Outpatient spine surgery: defining the outcomes, value, and barriers to implementation

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Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion.

Abstract

Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Spine surgery is one of the most impactful targets for reducing costs within the United States health care system.32 An estimated $90 billion is spent each year on the diagnosis and management of low-back pain alone.28 As summarized by Resnick et al., spinal disorders are an ideal target for cost reduction because of their high prevalence and significant contribution to morbidity- and disability-related costs.36 Furthermore, there is significant variability in the treatment paradigms for spinal disorders—representing the entire spectrum of pain medications, acupuncture, massage therapy, steroid injections, surgical decompression and fusion, and beyond. It is the enormous clinical burden of spinal disease paired with treatment heterogeneity that creates an opportunity to empirically define real value and produce savings for the health care system.

One promising but controversial cost reduction strategy involves transitioning surgical procedures to an outpatient setting. More than 54 million outpatient procedures are performed annually in the United States. Among Medicare beneficiaries, rates of outpatient surgery have increased by 40% in the last 10 years. And the number of ambulatory surgery centers has grown by 60% within the same time period.21 Although eye surgeries, arthroscopic procedures, peripheral nerve cases, and soft tissue cases represent the majority of ambulatory operations, an increasing proportion of spine surgeries has transitioned to the outpatient setting.2,5,7 Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations.

In this focused review, we clarify the different definitions used in studies describing outpatient spine surgery. We also discuss the body of evidence supporting the transition of each of these procedures to an outpatient setting and summarize the proposed cost savings. Finally, we examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Definitions

Within the current body of literature describing outpatient spine surgery, there exists a heterogeneous and ill-defined set of terms that obscures true understanding of the outcomes and cost savings. Fundamentally, any time a patient is discharged from the hospital and has not been admitted to an inpatient ward, they have undergone an outpatient surgery. However, from a reimbursement perspective, there is a clear delineation between a patient whose recovery is observed within a reasonable amount of time before discharge (for example, 4–6 hours in the Medicare Claims Processing Manual, Chapter 4, Section 290.2.2) and a patient who is observed for an extended period of time (< 24 hours). Both of these patient encounters, from an outcomes perspective, can be grouped together as an outpatient procedure but carry different hospital utilization costs.

Similarly, utilization differs between an outpatient procedure performed in association with a hospital and one performed at a freestanding ambulatory surgery center. Idowu et al. examined this difference and found that, although there has indeed been a dramatic increase in the number of hospital-associated outpatient spine operations, there has been a significantly less pronounced increase in spine surgery at freestanding ambulatory centers.23 In general, the lack of granularity regarding these definitions represents a significant limitation of the literature describing outpatient outcomes.

Outcomes

Lumbar Laminectomy and Discectomy

Lumbar laminectomy with or without discectomy remains the most common spine operation performed in the United States and was one of the earliest procedures to be successfully transitioned to the outpatient setting (Table 1). Several groups have reported clinical series describing favorable outcomes.8,10,22,25,33,47 Helseth et al. reported on a series of 1073 consecutive patients undergoing lumbar procedures at a freestanding neurosurgical clinic with a successful discharge rate of 99.8% on the day of surgery.19 No patients died within 30 days, and the 90-day readmission rate was 1.5%. Nine patients (0.6%) suffered a postoperative hematoma, which was recognized and evacuated postoperatively, and these patients were subsequently discharged the same day. Notably, this study was conducted in Oslo, Norway, in a health care ecosystem distinct from that of the United States. Another group of investigators studied 212 consecutive patients in the United States, who had undergone a first operation for lumbar disease; the authors reported the overall success rate at 2 years as 75%–80%, as defined by the visual analog scale and Oswestry Disability Index.4 In their cohort, the average hospital stay was 5 hours, and only 1 patient (0.5%) was admitted to the inpatient service following surgery. Best and Sasso analyzed outcomes for 233 consecutive patients 65 years of age or older who underwent outpatient lumbar decompression, finding an inpatient admission conversion rate of 4.1% and an overall complication rate of 7.1%.8 In addition to single-center cohort studies, the overall trends and outcomes for lumbar laminectomy and discectomy have been analyzed using large surgical databases. Pugely and colleagues performed a propensity score–matched analysis of 4310 lumbar discectomy cases in the American College of Surgeons database.34 Interestingly, in the matched cohort, the inpatient group had a significantly higher rate of complications (OR 1.521) even after adjusting for potential confounders. Moreover, an advanced age, diabetes, and operative times longer than 150 minutes were independent predictors of a postoperative complication. All data taken together, lumbar decompression has the strongest evidence for safety in the outpatient setting.

TABLE 1.

Summary on the safety of and outcomes for outpatient lumbar laminectomy and discectomy

