Standardized Preoperative Clearance for Elective Spine Surgery Using a Pre-Assessment Surgical Screening Clinic: A Retrospective Cohort Study

Elective spine surgery carries meaningful perioperative risk, highlighting the potential value of standardized preoperative optimization pathways. Traditional primary care physician (PCP) clearance can be limited by access barriers and variable workflows, whereas dedicated, anesthesia-led pre-assessment surgical screening (PASS) clinics offer a standardized pathway for preoperative evaluation and optimization. To compare surgical cancellation rates and postoperative outcomes among elective spine surgery patients evaluated preoperatively through a PASS clinic versus a PCP. Single institution, retrospective cohort study using a prospectively maintained institutional database. Adults aged 18-89 who underwent elective cervical, thoracic, lumbar, or sacral fusion, decompression, discectomy, or arthroplasty after preoperative clearance through either a PCP or the PASS clinic between July 2020 and December 2024 were included. Patients were excluded if they obtained clearance outside of a PCP or the PASS clinic, or their surgery was performed for fracture, infection, or another emergent indication. Primary outcomes were (1) preoperative surgical cancellations and (2) 90-day pooled complications. Secondary outcomes included discharge disposition, readmissions, ED visits, return to operating room (RTOR), intensive care unit (ICU) transfer, length of stay (LOS), operative time, intraoperative blood transfusions, and pain/opioid outcomes. Surgical cancellations were assessed across all scheduled elective spine surgery cases during the study period. A cancellation event was defined as a scheduled elective spine surgery that did not proceed as planned on the initially assigned operative date. As such, cancellations were analyzed at the scheduled-case level. All cancelled scheduled cases identified during the study period were included, without restriction to a specific interval before the operative date. Cancellations, which were based on the primary documented reason in the medical record, were reviewed and assigned to prespecified categories using a standardized classification framework. Multivariable logistic and linear regression analyses were performed to compare risk-adjusted postoperative outcomes between pathways. A matched-cohort sensitivity analysis was also performed using direct covariate matching, with exact matching on surgeon, sex, smoking status, surgery type, and spinal region. A total of 4,320 scheduled elective spine surgery cases met inclusion criteria, including 644 PASS and 3,676 PCP cases. Of these, 863 (20.0%) were canceled and 3,457 (80.0%) proceeded to surgery and were included in postoperative outcomes analyses. Cancellation rates were 0.9% (6/644) in the PASS group versus 23.3% (857/3,676) in the PCP group (p < .001). Among completed elective spine surgeries, 638 (18.5%) were PASS and 2,819 (81.5%) were PCP. Unadjusted 90-day complication rates were lower in the PASS group (4.7% vs. 8.0%, p = 0.004). After multivariable adjustment, there were no significant differences in 90-day pooled complication rates (OR: 0.697, 95%CI: 0.460-1.058, p = .090), 30-day (OR: 0.850, 95%CI: 0.504-1.435, p = .543) or 90-day readmissions (OR: 0.841, 95%CI: 0.546-1.295, p = 0.431), RTOR (OR: 1.096, 95%CI: 0.453-2.651, p = .838), 30-day ED visits (OR: 0.973, 95%CI: 0.664-1.427, p = .890), LOS (β: -0.002, 95%CI: -0.144-0.140, p = 0.977), or pain/opioid outcomes (p > .05 for all). In a matched cohort of 1,229 cases (383 PASS, 846 PCP), the 90-day complication rate was lower in the PASS group (4.7% vs 7.9%; OR: 0.573, 95%CI: 0.336-0.979, p = 0.039), with no differences in readmission, RTOR, ED visits, or LOS. In this single-center elective spine surgery cohort, preoperative clearance obtained through the anesthesia-led PASS clinic was associated with markedly lower surgical cancellation rates compared to PCP clearance, with no significant differences in risk-adjusted postoperative outcomes. These findings suggest that standardized preoperative screening clinics may substantially reduce surgical cancellations in patients scheduled for elective spine surgery, without evidence of worse postoperative outcomes.