of multilevel cervical ADR.

Methods: We have performed an analysis of all consecutive cervical ADR surgeries that we performed in an ASC over a 9-month period, including multilevel and revision surgery. The pre-, intra-, and postoperative data recorded included age, sex, body mass index, tobacco use, and diabetes; level and procedure, operating room time, estimated blood loss (EBL), and complications; and discharge site, occurrence of reoperation, hospital admission, or any medical complication or infection over a 90-day period.

Results: A total of 147 patients underwent 231 treated levels: 71 single-level, 76 multilevel: 69 two-level, 6 three-level, and 1 four-level. Average age was 50 ± 10 years; 71 women, 76 men. None of the patients had insulin-dependent diabetes, 4 were current smokers, and 16 were former smokers. Average body mass index was 26.8 ± 4.6 (range 18–40). Average total anesthesia time was 88 minutes (range 39–168 min). Average EBL was 15 mL (range 5–100 mL). Approximately 90.3% of patients were discharged directly home, 9.7% to an aftercare facility. In the 90-day postoperative period there were zero deaths and two hospital admissions (1.4%)—one for medical complication (0.7%) and one for a surgical site infection (0.7%).

Conclusion: In this consecutive case series we performed 231 ADRs in 147 patients in the outpatient setting, including multilevel and revision procedures, with 2 minor postoperative complications resulting in hospital unplanned admissions within 90 days. We believe that these procedures are safe to perform in an ASC. An efficient surgical team and careful patient selection criteria are critical in making this possible.

Level of Evidence: 3


As the cost of healthcare has been rising rapidly within the United States, an attempt is being made to perform an increasing proportion of spine surgery procedures in ambulatory surgery centers (ASCs). ASCs are more efficient than large hospitals, both economically and functionally. There have been reports of high rates of safety, economic efficiency, and patient satisfaction for outpatient anterior cervical discectomy and fusion (ACDF),[1–14] posterior cervical foraminotomy,[15,16] cervical total disc replacement,[17–21] posterior lumbar laminectomy/discectomy,[22–28] posterior lumbar fusion (minimally invasive transforaminal lumbar interbody fusion),[29,30] and lumbar direct lateral interbody fusions.[31,32]

Although several studies have reported on the safety of ACDF, there are few studies on outpatient cervical artificial disc replacement (ADR). Most of the prior literature reporting on outpatient cervical ADR has been for single-level procedures. Chin et al[18] reported no complications in a cohort of 55 patients that underwent single-level cervical ADR in an ASC, similar to the comparison group of 55 patients that underwent ACDF.

Two recent large national database studies have reported on the safety of single-level cervical ADR.[19,21] Both studies observed a lower rate of wound infection and unplanned hospital admission in the outpatient group. However, in these national database studies, outpatient is defined as same-day discharge (postoperative day 0). It is therefore not possible to determine within the database whether these procedures were performed in a true free-standing ASC or in a hospital setting with same-day discharge.

There has been uncertainty regarding the safety of outpatient multilevel anterior cervical procedures, as to date little has been published on this subset of patients—only one recent study, by Gornet et al,[20] has included two-level cervical ADR performed in an ASC. The authors compared 191 ADRs performed in 145 patients to historical controls consisting of 536 ADRs performed in 348 patients in an outpatient hospital setting and 111 ADRs performed in 65 patients in an inpatient hospital setting. Of the 145 patients that had surgery at the ASC, 99 were single-level and 46 were two-level ADRs. The authors report a very safe profile for outpatient cervical ADR, with lower rates of complication in the ASC for both one and two level.

We have been performing one-, two-, three-, and rarely, four-level anterior cervical discectomy and ADRs in an ASC. In the current study we analyze the safety of these procedures over the past year—9 months of surgery plus 3 months follow-up period.