Authors & YearStudy InformationType of SurgeryObservations/ConclusionsOutcomes
Asch et al., 2002Single institution, prospective, 212 outpatientsLumbar microdiscectomyWorkers’ comp & age had negative impact on outcomeSuccess rate 75%–80% at 2 yrs, 1 patient (0.5%) admitted to inpatient service after surgery
Best & Sasso, 20072 surgeons, patient age ≥65 yrs, study dates 1992–2001Lumbar decompression: 1377Lumbar spine surgical decompression safe as outpatient procedure in elderly patientsRequired hospital stay: 30 (11.4%), converted to inpatient due to complication: 10 (4.1%), any complication: 4 (7.1%), 72.5% patients who completed questionnaire said they would repeat outpatient procedure; 69.1% said surgical outcome produced good or better function than preop level
Walid et al., 2010Reviewed patients who went through common process of surgery venue selection: 97 outpatients, 578 inpatientsACDF (levels unspecified), lumbar microdiscectomy, lumbar decompression w/ or w/o fusionMean 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
Pugely et al., 2013NSQIP, study dates 2005–2010, 1652 (38.3%) outpatients, 2658 (61.7%) inpatientsSingle-level lumbar discectomyComplication rate higher in inpatients (p <0.0001); age, DM, preop wound infection, blood transfusion, op time, & inpatient hospital stay all independent risk factors for short-term complication; surgeons should consider outpatient surgery in appropriate candidatesComplication rates: 3.5% outpatients, 6.5% inpatients
Lang et al., 2014Two academic hospitals, study dates 2008–2012, 368 after outpatient protocol, 643 before outpatient protocolLumbar discectomyw/ implementation of outpatient protocol, outpatient lumbar discectomy safe & effective; improving periop pain management & ensuring cases scheduled early in the day may decrease admissionsBefore outpatient protocol: admission rate 96.4%, 30-day readmission 2.3%, ED visit w/o admission 1.1%; after outpatient protocol: admission rate 50.3%, 30-day readmission 4.6%, ED visit w/o admission 2.2%; most common reasons for admission after protocol implemented: uncontrolled pain 18.9%, late op start times 14.1%, comorbidities 13%, intraop complications (almost all dural tears) 11.9%
Best et al., 2015National Survey of Ambulatory SurgeryDiscectomy, laminectomy, fusionAmbulatory surgeries for intervertebral disc disorders & spinal stenosis increased btwn 1994 & 2006
Helseth et al., 2015Private clinic, single institution, prospectively recorded complications, study dates 2008–2013, 1449 outpatientsMicrosurgical decompression: lumbar 1073, cervical 376In favor of outpatient spinal surgery for properly selected patientsSurgical 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
Emami et al., 2016Single institution, study dates Jan–Dec 2012, 32 outpatients, 64 inpatients1- or 2-level MI TLIFsOutpatients significantly younger, had lower ASA physical status scores & lower CCIs than inpatients; no statistical difference in overall postop complication rate, readmission rate, final ODI or VAS scoresOutpatients: neurological (allograft malposition or persistent nerve root compression) 2, postop hematoma 0, incidental durotomy 0, SSI 0, instrumentation (pedicle screw malposition, hardware prominence, rod disengagement) 1; inpatients: neurological (allograft malposition or persistent nerve root compression) 3, postop hematoma 2, incidental durotomy 1, SSI 3, instrumentation (pedicle screw malposition, hardware prominence, rod disengagement) 1
Chin et al., 2016Multiple institutions, 30 outpatients, 40 inpatientsSingle-level LLIF w/ supplemental pst fixation at each lumbar level from L-1 to L-5; LLIF performed at ASC or as inpatient procedureLLIF as outpatient procedure has significant improvement in ODI scores compared to scores for inpatient procedure (p = 0.013); outpatient LLIF improves patient outcome w/ similar safety as inpatient procedureComplication rate for inpatient > that for ASC; ASC dermatome numbness: 2 (7%); inpatient dermatome numbness: 4 (10%); weakness: 3 (7.5%); inability to walk: 1 (2.5%)
Chin et al., 201713Single surgeon, ASC, study dates 2008–2014, 557 ASC, 210 inpatientsInpatient: decompression 71, fusion 138; outpatient: decompression 150, fusion/disc replacement 197Majority of spine surgery can be done as outpatient procedure after meeting certain eligibility criteriaOverall revision surgery 14%, overall complication rate 5%
Idowu et al., 2017Truven Health Marketscan Research Databases, study dates 2003–2014, inpatient hospital, outpatient hospital, ASCLumbar fusion, lumbar decompression, ant cervical fusion, pst cervical decompression, pst cervical fusionTrue ambulatory surgeries (defined as at ASC) not increasing at same rate as outpatient procedures
Yen & Albargi, 2017Single institution, 2 18-mo periods, pre- & postimplementation of ambulatory outpatient protocolLumbar laminectomy1 readmission in inpatient cohort, outpatient & overnight laminectomy safe, out of town patients also safeNo patients required postop admission to hospital or readmission in 30 days; inpatient readmission: 1

ant = anterior; ASA = American Society of Anesthesiologists; ASC = ambulatory surgery center; CABG = coronary artery bypass grafting; CCI = Charlson Comorbidity Index; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; ED = emergency department; LLIF = lateral lumbar interbody fusion; MI = minimally invasive; NSQIP = National Surgical Quality Improvement Program; ODI = Oswestry Disability Index; pst = posterior; SSI = surgical site infection; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

Lumbar Fusion

The literature regarding lumbar fusion in the outpatient setting is more limited than that regarding decompression with or without discectomy (Table 2). Conceptually, as minimally invasive fusion techniques continue to evolve, this is a promising group of operations to transition to outpatient procedures. Several smaller cohort studies have reported favorable outcomes from minimally invasive transforaminal lumbar interbody fusion and posterior fusion performed in the outpatient setting.16 One technical modification to posterior fusion includes the use of midline cortical bone trajectory pedicle screws to reduce the amount of muscle dissection and tissue destruction without sacrificing fusion rates.12 Another promising avenue involves the use of lateral fusion techniques, which may also reduce postoperative pain and thus enable earlier discharge. Smith et al. performed a retrospective analysis of 1033 patients treated with minimally invasive lateral interbody fusion and grouped patients according to length of stay.39 They found that a younger age, lower body mass index, less advanced disease, and higher preoperative hemoglobin levels were predictive factors for discharge within 24 hours. In the prospective arm, the authors performed 54 lateral and 18 posterior fusions in an ambulatory setting with no transfers to an inpatient facility. Two additional patients (3.7%) visited the emergency department within 30 days. Another author group prospectively compared 70 consecutive patients undergoing lateral fusion in either an inpatient or outpatient setting.11 There were no significant baseline differences in characteristics between the two cohorts, including age, body mass index, or pathological level treated. Additionally, fusion was achieved in all patients. Between the two groups, the outpatient cohort benefited from significant improvement in the Oswestry Disability Index, less blood loss, and shorter operative time. Overall, these studies suggest that for young, healthy patients, a lateral fusion may be well tolerated with same-day discharge. However, the overall reported readmission rates tended to be higher than those in the lumbar decompression and/or discectomy literature.

