Introduction: In this era of comparative effectiveness and quality improvement, attention has been recently drawn to outcomes and safety of anterior versus posterior approaches for cervical spine surgery. Single institution studies suggest that posterior approach might be associated with greater morbidity. However, these findings are yet to be validated in a multicenter analysis. Therefore, we analyzed a prospective quality improvement registry(National Surgical Quality Improvement Program-NSQIP) to determine if there is a difference in surgical safety between the two approaches.
Methods: Patients undergoing cervical surgery(2005-2011) were identified based on the primary CPT codes from the NSQIP database. Patients were divided into two cohorts based on surgical approach and, peri-operative outcomes and 30-day morbidity was compared. Propensity score matching and multivariate logistic regression analysis was used to adjust for confounding factors and identify predictors of morbidity.
Results: A total of 9,698 cervical surgery cases were identified(Anterior approach=7288,Posterior Approach=2410). Unadjusted overall length of stay, rates of major morbidity and return to OR within 30 days were significantly higher in posterior approach vs. anterior,Table 1. A total of 2,783 cases(Anterior approach=1182,Posterior Approach=1601) were propensity matched based on 32 covariates,Table 2. After propensity matching, length of hospital stay, rates of major morbidity and return to OR were still higher in posterior approach,Table 1. Adjusted comparison using multivariate logistic regression demonstrated same results: patients in posterior approach had 1.5 times higher odds of having a major morbidity and 1.7 times higher odds of return to OR within 30 days.
Conclusions: In a nation-wide quality improvement registry representing more than 250 hospitals, anterior approach for cervical surgery was associated with significantly lower length of stay, surgical morbidity and return to OR. For patients who can be effectively treated by either anterior or posterior approach, giving preference to anterior approach may offer the opportunity for quality improvement and greater patient safety.
Patient Care: Our research highlights that for patients who can be effectively treated by either anterior or posterior approach, giving preference to anterior approach may offer the opportunity for quality improvement and greater patient safety.
Learning Objectives: At the end of the session, participants should be able to: 1) Understand the differences in perioperative outcomes and surgical morbidity between anterior vs posterior approach for cervical surgery; 2) Identify that anterior approach is associated with improved surgical safety.