The Safety of Instrumented Outpatient Anterior Cervical Discectomy and Fusion

Background Context: Reported hospitalization times after an anterior cervical discectomy and fusion (ACDF) procedure range between 20 hours to 4 days. Reasons for this wide variation are manifold, but the safety of an instrumented ACDF in the setting of a hostile medical-legal climate is most likely the primary concern influencing such a discrepancy.

Purpose: The purpose of this study was to evaluate the safety and feasibility of performing single, two- and three-level ACDF with instrumentation on an outpatient or 23-hour observation period basis in order to potentially diminish the additional cost of hardware without compromising the purported benefits of surgery.

Study Design/setting: A retrospective chart review of patients undergoing instrumented ACDF on an outpatient basis was performed.

Patient Sample: A total of 103 patients with neck pain and/or radiculopathy undergoing ACDF were enrolled into this study.

Outcome Measures: Included the evaluation of intraoperative and perioperative complications, which were reported for a total of 6 months after surgery. Clinical examination and radiographical assessment, including plain radiographs and computed tomography and magnetic resonance imaging (when required), were performed to assess complications.

Methods: Complications were divided into two groups: major and minor. Major complications included vertebral fracture and dehydration resulting in readmission. Minor complications included allergic reactions to medications that did not require hospitalization, and transient (< or = 3 months) neurologic deficit. A comprehensive literature search and meta-analysis was performed to generate a large comparison group in order to compare the complication rates in our outpatient series to those reported in the literature.

Results: A total of 99 patients (96.1%) undergoing single and two-level ACDF were discharged less than 15 hours after their surgeries (median time: 8 hours; range: 2-15 hours), and 4 patients (3.9%) were discharged after a 23-hour observation period following three-level ACDF. The overall complication rate in our outpatient series was 3.8% (n=4), including 1.9% (n=2) major and 1.9% (n=2) minor complications. The overall complication rate in the 633 patient meta-analysis derived comparison group was 0.95% (n=6). The difference between overall complication rates was not found to be significantly different (p = .12). The hardware-related complication rate in the meta-analysis comparison group was 0.5% (n=3), and was not found to be significantly different from our rate of 0% (p < or = 1).

Conclusion: Performing ACDF with instrumentation on an outpatient basis is feasible, and it is not associated with higher overall or hardware-related complication rates as compared with complication rates reported in the literature, suggesting that this procedure is safe to perform on an outpatient basis.