TABLE 2.

Summary on the safety of and outcomes for outpatient lumbar fusion

Authors & YearStudy InformationType of SurgeryObservations/ConclusionsOutcomes
Walid et al., 2010Reviewed patients who went through common process of surgery venue selection: 97 outpatients, 578 inpatientsACDF (levels unspecified), lumbar microdiscectomy, lumbar decompression w/ or w/o fusionMean 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
Best et al., 2015National Survey of Ambulatory SurgeryDiscectomy, laminectomy, fusionAmbulatory surgeries for intervertebral disc disorders & spinal stenosis increased btwn 1994 & 2006
Chin et al., 201712ASC, single surgeon, 16 outpatients1-level PLIF or TLIF (direct open, single-level PLIF)Direct open PLIF done safely w/ significant reduction in average pain & ODI scoresWorsened back pain & possible aseptic discitis: 1 (6.3%)
Chin et al., 2016Multiple institutions, 30 outpatients, 40 inpatientsSingle-level LLIF w/ supplemental pst fixation at each lumbar level from L-1 to L-5; LLIF performed at ASC or as inpatient procedureLLIF as outpatient procedure has significant improvement in ODI scores compared to scores for inpatient procedure (p = 0.013); outpatient LLIF improves patient outcome w/ similar safety as inpatient procedureComplication rate for inpatients > that for outpatients; ASC dermatome numbness: 2 (7%); inpatient dermatome numbness: 4 (10%), weakness: 3 (7.5%), inability to walk: 1 (2.5%)
Emami et al., 2016Single institution, study dates Jan–Dec 2012, 32 outpatients, 64 inpatients1- or 2-level MI TLIFsOutpatients significantly younger, had lower ASA physical status scores & lower CCIs than inpatients; no statistical difference in overall postop complication rate, readmission rate, final ODI or VAS scoresOutpatients: neurological 2, postop hematoma 0, incidental durotomy 0, SSI 0, instrumentation (pedicle screw malposition, hardware prominence, rod disengagement) 1; inpatients: neurological 3, postop hematoma 2, incidental durotomy 1, SSI 3, instrumentation (pedicle screw malposition, hardware prominence, rod disengagement) 1
Smith et al., 2016ASC, predictive arm: 873 d/c <24 hrs (outpatients), 160 d/c >23 hrs (inpatients); clinical study: 54 consecutive XLIF & 18 consecutive MI pst fusionLumbar fusion (1–4 levels), XLIF, MI pst fusionSelect patients can be treated as outpatients w/ XLIF & other MI surgical approaches; based on predictive study: younger age, higher preop hemoglobin, fewer levels, lower BMI, & less advanced disease may predict early d/cClinical study (72): no intraop or postop complications in either XLIF or MI pst fusion cohort; no transfers to inpatient facility
Idowu et al., 2017Truven Health Marketscan Research Databases, study dates 2003–2014, inpatient hospital, outpatient hospital, ASCLumbar fusion, lumbar decompression, ant cervical fusion, pst cervical decompression, pst cervical fusionTrue ambulatory surgery (defined as at ASC) not increasing at same rate as outpatient procedures
Chin et al., 201712Prospective, single institution, 30 CBT pedicle screws OSC, 30 traditional pedicle screws inpatientPst lumbar fixationSuccessful lumbar fusions in OSC using midline CBT pedicle screw; traditional method may still work as outpatient procedure, but authors claim midline technique is more advantageous; OSC led to significant improvement in VAS back pain (p = 0.004) and ODI (p = 0.027) scores; similar fusion rate at 2 yrs
Chin et al., 201713Single surgeon, ASC, study dates 2008–2014, 557 ASC, 210 inpatientsInpatient: decompression 71, fusion 138; outpatient: decompression 150, fusion/disc replacement 197Majority of spine surgery can be done as outpatient procedure after meeting certain eligibility criteriaOverall revision surgery 14%, overall complication rate 5%

BMI = body mass index; d/c = discharge; LLIF or XLIF = lateral lumbar interbody fusion; CBT = cortical bone trajectory; OSC = outpatient surgery center; PLIF = posterior lumbar interbody fusion.

Anterior Cervical Discectomy and Fusion

There is a growing body of evidence in support of anterior cervical discectomy and fusion (ACDF) performed in the outpatient setting (Table 3). However, unlike in lumbar surgery, the specter of neck hematoma and airway compromise creates an additional barrier to changes in practice.

TABLE 3.

Summary on the safety of and outcomes for outpatient anterior cervical spine surgeries

