Debuting in 1550 BC in Ancient Egypt and honed in modern medical settings in the 1970s ¹, spinal surgery is critical to a number of ailments, spanning lumbar decompression for spinal stenosis to lumbar discectomy, herniated disc surgery, and spinal fusion surgery. As a result of the decreased invasiveness of surgery, patients’ preference to recover at home, and significant cost reductions, spine surgery has been slowly shifting out of the inpatient setting and into ambulatory surgery centers ^2,3.

Ambulatory spine surgery is associated with many benefits for patients, healthcare systems, and society as a whole. First, even considering the fact that only healthier patients are selected for ambulatory surgical options, ambulatory spine surgery results in significant cost savings for both patients and healthcare systems, as payments in ambulatory centers are generally 50-60% lower than those in hospital outpatient departments ⁴. Second, despite similar pain outcomes, patients end up being postoperatively administered far fewer long-term opioid medications in an ambulatory setting than following a hospital-based surgery, the latter which has been reproducibly associated with greater average doses of morphine, fentanyl and oxycodone ^5,6 – of pressing relevance in the context of the current opioid epidemic. Third, many recent studies have demonstrated that ambulatory spine surgeries are safe and useful while yielding positive clinical outcomes. A recent study, for example, highlighted ample evidence of both the safety and effectiveness of outpatient cervical and lumbar surgery ⁷. Safety and efficacy were further confirmed by studies demonstrating significantly reduced levels of pain and disability following spinal surgeries conducted in ambulatory settings ⁸. Finally, in general, a slew of studies have revealed lower rates of complications, reoperations, and mortality among patients operated on in ambulatory settings ^9,10.

However, the shift of spinal surgery to ambulatory settings must be performed with a number of key considerations in mind and is not devoid of complications and side effects. A number of best practices have been developed to guide clinicians with the postoperative management of patients following ambulatory spinal surgery to this end. These guide, for example, the selection of patients based on an appropriate surgical load, administration of anesthesia, as well as the implementation of a period of postoperative observation, mobilization in the recovery room, and a postoperative checklist ¹¹. American Society of Anesthesiologists (ASA) guidelines have also been established to incorporate comorbidities and independent risk factors linked to complications in order to best predict individual patients’ risks for such surgeries ¹².

Despite the best of guidelines, ambulatory spine surgery is still associated with a number of complications. A recent literature review revealed a number of complications, the most common being urological (0.8%) and the rarest pulmonary (0.05%) ¹³. Overall however, case reports vary significantly with regard to the type and rate of complications reported, and adverse side effects remain rare overall. In addition, considering value as quality over cost, it is clear that ambulatory spine surgery remains of tremendous clinical and social value.

Complication profiles of ambulatory spine surgery are critical for surgeons to counsel patients on their most realistic expectations. Indeed, while ambulatory spine surgery has many financial and logistical benefits, patients should be thoroughly selected and postoperative protocols should be established in order to guarantee a safe perioperative experience; further research is warranted to this end as well.

References

1. Knoeller SM, Seifriend C. History of Spinal Surgery. https://journals.lww.com/spinejournal/Abstract/2000/11010/Historical_Perspective__History_of_Spinal_Surgery_.20.aspx.
2. Fabricant PD, Seeley MA, Rozell JC, et al. Cost savings from utilization of an ambulatory surgery center for orthopaedic day surgery. J Am Acad Orthop Surg. 2016. doi:10.5435/JAAOS-D-15-00751
3. DelSole EM, Makanji HS, Kurd MF. Current trends in ambulatory spine surgery: a systematic review. J Spine Surg. 2019. doi:10.21037/jss.2019.04.12
4. Kurd MF, Schroeder GD, Vaccaro AR. Spine surgery in an ambulatory setting: What can be done safely? JBJS Rev. 2015. doi:10.2106/JBJS.RVW.N.00093
5. Massel DH, Narain AS, Hijji FY, et al. A comparison of narcotic consumption between hospital and ambulatory-based surgery centers following anterior cervical discectomy and fusion. Int J Spine Surg. 2018. doi:10.14444/5075
6. Hirsch BP, Khechen B, Patel D V., Cardinal KL, Guntin JA, Singh K. Safety and Efficacy of Revision Minimally Invasive Lumbar Decompression in the Ambulatory Setting. Spine (Phila Pa 1976). 2019. doi:10.1097/BRS.0000000000002881
7. Sivaganesan A, Hirsch B, Phillips FM, McGirt MJ. Spine surgery in the ambulatory surgery center setting: Value-based advancement or safety liability? Clin Neurosurg. 2018. doi:10.1093/neuros/nyy057
8. Chin KR, Coombs A V., Seale JA. Feasibility and patient-reported outcomes after outpatient single-level instrumented posterior lumbar interbody fusion in a surgery center: Preliminary results in 16 patients. Spine (Phila Pa 1976). 2015. doi:10.1097/BRS.0000000000000604
9. Khanna R, Kim RB, Lam SK, Cybulski GR, Smith ZA, Dahdaleh 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. 2018.
10. McGirt MJ, Godil SS, Asher AL, Parker SL, Devin 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. 2015. doi:10.3171/2015.9.FOCUS15335
11. Helseth Ø, Lied B, Halvorsen CM, Ekseth K, Helseth E. Outpatient cervical and lumbar spine surgery is feasible and safe: A consecutive single center series of 1449 patients. Neurosurgery. 2015. doi:10.1227/NEU.0000000000000746
12. Gerling MC, Hale SD, White-Dzuro C, et al. Ambulatory spine surgery. J Spine Surg. 2019. doi:10.21037/jss.2019.09.19
13. Hrynewycz N, Brundage T, Jenkins N, Parrish J, Singh K. 49. A systematic review of spine surgery complications in the ambulatory surgical center setting. Spine J. 2020. doi:10.1016/j.spinee.2020.05.152