Ambulatory care may be noninferior to hospitalization for spinal fusion surgery

Kris Radcliff, MD

The authors should be congratulated for conducting a well-designed, prospective study in the field of spine surgery, a rare accomplishment in this area of research. However, the clinical outcome measures used in the study raise some questions.

The resolution of neck and arm pain is highly dependent on the baseline severity of these symptoms, as well as the adequacy of the decompression and the likelihood of a successful fusion. By 6 months post-surgery, patients are likely to report successful outcomes regardless of the surgical setting. Therefore, a 6-month outcome endpoint is not clinically meaningful to the study question.

It would have been more informative to assess patient-reported outcomes at earlier time points, such as 1, 2 or 5 days post-surgery, to better capture the potential benefits of ambulatory surgery, including improved patient experience and reduced risk of certain complications. Cost should have also been captured.

The true benefits of ambulatory surgery lie in improved OR efficiency, enhanced patient experience and reduced rates of surgical site infections. In ASCs, the entire team is focused on the next steps, including discharge and patient safety, which may not always be the case in hospital settings due to staff turnover and shift changes. ASCs offer the advantage of a consistent team, with the surgeon having a direct role in selecting staff members. This leads to a more knowledgeable and efficient team that is less likely to waste resources or encounter issues with equipment availability. In contrast, hospitals often face staffing challenges that result in a chronic lack of consistency and familiarity among team members.

The authors could have also strengthened their study by providing more detail on the anesthesia protocol used. Postoperative nausea and vomiting in the ambulatory group requiring hospitalization suggest an enhanced recovery after surgery (ERAS) protocol may not have been followed. The use of tranexamic acid, which can significantly reduce postoperative oozing and bleeding, is another factor that should have been addressed in the study.

While the noninferiority language used in the study may not be the most encouraging, it is important to recognize that ASCs offer several advantages over hospital settings. These include improved efficiency, reduced costs and the potential for better patient outcomes. Further research should focus on cost, optimizing anesthesia protocols, incorporating ERAS principles and assessing patient-reported outcomes at earlier time points to fully understand the benefits of ambulatory spine surgery.