Authors & YearStudy InformationType of SurgeryObservations/ConclusionsOutcomes
Silvers et al., 1996Single institution, study dates May–Dec 1994, 50 prospectively analyzed outpatients, 53 retrospectively analyzed inpatient controls1- to 2-level ACDFNo statistically significant difference btwn inpatient & outpatient groups on any parameters; ambulatory surgery does not compromise safety or efficacy of ACDFMortality: 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., 2011One physician’s practice, study dates Nov 2005–Apr 2009, 59 outpatients, 58 inpatients1- to 2-level ACDF: 1-level 68, 2-level 491- 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 periodOutpatients: any complication 1 (1.4%), neck swelling & difficulty breathing & anxiety requiring readmission 1 (1.4%)
Stieber et al., 2005Two senior authors, freestanding ASC, study dates 1998–2002, 30 ASC, 60 inpatients1- 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: 50Outpatient group had lower complication rate than controls (likely due to selection bias); transient dysphagia most common complication in outpatientsASC: 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., 2008Single institution, 390 outpatientsACDF: 278 fused w/ autologous iliac crest, 112 fused w/ PEEK graft6-hr postop observation, then discharge is safeMortality: 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., 2007Single 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 ACDFACDF w/ instrumentation as outpatient is safe & feasible & not associated w/ increased complicationsOverall 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, 2010Single surgeon, prospective, study dates Nov 1993–May 2006, 645 outpatients1-level ACDF1-level ACDF safe in outpatient setting w/ 4-hr observation; using postop drain is questionableMortality: 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, 2012ASC dedicated to spine surgery, study dates 2007–2009, 152 ASC1- to 2-level ACDF75 patients completed self-reported survey w/in 6 mos, reporting 100% satisfaction rate; ACDF safe in selected patients as outpatient procedure w/ high patient satisfactionED 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, 2010Single institution, study dates Feb 2009–May 2010, 14 ASC, 12 hospital-based outpatientsCervical disc arthroplasty100% 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: $61,095.49No mortality, complications, cases requiring hospital transfer, postop ED visit
Walid et al., 2010Reviewed patients who went through common process of surgery venue selection, 97 outpatients, 578 inpatientsACDF (levels unspecified), lumbar microdiscectomy, lumbar decompression w/ or w/o fusionMean 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., 2013Single institution, 96 outpatients1- or 2-level ACDF: 1-level: 60, 2-level: 3691% 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 procedureMortality: 0%; surgical morbidity: 5.2%, hematoma 2 (2.1%), dysphagia 2 (2.1%), neurological deterioration 1 (1%)
Baird et al., 2014US HCUP SID & SASD for CA, NY, FL, & MD; study dates 2005–2009Cervical spine surgery in outpatient settingIncrease 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., 2008NSQIP, 597 outpatients, 2317 inpatients1-level ACDFAge >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 factorsMortality: 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., 2015National Survey of Ambulatory SurgeryDiscectomy, laminectomy, fusionAmbulatory surgeries for intervertebral disc disorders & spinal stenosis increased btwn 1994 & 2006
Helseth et al., 2015Private clinic, single institution, prospectively recorded complications, study dates 2008–2013, 1449 outpatientsMicrosurgical decompression: lumbar 1073, cervical 376In favor of outpatient spinal surgery for properly selected patientsSurgical 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., 2015NSQIP, study dates 2005–2011, 1168 outpatients, 6120 inpatients1- to 2-level ACDFReturn to OR w/in 30 days & major morbidity lower in outpatientsOutpatients: 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., 2016Single institution, ASC, study dates 2006–2013, 1000 ASC, 484 inpatients1-, 2-, >2-level ACDF; ASC: 1-level 629, 2-level 365, >2-level 6; inpatient: 1-level 274, 2-level 210Surgical 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 ACDFTransfer 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., 2017Humana-insured patients, study dates 2011–2016, 1215 outpatients, 10,964 inpatient1- to 2-level ACDFAdjusting 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 failureOutpatients: 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., 201714Single center, ASCTDR: 55; 1-level ACDF: 551-level TDR safe in ASC w/ satisfactory clinical & patient-reported outcomes; comparable w/ ACDF in outpatient settingDysphagia most common postop complaint in both groups (6 total), no intergroup significant differences
Chin et al., 201713Single surgeon, ASC, study dates 2008–2014, 557 ASC, 210 inpatientsInpatient: decompression 71, fusion 138; outpatient: decompression 150, fusion/disc replacement 197Majority of spine surgery can be done as outpatient procedure after meeting certain eligibility criteriaOverall revision surgery 14%, overall complication rate 5%
Idowu et al., 2017Truven Health Marketscan Research Databases, study dates 2003–2014, inpatient hospital, outpatient hospital, ASCLumbar fusion, lumbar decompression, ant cervical fusion, pst cervical decompression, pst cervical fusionTrue ambulatory surgery (defined as at ASC) not increasing at same rate as outpatient procedures
Fu et al., 2017NSQIP database, study dates 2011–2014, 4759 outpatients, 17,211 inpatients1- 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 procedure2-level ACDF complications: 1.47% outpatient, 3.94% inpatient (p<0.001)
Khanna et al., 2018NSQIP, study dates 2011–2013, 1778 (25.6%) outpatients, 5162 (74.4%) inpatients1-level ACDF 6940Complication rate higher in inpatient group (p=0.003); outpatient surgery for 1-level ACDF safe & favorable for select patientsOverall 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., 2017CA, FL, NY SID & SASD, 3135 ambulatory, 46,966 inpatientsACDFAmbulatory 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 $74,667.04Ambulatory: 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

ACDF+P = ACDF with plating; CVA = cerebrovascular accident; DD = degenerative disease; EEG = electroencephalography; HCUP = United States Healthcare and Cost Utilization Project; HTN = hypertension; LOS = length of stay; NASSQ = North American Spine Society Questionnaire; OR = operating room; PACU = post-anesthesia care unit; PEEK = polyetheretherketone; SID = State Inpatient Databases; SASD = State Ambulatory Surgery and Services Databases; TDR = total disc replacement.

