Introduction: We conducted a retrospective cohort analysis of early outcomes after elective anterior cervical discectomy and fusion (ACDF) versus cervical artificial disc replacement (C-ADR) using the National Surgical Quality Improvement Program database. Risk factors associated with operation time, hospital length of stay, early complications and discharge destination were studied.
Methods: Adult patients undergoing elective ACDF or C-ADR were abstracted from American College of Surgeons National Surgical Quality Improvement Program years 2011-2014. Univariate analyses were performed by surgery cohort for each outcome, and corrected for demographic/clinical variables (age=65, sex, race, BMI, ASA score, functional status, inpatient/outpatient status, smoking, hypertension, Charlson Comorbidity Index) using multivariable regression. Means, standard errors, odds ratios (OR) and 95% confidence intervals (CI) are reported. Significance was assessed at p<0.05.
Results: Of 18,067 subjects (ACDF=17,296, C-ADR=771), C-ADR subjects were on average younger (<65-years: 97.4% vs. 84.2%; p<0.001), less obese (non-obese: 6.10% vs. 49.1%; p<0.001), less physically burdened (ASA 1: 13.1% vs. 4.3%; ASA 3-4: 17.9% vs. 38.3%; p<0.001), less functionally dependent (0.5% vs. 2.2%; p<0.001), and presented with fewer overall comorbidities (3.9% vs. 6.4%; p<0.001). Overall, 31 (0.17%) patients died. Univariate analyses showed C-ADR had shorter operation time (111.27±1.89-minutes vs. 125.59±0.53-minutes; p<0.001), shorter HLOS (1.06±0.03-days vs. 1.64±0.04-days; p=0.003), and higher likelihood of being discharged to home (99.5% vs. 96.9%, p<0.001). Multivariable analysis confirmed C-ADR association with shorter operation time (B= -9.37, 95% CI [-14.34, -4.01]) and with greater likelihood of returning home (OR 2.74 [1.01, 7.41]), while a nonsignificant statistical trend was demonstrated for HLOS (B= -0.35 [-0.73, 0.03]). Incidences of early complications did not differ between C-ADR and ACDF (1.4% vs. 2.5%, p=0.620).
Conclusions: Patients selected for elective C-ADR demonstrate lower comorbidity profiles than ACDF. Compared to ACDF, C-ADR is associated with decreased operative times and increased likelihood of being discharged home. Future studies are needed to confirm these findings.
Patient Care: The incidence of cervical spine disease in patients over 65 is 95% for males and 75% for females. Few studies have characterized outcomes, optimal indications or risk profiles between elective ACDF or C-ADR in this population. Our study is the first to characterize the presentation and predictors of early outcomes, including discharge destination, across these two surgical cohorts. As such it will inform prudent surgical decision making.
Learning Objectives: By the conclusion of this presentation, participants should be able to:
1) Describe the differences between patient populations receiving ACDF and C-ADR.
2) Identify with greater precision the risks and benefits associated with ACDF and C-ADR in treatment of cervical spine degeneration.
3) Discuss evidence for potential broadening of the indications for C-ADR treatment.