Preoperative disability is independently associated with postoperative care intensity following anterior cervical discectomy and fusion.

PURPOSE: Postoperative outcomes following anterior cervical discectomy and fusion (ACDF) are traditionally assessed using complications or long-term patient-reported outcomes (PROMs). However, determinants of immediate postoperative recovery and in-hospital resource utilization remain less well defined. This is particularly relevant with the increasing adoption of outpatient ACDF pathways, where accurate preoperative risk stratification is critical. The objective of this study was to evaluate whether preoperative PROMs are associated with postoperative care intensity following ACDF, in addition to established surgical factors.

METHODS: We performed a retrospective analysis of a prospectively collected cohort of patients undergoing ACDF for degenerative pathology. Both primary and revision ACDF procedures were eligible, while hybrid constructs, posterior procedures, cervical disc arthroplasty, and other non-ACDF operations were excluded. A composite postoperative care intensity score (0-3) was defined as the primary outcome, reflecting in-hospital recovery burden based on: (1) prolonged length of stay (LOS ≥ 2 days), (2) delayed extubation, and (3) stepdown/orthopedic special care unit (OSCU) admission. A sensitivity analysis used a stricter LOS definition (≥ 3 days). Multivariable Poisson regression was used to evaluate associations between preoperative variables, including Neck Disability Index (NDI), expectations score, PHQ-8, and postoperative care intensity, adjusting for age, operative duration, revision status, and number of levels fused.

RESULTS: Of 333 patients, 299 were included in the multivariable analysis. Increasing number of fused levels was independently associated with greater postoperative care intensity (incidence rate ratio [IRR] 1.54 per level, p < 0.001). Higher preoperative disability (NDI) was independently associated with increased care intensity (IRR 1.11 per 10 points, p = 0.018). Age was also independently associated with increased care intensity (IRR 1.20 per 10 years, p = 0.011). Operative duration, revision status, patient expectations, and PHQ-8 scores were not significantly associated with the outcome. In sensitivity analysis (LOS ≥ 3 days), number of fused levels (IRR 1.88, p < 0.001), age (IRR 1.37 per 10 years, p = 0.002), operative duration (IRR 1.06 per 30 min, p = 0.042), and NDI (IRR 1.13 per 10 points, p = 0.041) remained significant.

CONCLUSION: While surgical complexity was consistently associated with postoperative care needs following ACDF, preoperative disability was independently associated with increased postoperative care intensity, even after accounting for operative factors. In contrast, patient expectations and depressive symptoms were not associated with early postoperative resource utilization. These findings suggest that immediate postoperative recovery is influenced by baseline functional status in addition to surgical factors. Baseline disability may therefore provide incremental information for perioperative assessment and could serve as an additional factor to help refine patient selection for outpatient versus inpatient ACDF pathways.