The first reports of outpatient ACDF were small, single-surgeon feasibility studies reporting on fewer than 100 patients undergoing 1- or 2-level surgery with same-day discharge.38,40,42,43 There were no reported deaths, and overall complication rates ranged from 0% to 2%. In these reports, only 1 patient required conversion to inpatient status for neck swelling and this patient did not require reoperation. The initial studies provided proof of concept but were limited by a lack of statistical power to show a difference between inpatient and outpatient ACDF. More recently, there have been several larger clinical series and database studies reporting direct comparisons of inpatient and outpatient ACDF. McGirt et al. obtained 1442 ACDF cases (650 inpatients, 792 outpatients) from the American College of Surgeons database, and after propensity matching for 32 covariates such as number of levels, medical comorbidities, age, and sex, these authors found that outpatient ACDF had 58% reduced odds of a major morbidity and 80% lower odds of reoperation within 30 days (ORs 0.42 and 0.20, respectively).29 The same author group analyzed 1000 consecutive ACDF patients, all of whom had been observed for at least 4 hours prior to discharge.1 Notably, all of the patients had American Society of Anesthesiologists physical status class I or II, all underwent 1- or 2-level ACDF, and all cases began before noon. Overall, 8 patients (0.08%) were transferred to inpatient status. There were no significant differences between the inpatient and outpatient cohort in the 30- and 90-day readmission or reoperation rate. Several other surgical database studies have since corroborated these findings in support of outpatient 1- or 2-level ACDF with an overall low comorbidity profile.17,24,35 Additionally, Ban and colleagues performed a meta-analysis and systematic review, including 12 articles and 1693 treated levels, which revealed an overall complication rate of 1.71% and a risk ratio of 0.99, suggesting no statistical difference between inpatient and outpatient groups.6

There may be a longer-term negative effect of outpatient ACDF. Arshi et al. examined more than 12,000 patients in a private insurance database and reported that outpatient ACDF was associated with higher odds of repeat anterior surgery at 1 year (OR 1.46) as well as a higher likelihood of undergoing posterior surgery at 6 months and 1 year (ORs 1.58 and 1.79, respectively).3 The authors speculate that pressures for high throughput in an ambulatory setting may force surgeons to be less rigorous in endplate preparation, discectomy, or proper instrumentation, leading to higher rates of pseudarthrosis. Another interesting theory posits that the bias against the treatment of more than 2 levels may increase the proportion of patients with untreated milder adjacent segment disease, which subsequently progresses. Their findings underline the importance of studying longer-term outcomes beyond 30 or 90 days to truly evaluate whether outpatient spine surgery has an unanticipated impact.

Cervical Disc Arthroplasty

Cervical disc arthroplasty is a logical companion to outpatient ACDF and may actually lend itself to superior outcomes as patients in these cases are often younger with fewer baseline comorbidities. Moreover, the surgical principles favor less bony and soft tissue disruption. For now, the data on outpatient surgery are limited. Wohns reported on a personal series of 26 consecutive cervical disc arthroplasties with a minimum 4-hour observation period in a cohort of patients with a mean age of 46 years and no comorbidities.46 There were no transfers to inpatient status, nor any readmissions or reoperations within 30 days. Another group compared 55 outpatient disc arthroplasty cases to an outpatient ACDF control group (55 patients) and again found no readmissions or reoperations within 30 days.14

Cost

As described earlier, the difference between outpatient surgery performed at a hospital and that performed at an ambulatory center confounds direct comparison of the cost savings. However, in single-center studies, several authors have reported their own cost savings. For example, performing lumbar laminectomy in an ambulatory surgery center can produce a 30% facility fee reduction.29 Similarly, Silvers et al. reported a cost savings of $1800 per ACDF performed in 1996 and estimated a cost savings of $140 million nationwide for that same year if every 1- or 2-level ACDF were performed in the outpatient setting.38 Wohns found the cost of a single-level outpatient cervical disc arthroplasty to be 62% less than an outpatient ACDF and 84% less than an inpatient cervical disc arthroplasty.46 This suggests that cost is a complex result of procedure, instrumentation, facility fee, and length of stay.30 Purger et al. modeled costs and charges including all complications, readmissions, and reoperations within 90 days as a bundled charge and found significant savings in the outpatient ACDF cohort—nearly half the total for inpatient ACDF.35 The 90-day bundled charge represents one of the proposed Medicare value-based reimbursement paradigms and is an ideal metric for future cost studies.

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

Surgeon Preference

One additional consideration highlights the role of surgeon preference. In the United States medicolegal environment, the impact of a single death cannot be understated from the perspective of cost as well as surgeon willingness to send a patient home early.45 For ACDF and cervical disc arthroplasty specifically, this may prevent the adoption of outpatient surgery at large regardless of the outcomes.

Conclusions

As the economic burden of United States health care continues to increase, we are obligated to produce novel solutions to rising costs. Here, we present evidence describing ambulatory spine surgery outcomes with related proposed cost savings. With proper patient selection and close follow-up, outpatient surgery may be an ideal model for innovation and significant cost reduction.

Disclosures

The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Pendharkar, Ho, Sussman, Purger, Veeravagu, Ratliff, Desai. Acquisition of data: Pendharkar, Shahin, Ho, Sussman, Purger, Veeravagu, Desai. Analysis and interpretation of data: all authors. Drafting the article: Pendharkar, Shahin, Ho, Sussman, Purger, Veeravagu, Desai. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Pendharkar. Administrative/technical/material support: Pendharkar, Shahin, Ho.

