Best Practices for Outpatient Anterior Cervical Surgery: Results From a Delphi Panel.

STUDY DESIGN: Delphi Panel expert panel consensus and narrative literature review. OBJECTIVE: To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)). SUMMARY OF BACKGROUND DATA: Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings are lacking. METHODS: A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Predetermined consensus was set at 70% for each best-practice statement. RESULTS: A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and subcategories) achieved consensus, including preoperative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6). CONCLUSION: This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment. LEVEL OF EVIDENCE: 4.

Outpatient Minimally Invasive Lumbar Interbody: Fusion Predictive Factors and Clinical Results.

STUDY DESIGN: Retrospective review of data from a prospective patient outcomes registry. OBJECTIVE: The object of this work was to examine patient and surgical predictors of early postoperative discharge and test the predictive model against two clinical series of outpatient minimally invasive lumbar fusion patients. SUMMARY OF BACKGROUND DATA: Outpatient and ambulatory surgery centers are regularly utilized for procedures with low-risk profiles and minimal need for extended postoperative observation, but little has been reported in lumbar spinal fusion producers. METHODS: Two analyses were undertaken, an examination of patient characteristics to determine predictors of early (<24 hours) postoperative discharge and then clinical examinations of patients treated with lumbar fusion at an ambulatory surgery center. For the predictive arm of the study, 1033 patients treated with minimally invasive (MIS) lateral interbody fusion (XLIF) were grouped according to length of postoperative hospitalization with 873 patients discharged <24 hours (outpatients), and 160 discharged >23 hours after surgery (inpatients). For the clinical studies, 54 consecutive XLIF and 18 consecutive MIS posterior fusion patients were treated at an ambulatory surgery center with demographic, treatment, and complication data collected. RESULTS: From the predictive study, the strongest baseline predictors of early postoperative discharge were a less advanced diagnosis (non-deformity), younger age, elevated baseline hemoglobin levels, and lower body mass index. The most predictive treatment variables that predicted early postoperative discharge were fewer number of levels treated and elevated postoperative hemoglobin levels.In the clinical series, outpatient surgeries were performed in younger patients (50.6 and 53.2 yr), at relatively few levels (96% of cases were at one or two levels), for simple degenerative disease. No intraoperative and few postoperatives complications were seen in either XLIF or MIS posterior fusions performed in ambulatory settings with no emergent transfers to inpatient facilities. CONCLUSION: Select patients, by health and indication, can safely be treated as outpatients with XLIF or other modern MIS approaches. Being younger, having elevated preoperative hemoglobin levels, fewer levels being treated, for less advanced disease may predict early postoperative discharge. LEVEL OF EVIDENCE: 3.

What is a "fair salary" for a surgical subspecialist?

The author presents a net present model by which a "fair salary" for surgical subspecialists is justified. Neurosurgical practitioners are used as an example, based on assumed fair salary for family physicians.