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Outpatient Cervical Spine Surgery
TO THE EDITOR: I read with enthusiasm the paper by Tomaras and colleagues (Tomaras CR, Blacklock JB, Parker WD, et al: Outpatient surgical treatment of cervical radiculopathy. J Neurosurg 87; 41-43, July, 1997). The authors have provided further evidence that the ideal surgical approach to cervical radiculopathy is consistent with the growing evolution toward outpatient surgery. Furthermore, the gratifying results of their limited meticulous dissection have been achieved by adhering to the basic principles of this approach. They have been performing the right operation on the right patients. Their surgery has been limited to the single-level nerve root compression and has uniformly given dramatic relief of radicular pain and dysfunction. This series includes only 18 patients with work-related injuries: this population reflects my own experience that approximately 10% of cervical disc herniations are trauma related, and even these have faired quite well. This is particularly refreshing in these days when many patients undergo multiple level anterior discectomy, plating, and fusion for such various complaints as neck pain, vague or shifting upper extremity symptoms, tension headache, or neck strain following motor vehicle or work-related injury. These procedures, including multiple level and bilateral foraminotomy, have been performed on the basis of asymptomatic radiological and imaging abnormalities, enhanced by magnetic resonance imaging in modern times. It may be of some historical interest to note that following a serious fire at the Hartford Hospital approximately 30 years ago, Dr. William Scoville performed his so-called "keyhole" surgery in several outpatients. I am confident he would join me in congratulating these surgeons on a splendid endeavor.
TO THE EDITOR: We were pleased to see the recent article (Tomaras CR, Blacklock JB, Parker WD, et al: Outpatient surgical treatment of cervical radiculopathy. J Neurosurg 87; 41-43, July, 1997) describing the distinct advantages of outpatient as compared with inpatient protocol for cervical radiculopathy. The first publication devoted to ambulatory surgery for radiculopathy was from our neurosurgical group. Our results compared outcomes for inpatients with those for outpatients. Outcomes for our patients were not as successful as those in the Tomaras, et al., study. Specifically we found success rates of 80% for relief of pain, 86% for satisfaction with the results of surgery, and 65% for return to work, compared with their findings of a 93 to 97% success rate in their combined pain-function scoring instrument. While considering possible reasons for this discrepancy, we discerned that most of the differences could be explained by the higher proportion of Workers' Compensation cases in our patient population (46%) than in theirs (9.7%). Nonetheless, differences remain that they may relate to their surgical procedure (posterior approach without fusion) compared with our (modified Cloward's anterior approach with fusion) or to their selected criteria. Unfortunately, their paper does not clearly explain their selection criteria. Thus, only two exclusionary criteria are given in the Methods section: medical conditions requiring inpatient monitoring and patient self-selection of inpatient surgery. Yet this is obfuscated by their discussion statement that "Caution must be exercised when discussing outpatient spine surgery because many patients are not candidates." Does that mean that they culled patients from the 505 original surgical candidates by use of some additional exclusionary criteria? Or did the process of allowing the patient to choose between inpatient and outpatient protocols result in a potent selection of likely successes? That only 40% of the original candidates opted for outpatient surgery contrasts with our experiences (> 90%> and that of others and may suggest an alternative explanation for these discrepancies. In addition, we are impressed by the brief time they report was required for successful return to work: 20 days average for noncompensation and 53 days for compensation cases, whereas we found an average of 97 days for all patients. In fact, only 13% of our patients were successfully at work within 28 days. These are important confounding factors that we would appreciate having clarified by the authors, if possible, and which call for further study.
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RESPONSE:
Dr. Fager's comments are appreciated. We believe that this posterior, limited approach is appropriate for many patients with cervical radiculopathy. We are also enthusiastic about its application in the outpatient setting and we believe our ariticle supports that concept. The comments by Dr. Lewis and his colleagues are certainly also appreciated. We believe that their publication of a review of 53 patients who underwent outpatient cervical discectomy and fusion is a significant contribution to our understanding of the appropriate application of outpatient surgery in our speciality. There are differences in the outcomes in their group of patients and ours and we believe that these differences are easily explained. The high percentage of Workers' Compensation cases in their series (46%) and the lower percentage in our series (9.7%) is an obvious cause for major differences between the two groups. It is not likely that one can actually sort out to what extent this plays a rolem but we believe it is probably the single largest factor in the differing outcomes. It is possible that the anterior procedure with an allograft does not provide such an immediate relief of radiculopathy as a foraminotomy, and this may account for some differences in short-term outcome and the time back to work. A further possibility is that the candidates for the anterior procedure performed by this group may have had a differing disease, as all of our patients undergoing the posterior foraminotomy had lateral ruptures or bone impingement at the level of the foramen. Regarding the selection of the patients for outpatient procedures, it can truthfully be stated that we were not aggressive in recruiting patients in the early phases of each of the three surgeons' experiences in the outpatient setting. As time passed during the period of observation described in our article the individual surgeons undoubtedly became more effective recruiters of patients willing to undergo this surgery as outpatients. In other words, initially only our "best" patients undetwent the outpatient procedures. Now, just about all are done in an outpatient setting. In their article, Lewis and colleagues demonstrate a cost savings by performing cervical spine surgery in the outpatient setting. It has been our experience that a foraminotomy provides an even greater cost savings compared with an anterior procedure with fusion. Our exclusion criteria were limited to medical conditions requiring inpatient monitoring and patient self-selection. It would be a fair observation to state that patient self-selection may create a group of individuals who are more motivated to have a good outcome. This may also be a contributing factor to the difference in the outcome between Dr. Lewis' group and our group. Our statement advocating caution when discussing outpatient outpatient surgery was intended as a general statement to emphasize that we do not suggest that all patients are candidates for outpatient surgery. We did not use other exlusionary criteria. It is very difficult to compare the results of these two series for the reasons discussed here by Dr. Lewis and his colleagues and in our reply. We hope that the fundamental point of both our articles is not overlooked by the members of our specialty - that these procedures can be safely performed in the outpatient setting. Case selection, the appropriate operation for each patient, and the appropriate setting for the performance of that operation must continue to be issues of clinical judgement. We believe that both of these articles demonstrate that cervical spine surgery can be performed successfully and safely in the outpatient setting. In our opinion this is the common ground of the two articles and represents the most important point for all of us.
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