References

  • 1

    Adamson TGodil SSMehrlich MMendenhall SAsher ALMcGirt MJ: Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases. J Neurosurg Spine 24:8788842016

  • 2

    Ahn JBohl DDTabaraee EBasques BASingh K: Current trends in outpatient spine surgery. Clin Spine Surg 29:3843862016

  • 3

    Arshi AWang CPark HYBlumstein GWBuser ZWang JC: Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database. Spine J [epub ahead of print]2017

  • 4

    Asch HLLewis PJMoreland DBEgnatchik JGYu YJClabeaux DE: Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm? J Neurosurg 96 (1 Suppl):34442002

  • 5

    Baird EOEgorova NNMcAnany SJQureshi SAHecht ACCho SK: National trends in outpatient surgical treatment of degenerative cervical spine disease. Global Spine J 4:1431502014

  • 6

    Ban DLiu YCao TFeng S: Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis. Eur J Med Res 21:342016

  • 7

    Best MJBuller LTEismont FJ: National trends in ambulatory surgery for intervertebral disc disorders and spinal stenosis: a 12-year analysis of the national surveys of ambulatory surgery. Spine (Phila Pa 1976) 40:170317112015

  • 8

    Best NMSasso RC: Outpatient lumbar spine decompression in 233 patients 65 years of age or older. Spine (Phila Pa 1976) 32:113511402007

  • 9

    Buerba RAGiles EWebb MLFu MCGvozdyev BGrauer JN: Increased risk of complications after anterior cervical discectomy and fusion in the elderly: an analysis of 6253 patients in the American College of Surgeons National Surgical Quality Improvement Program database. Spine (Phila Pa 1976) 39:206220692014

  • 10

    Cenic AKachur E: Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J Neurol Sci 36:1962002009

  • 11

    Chin KRPencle FJRCoombs AVBrown MDConklin KJO’Neill AM: Lateral lumbar interbody fusion in ambulatory surgery centers: patient selection and outcome measures compared with an inhospital cohort. Spine (Phila Pa 1976) 41:6866922016

  • 12

    Chin KRPencle FJRCoombs AVElsharkawy MPacker CFHothem EA: Clinical outcomes with midline cortical bone trajectory pedicle screws versus traditional pedicle screws in moving lumbar fusions from hospitals to outpatient surgery centers. Clin Spine Surg 30:E791E7972017

  • 13

    Chin KRPencle FJRCoombs AVPacker CFHothem EASeale JA: Eligibility of outpatient spine surgery candidates in a single private practice. Clin Spine Surg 30:E1352E13582017

  • 14

    Chin KRPencle FJRSeale JAPencle FK: Clinical outcomes of outpatient cervical total disc replacement compared with outpatient anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 42:E567E5742017

  • 15

    Debono BSabatier PGarnault VHamel OBousquet PLescure JP: Outpatient lumbar microdiscectomy in France: from an economic imperative to a clinical standard—an observational study of 201 cases. World Neurosurg 106:8918972017

  • 16

    Emami AFaloon MIssa KShafa EPourtaheri SSinha K: Minimally invasive transforaminal lumbar interbody fusion in the outpatient setting. Orthopedics 39:e1218e12222016

  • 17

    Fu MCGruskay JASamuel AMSheha EDDerman PBIyer S: Outpatient anterior cervical discectomy and fusion is associated with fewer short-term complications in one- and two-level cases: a propensity-adjusted analysis. Spine (Phila Pa 1976) 42:104410492017

  • 18

    Garringer SMSasso RC: Safety of anterior cervical discectomy and fusion performed as outpatient surgery. J Spinal Disord Tech 23:4394432010

  • 19

    Helseth ØLied BHalvorsen CMEkseth KHelseth E: Outpatient cervical and lumbar spine surgery is feasible and safe: a consecutive single center series of 1449 patients. Neurosurgery 76:7287382015

  • 20

    Hersht MMassicotte EMBernstein M: Patient satisfaction with outpatient lumbar microsurgical discectomy: a qualitative study. Can J Surg 50:4454492007

  • 21

    Hollenbeck BKDunn RLSuskind AMZhang YHollingsworth JMBirkmeyer JD: Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries. Med Care 52:9269312014

  • 22

    Hudak EMPerry MW: Outpatient minimally invasive spine surgery using endoscopy for the treatment of lumbar spinal stenosis among obese patients. J Orthop 12:1561592015

  • 23

    Idowu OABoyajian HHRamos EShi LLLee MJ: Trend of spine surgeries in the outpatient hospital setting versus ambulatory surgical center. Spine (Phila Pa 1976) 42:E1429E14362017

  • 24

    Khanna RKim RBLam SKCybulski GRSmith ZADahdaleh NS: comparing short-term complications of inpatient versus outpatient single-level anterior cervical discectomy and fusion: an analysis of 6940 patients using the ACS-NSQIP database. Clin Spine Surg 31:43472018

  • 25

    Lang SSChen HIKoch MJKurash LMcGill-Armento KRPalella JM: Development of an outpatient protocol for lumbar discectomy: our institutional experience. World Neurosurg 82:8979012014

  • 26

    Lied BRønning PAHalvorsen CMEkseth KHelseth E: Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients. Acta Neurol Scand 127:31372013

  • 27

    Lied BSundseth JHelseth E: Immediate (0–6 h), early (6–72 h) and late (>72 h) complications after anterior cervical discectomy with fusion for cervical disc degeneration; discharge six hours after operation is feasible. Acta Neurochir (Wien) 150:1111182008

  • 28

    Martin BIDeyo RAMirza SKTurner JAComstock BAHollingworth W: Expenditures and health status among adults with back and neck problems. JAMA 299:6566642008 (Erratum in JAMA)

  • 29

    McGirt MJGodil SSAsher ALParker SLDevin CJ: Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. Neurosurg Focus 39(6):E92015

  • 30

    Missios SBekelis K: Hospitalization cost after spine surgery in the United States of America. J Clin Neurosci 22:163216372015

  • 31

    Mohandas ASumma CWorthington WBLerner JFoley KTBohinski RJ: Best practices for outpatient anterior cervical surgery: results from a Delphi panel. Spine (Phila Pa 1976) 42:E648E6592017

  • 32

    Moses H IIIMatheson DHMDorsey ERGeorge BPSadoff DYoshimura S: The anatomy of health care in the United States. JAMA 310:194719632013

  • 33

    Nataraj A: Admission and acute complication rate for outpatient lumbar microdiscectomy. Can J Neurol Sci 37:12010

