Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting

ABSTRACT Background: Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol. Methods: A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered. Results: A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day. Conclusion: In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting. Level of Evidence: 3. Clinical Relevance: Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

[1]  E. Delsole,et al.  Current trends in ambulatory spine surgery: a systematic review. , 2019, Journal of spine surgery.

[2]  M. Fu,et al.  Incidence, Risk Factors, and Clinical Implications of Postoperative Hematoma Requiring Reoperation Following Anterior Cervical Discectomy and Fusion , 2019, Spine.

[3]  Kern Singh,et al.  Comparison of Multilevel Anterior Cervical Discectomy and Fusion Performed in an Inpatient Versus Outpatient Setting , 2019, Global spine journal.

[4]  S. Hohmann,et al.  Does patient selection account for the perceived cost savings in outpatient spine surgery? A meta-analysis of current evidence and analysis from an administrative database. , 2018, Journal of neurosurgery. Spine.

[5]  S. Jeon,et al.  Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery , 2018, Journal of Korean medical science.

[6]  W. Xu,et al.  Risk Factors for Dysphagia After Anterior Cervical Spine Surgery. , 2017, Orthopedics.

[7]  K. Chin,et al.  Eligibility of Outpatient Spine Surgery Candidates in a Single Private Practice , 2017, Clinical spine surgery.

[8]  M. Fu,et al.  Outpatient Anterior Cervical Discectomy and Fusion is Associated With Fewer Short-term Complications in One- and Two-level Cases: A Propensity-adjusted Analysis , 2017, Spine.

[9]  K. Foley,et al.  Best Practices for Outpatient Anterior Cervical Surgery: Results From a Delphi Panel , 2017, Spine.

[10]  A. Vaccaro,et al.  The Role of Multimodal Analgesia in Spine Surgery. , 2017, The Journal of the American Academy of Orthopaedic Surgeons.

[11]  R. Urman,et al.  Techniques to Optimize Multimodal Analgesia in Ambulatory Surgery , 2017, Current Pain and Headache Reports.

[12]  N. Dahdaleh,et al.  Evaluation of American Society of Anesthesiologists classification as 30-day morbidity predictor after single-level elective anterior cervical discectomy and fusion. , 2017, The spine journal : official journal of the North American Spine Society.

[13]  W. Ding,et al.  Risk factors for dysphagia after anterior cervical spine surgery , 2017, Medicine.

[14]  Peter D. Fabricant,et al.  Cost Savings From Utilization of an Ambulatory Surgery Center for Orthopaedic Day Surgery , 2016, The Journal of the American Academy of Orthopaedic Surgeons.

[15]  S. McClelland,et al.  Outpatient anterior cervical discectomy and fusion: A meta-analysis , 2016, Journal of Clinical Neuroscience.

[16]  S. Shaikh,et al.  Postoperative nausea and vomiting: A simple yet complex problem , 2016, Anesthesia, essays and researches.

[17]  U. Werneke,et al.  Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases , 2016, BMC Neurology.

[18]  M. McGirt,et al.  Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases. , 2016, Journal of neurosurgery. Spine.

[19]  T. Ganley,et al.  Do Surgical Times and Efficiency Differ Between Inpatient and Ambulatory Surgery Centers That are Both Hospital Owned? , 2016, Journal of pediatric orthopedics.

[20]  D. Larson,et al.  Thromboembolic Disease after Cervical Spine Surgery: A Review of 5,405 Surgical Procedures and Matched Cohort Analysis , 2015, Global spine journal.

[21]  M. McGirt,et al.  Effect of obesity on cost per quality-adjusted life years gained following anterior cervical discectomy and fusion in elective degenerative pathology. , 2015, The spine journal : official journal of the North American Spine Society.

[22]  M. McGirt,et al.  Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database. , 2015, Neurosurgical focus.

[23]  James D. Kang,et al.  The Revision Rate and Occurrence of Adjacent Segment Disease After Anterior Cervical Discectomy and Fusion: A Study of 672 Consecutive Patients , 2014, Spine.

[24]  M. Fu,et al.  Anterior and posterior cervical fusion in patients with high body mass index are not associated with greater complications. , 2014, The spine journal : official journal of the North American Spine Society.

[25]  D. Avery,et al.  The efficiency of a dedicated staff on operating room turnover time in hand surgery. , 2014, The Journal of hand surgery.

[26]  Š. Alušík,et al.  Serotonin syndrome. , 2014, Neuro endocrinology letters.

[27]  A. Shanks,et al.  Patient Selection for Day Case-eligible Surgery: Identifying Those at High Risk for Major Complications , 2013, Anesthesiology.

[28]  J. Xerogeanes,et al.  Surgical site infection: A comparison of multispecialty and single specialty outpatient facilities. , 2013, Journal of orthopaedics.

[29]  Wael K Barsoum,et al.  Dedicated orthopedic operating room unit improves operating room efficiency. , 2013, The Journal of arthroplasty.

[30]  A. Pugely,et al.  Outpatient Surgery Reduces Short-Term Complications in Lumbar Discectomy: An Analysis of 4310 Patients From the ACS-NSQIP Database , 2013, Spine.

[31]  A. Rabinstein,et al.  Serotonin Syndrome in the Intensive Care Unit: Clinical Presentations and Precipitating Medications , 2013, Neurocritical Care.

[32]  M. Boakye,et al.  Morbid Obesity Increases Cost and Complication Rates in Spinal Arthrodesis , 2012, Spine.

[33]  A. Buvanendran,et al.  Preoperative and Postoperative Anesthetic and Analgesic Techniques for Minimally Invasive Surgery of the Spine , 2010, Spine.

[34]  R. Sasso,et al.  Safety of Anterior Cervical Discectomy and Fusion Performed as Outpatient Surgery , 2010, Journal of spinal disorders & techniques.

[35]  Jean M. Mitchell,et al.  Effect of physician ownership of specialty hospitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery. , 2010, Archives of surgery.

[36]  C. Nunes,et al.  Patient satisfaction following day surgery. , 2009, Journal of clinical anesthesia.

[37]  Jean M. Mitchell.  Do Financial Incentives Linked to Ownership of Specialty Hospitals Affect Physicians’ Practice Patterns? , 2008, Medical care.

[38]  E. Helseth,et al.  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 , 2008, Acta Neurochirurgica.

[39]  A. McGee,et al.  Outpatient anterior cervical discectomy and fusion. , 2007, American journal of orthopedics.

[40]  D. Anderson,et al.  The effect of nonsteroidal anti-inflammatory agents on spinal fusion. , 2005, Orthopedics.