Is Outpatient Anterior Lumbar Fusion (ALIF) Safe? An Analysis of 30-day Outcomes

Anterior lumbar discectomy and fusion: an effective technique in treating lumbar disc herniation-- a retrospective case study

OBJECTIVE

Lumbar disc herniation is a syndrome triggered by degenerative changes in the intervertebral disc. Based on the technique of ALIF, combining the concept of Anterior Cervical Discectomy and Fusion (ACDF), we summarized Anterior Lumbar Discectomy Fusion (ALDF) in our previous clinical experience. This study is to explore the clinical efficacy and safety of this method for treating lumbar disc herniation.

METHOD

We retrospectively analyzed the medical records of 44 patients with L5/S1 lumbar disc herniation treated in the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, from December 2020 to April 2023. The Japan orthopaedic association (JOA) scoring system, Oswestry disability index (ODI), and Numerical rating scale (NRS, to evaluate pain) were used to assess patients' clinical symptoms before and after surgery. Radiographic examinations, including X-ray, CT, and MRI, were performed to record preoperative and postoperative imaging indicators, such as surgical segment, intervertebral disc height, and dural sac cross-sectional area. Postoperative follow-up records noted the time of bony fusion and postoperative complications.

RESULTS

All 44 patients successfully completed the ALDF operation. No vascular, ureteral, or abdominal organ damage occurred during the operation. All patients' symptoms were alleviated. Postoperative CT scans revealed a significant improvement in intervertebral disc height (7.32 ± 2.07 mm vs. 12.15 ± 1.79 mm, p < 0.05). Postoperative MRI scans showed a significant increase in the cross-sectional area of the dural sac (0.95 ± 0.33cm2 vs. 1.30 ± 0.37cm2, p < 0.05). X-ray re-examination 6 months after surgery showed bony fusion in all operated segments. 12 months postoperatively, the average JOA was 25.57 ± 2.29, ODI was 4.45 ± 3.43%, and NRS was 1.43 ± 1.13, all significantly improved compared to preoperative levels, p < 0.05. There were no complications such as implant failure, cage subsidence, or wound infection.

CONCLUSION

ALDF provides an effective treatment strategy for patients with lumbar disc herniation. This procedure allows direct removal of protruding discs and calcified posterior longitudinal ligaments under the microscope, achieving the goal of direct decompression of the surgical segment. At the same time, it can reduce the damage to posterior muscles and skeletal structures caused by surgery. Comprehensive preoperative assessment and meticulous microscopic operation can help avoid complications such as nerve and vascular injuries.

Growing utilization of ambulatory spine surgery in Medicare patients from 2010-2021

Background

There is growing interest in transitioning various surgical procedures to the outpatient care setting. However, for Medicare patients, the site of service for surgical procedures is influenced by regulations within the Inpatient and Outpatient Prospective Payment Systems. The purpose of this study is to quantify changes in utilization of outpatient spine surgery within the Medicare population, as well as to determine changes in outpatient volume after removal of a procedure from the "inpatient-only" list.

Methods

This is a cross-sectional study of Medicare billing database information for selected spine procedures included in the Medicare Physician/Supplier Procedure Summary (PSPS) public use files from 2010-2021. These files include aggregated data from Medicare Part B fee-for-service claims, published yearly. Procedures from Healthcare Common Procedural Coding System (HCPCS) code ranges 22010-22899 and 62380-63103 were selected for analysis, limited to surgical services delivered in the inpatient, hospital outpatient department (HOPD), and ambulatory surgical center (ASC) settings. For each HCPCS code included, estimates of the total number of services and corresponding changes in volume were calculated.

Results

Within the range of codes included in the study, the total number of outpatient spine procedures rose approximately 193% from 2010 to 2021, with compound annual growth rate (CAGR) for outpatient procedures per year of 9.9% for HOPDs and 15.7% for ASCs (-2.2% for inpatient procedures). Within this period, the ASC list grew from 12 procedures to 58 procedures. In 2021, the highest volume ASC procedure was HCPCS 63047, at approximately 4970 procedures.

Conclusions

This study demonstrates a trend of increasing utilization of HOPDs and ASCs for spine procedures among Medicare beneficiaries from 2010 to 2021. Though HOPDs are currently more widely utilized, the ongoing additions of spine procedures to the ASC covered procedures list may shift this balance.

Comparison of the Safety of Inpatient Versus Outpatient Lumbar Fusion : A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The objective of this study is to synthesize the early data regarding and analyze the safety profile of outpatient lumbar fusion.

SUMMARY OF BACKGROUND DATA

Performing lumbar fusion in an outpatient or ambulatory setting is becoming an increasingly employed strategy to provide effective value-based care. As this is an emerging option for surgeons to employ in their practices, the data is still in its infancy.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that described outcomes of inpatient and outpatient lumbar fusion cohorts were searched from PubMed, Medline, The Cochrane Library, and Embase. Rates of individual medical and surgical complications, readmission, and reoperation were collected when applicable. Patient-reported outcomes (PROMs) were additionally collected if reported. Individual pooled comparative meta-analysis was performed for outcomes of medical complications, surgical complications, readmission, and reoperation. PROMs were reviewed and qualitatively reported.

RESULTS

The search yielded 14 publications that compared outpatient and inpatient cohorts with a total of 75,627 patients. Odds of readmission demonstrated no significant difference between outpatient and inpatient cohorts [OR=0.94 (0.81-1.11)]. Revision surgery similarly was no different between the cohorts [OR=0.81 (0.57-1.15)]. Pooled medical and surgical complications demonstrated significantly decreased odds for outpatient cohorts compared with inpatient cohorts [OR=0.58 (0.34-0.50), OR=0.41 (0.50-0.68), respectively]. PROM measures were largely the same between the cohorts when reported, with few studies showing better ODI and VAS Leg outcomes among outpatient cohorts compared with inpatient cohorts.

CONCLUSION

Preliminary data regarding the safety of outpatient lumbar fusion demonstrates a favorable safety profile in appropriately selected patients, with PROMs remaining comparable in this setting. There is no data in the form of prospective and randomized trials which is necessary to definitively change practice.