  • 34

    Pugely AJMartin CTGao YMendoza-Lattes SA: Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-NSQIP database. Spine (Phila Pa 1976) 38:2642712013

  • 35

    Purger DAPendharkar AVHo ALSussman ESYang LDesai M: Outpatient vs inpatient anterior cervical discectomy and fusion: a population-level analysis of outcomes and cost. Neurosurgery [epub ahead of print]2017

  • 36

    Resnick DKTosteson ANAGroman RFGhogawala Z: Setting the equation: establishing value in spine care. Spine (Phila Pa 1976) 39 (22 Suppl 1):S43S502014

  • 37

    Sheperd CSYoung WF: Instrumented outpatient anterior cervical discectomy and fusion: is it safe? Int Surg 97:86892012

  • 38

    Silvers HRLewis PJSuddaby LSAsch HLClabeaux DEBlumenson LE: Day surgery for cervical microdiscectomy: is it safe and effective? J Spinal Disord 9:2872931996

  • 39

    Smith WDWohns RNChristian GRodgers EJRodgers WB: Outpatient minimally invasive lumbar interbody: fusion predictive factors and clinical results. Spine (Phila Pa 1976) 41 (Suppl 8):S106S1222016

  • 40

    Stieber JRBrown KDonald GDCohen JD: Anterior cervical decompression and fusion with plate fixation as an outpatient procedure. Spine J 5:5035072005

  • 41

    Techy FBenzel EC: Implementing an outpatient ambulatory discectomy protocol at a large academic center: a change for the better. World Neurosurg 83:3413422015

  • 42

    Trahan JAbramova MVRichter EOSteck JC: Feasibility of anterior cervical discectomy and fusion as an outpatient procedure. World Neurosurg 75:

  • 43

    Villavicencio ATPushchak EBurneikiene SThramann JJ: The safety of instrumented outpatient anterior cervical discectomy and fusion. Spine J 7:1481532007

  • 44

    Walid MSRobinson JS IIIRobinson ERMBrannick BBAjjan MRobinson JS Jr: Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci 17:149714982010

  • 45

    Wang MY: Outpatient anterior cervical discectomy and fusion. World Neurosurg 75:442011

  • 46

    Wohns R: Safety and cost-effectiveness of outpatient cervical disc arthroplasty. Surg Neurol Int 1:77742010

  • 47

    Yen DAlbargi A: Results and limitations of outpatient and overnight stay laminectomies for lumbar spinal stenosis. Can J Surg 60:3293342017

Article Information

Correspondence Arjun Vivek Pendharkar: Stanford University School of Medicine, Stanford, CA. apendhar@stanford.edu.

INCLUDE WHEN CITING DOI: 10.3171/2018.2.FOCUS17790.

Disclosures The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Adamson TGodil SSMehrlich MMendenhall SAsher ALMcGirt MJ: Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases. J Neurosurg Spine 24:8788842016

2

Ahn JBohl DDTabaraee EBasques BASingh K: Current trends in outpatient spine surgery. Clin Spine Surg 29:3843862016

3

Arshi AWang CPark HYBlumstein GWBuser ZWang JC: Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database. Spine J [epub ahead of print]2017

4

Asch HLLewis PJMoreland DBEgnatchik JGYu YJClabeaux DE: Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm? J Neurosurg 96 (1 Suppl):34442002

5

Baird EOEgorova NNMcAnany SJQureshi SAHecht ACCho SK: National trends in outpatient surgical treatment of degenerative cervical spine disease. Global Spine J 4:1431502014

6

Ban DLiu YCao TFeng S: Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis. Eur J Med Res 21:342016

7

Best MJBuller LTEismont FJ: National trends in ambulatory surgery for intervertebral disc disorders and spinal stenosis: a 12-year analysis of the national surveys of ambulatory surgery. Spine (Phila Pa 1976) 40:170317112015

8

Best NMSasso RC: Outpatient lumbar spine decompression in 233 patients 65 years of age or older. Spine (Phila Pa 1976) 32:113511402007

9

Buerba RAGiles EWebb MLFu MCGvozdyev BGrauer JN: Increased risk of complications after anterior cervical discectomy and fusion in the elderly: an analysis of 6253 patients in the American College of Surgeons National Surgical Quality Improvement Program database. Spine (Phila Pa 1976) 39:206220692014

10

Cenic AKachur E: Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J Neurol Sci 36:1962002009

11

Chin KRPencle FJRCoombs AVBrown MDConklin KJO’Neill AM: Lateral lumbar interbody fusion in ambulatory surgery centers: patient selection and outcome measures compared with an inhospital cohort. Spine (Phila Pa 1976) 41:6866922016

12

Chin KRPencle FJRCoombs AVElsharkawy MPacker CFHothem EA: Clinical outcomes with midline cortical bone trajectory pedicle screws versus traditional pedicle screws in moving lumbar fusions from hospitals to outpatient surgery centers. Clin Spine Surg 30:E791E7972017

13

Chin KRPencle FJRCoombs AVPacker CFHothem EASeale JA: Eligibility of outpatient spine surgery candidates in a single private practice. Clin Spine Surg 30:E1352E13582017

14

Chin KRPencle FJRSeale JAPencle FK: Clinical outcomes of outpatient cervical total disc replacement compared with outpatient anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 42:E567E5742017

15

Debono BSabatier PGarnault VHamel OBousquet PLescure JP: Outpatient lumbar microdiscectomy in France: from an economic imperative to a clinical standard—an observational study of 201 cases. World Neurosurg 106:8918972017

16

Emami AFaloon MIssa KShafa EPourtaheri SSinha K: Minimally invasive transforaminal lumbar interbody fusion in the outpatient setting. Orthopedics 39:e1218e12222016

17

Fu MCGruskay JASamuel AMSheha EDDerman PBIyer S: Outpatient anterior cervical discectomy and fusion is associated with fewer short-term complications in one- and two-level cases: a propensity-adjusted analysis. Spine (Phila Pa 1976) 42:104410492017

18

Garringer SMSasso RC: Safety of anterior cervical discectomy and fusion performed as outpatient surgery. J Spinal Disord Tech 23:4394432010

19

Helseth ØLied BHalvorsen CMEkseth KHelseth E: Outpatient cervical and lumbar spine surgery is feasible and safe: a consecutive single center series of 1449 patients. Neurosurgery 76:7287382015

20

Hersht MMassicotte EMBernstein M: Patient satisfaction with outpatient lumbar microsurgical discectomy: a qualitative study. Can J Surg 50:4454492007

21

Hollenbeck BKDunn RLSuskind AMZhang YHollingsworth JMBirkmeyer JD: Ambulatory surgery centers and outpatient procedure use among Medicare beneficiaries. Med Care 52:9269312014

22

Hudak EMPerry MW: Outpatient minimally invasive spine surgery using endoscopy for the treatment of lumbar spinal stenosis among obese patients. J Orthop 12:1561592015

23

Idowu OABoyajian HHRamos EShi LLLee MJ: Trend of spine surgeries in the outpatient hospital setting versus ambulatory surgical center. Spine (Phila Pa 1976) 42:E1429E14362017

24

Khanna RKim RBLam SKCybulski GRSmith ZADahdaleh NS: comparing short-term complications of inpatient versus outpatient single-level anterior cervical discectomy and fusion: an analysis of 6940 patients using the ACS-NSQIP database. Clin Spine Surg 31:43472018

25

Lang SSChen HIKoch MJKurash LMcGill-Armento KRPalella JM: Development of an outpatient protocol for lumbar discectomy: our institutional experience. World Neurosurg 82:8979012014

26

Lied BRønning PAHalvorsen CMEkseth KHelseth E: Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients. Acta Neurol Scand 127:31372013

27

Lied BSundseth JHelseth E: Immediate (0–6 h), early (6–72 h) and late (>72 h) complications after anterior cervical discectomy with fusion for cervical disc degeneration; discharge six hours after operation is feasible. Acta Neurochir (Wien) 150:1111182008

28

Martin BIDeyo RAMirza SKTurner JAComstock BAHollingworth W: Expenditures and health status among adults with back and neck problems. JAMA 299:6566642008 (Erratum in JAMA)

29

McGirt MJGodil SSAsher ALParker SLDevin CJ: Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. Neurosurg Focus 39(6):E92015

30

Missios SBekelis K: Hospitalization cost after spine surgery in the United States of America. J Clin Neurosci 22:163216372015

31

Mohandas ASumma CWorthington WBLerner JFoley KTBohinski RJ: Best practices for outpatient anterior cervical surgery: results from a Delphi panel. Spine (Phila Pa 1976) 42:E648E6592017

32

Moses H IIIMatheson DHMDorsey ERGeorge BPSadoff DYoshimura S: The anatomy of health care in the United States. JAMA 310:194719632013

33

Nataraj A: Admission and acute complication rate for outpatient lumbar microdiscectomy. Can J Neurol Sci 37:12010

34

Pugely AJMartin CTGao YMendoza-Lattes SA: Outpatient surgery reduces short-term complications in lumbar discectomy: an analysis of 4310 patients from the ACS-NSQIP database. Spine (Phila Pa 1976) 38:2642712013

35

Purger DAPendharkar AVHo ALSussman ESYang LDesai M: Outpatient vs inpatient anterior cervical discectomy and fusion: a population-level analysis of outcomes and cost. Neurosurgery [epub ahead of print]2017

36

Resnick DKTosteson ANAGroman RFGhogawala Z: Setting the equation: establishing value in spine care. Spine (Phila Pa 1976) 39 (22 Suppl 1):S43S502014

37

Sheperd CSYoung WF: Instrumented outpatient anterior cervical discectomy and fusion: is it safe? Int Surg 97:86892012

38

Silvers HRLewis PJSuddaby LSAsch HLClabeaux DEBlumenson LE: Day surgery for cervical microdiscectomy: is it safe and effective? J Spinal Disord 9:2872931996

39

Smith WDWohns RNChristian GRodgers EJRodgers WB: Outpatient minimally invasive lumbar interbody: fusion predictive factors and clinical results. Spine (Phila Pa 1976) 41 (Suppl 8):S106S1222016

40

Stieber JRBrown KDonald GDCohen JD: Anterior cervical decompression and fusion with plate fixation as an outpatient procedure. Spine J 5:5035072005

41

Techy FBenzel EC: Implementing an outpatient ambulatory discectomy protocol at a large academic center: a change for the better. World Neurosurg 83:3413422015

42

Trahan JAbramova MVRichter EOSteck JC: Feasibility of anterior cervical discectomy and fusion as an outpatient procedure. World Neurosurg 75:

43

Villavicencio ATPushchak EBurneikiene SThramann JJ: The safety of instrumented outpatient anterior cervical discectomy and fusion. Spine J 7:1481532007

44

Walid MSRobinson JS IIIRobinson ERMBrannick BBAjjan MRobinson JS Jr: Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection. J Clin Neurosci 17:149714982010

45

Wang MY: Outpatient anterior cervical discectomy and fusion. World Neurosurg 75:442011

46

Wohns R: Safety and cost-effectiveness of outpatient cervical disc arthroplasty. Surg Neurol Int 1:77742010

47

Yen DAlbargi A: Results and limitations of outpatient and overnight stay laminectomies for lumbar spinal stenosis. Can J Surg 60:3293342017

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