Jude Geldart, Katie Mathieson, Sayan Biswas, Ella Snowdon, Ved Sarkar, Callum Tetlow, & K. Joshi George. Is a wound drain needed routinely after anterior cervical discectomy and fusion? North American Spine Society Journal (NASSJ) 2025; 22, 100606. https://doi.org/10.1016/j.xnsj.2025.100606

This commentary reviews a retrospective study by Geldart et al which was published in North American Spine Society Journal (NASSJ). The study examined whether routine subfascial drain placement during anterior cervical discectomy and fusion (ACDF) prevents postoperative complications. While wound drains are commonly used in ACDF to mitigate risks of postoperative issues, their necessity has long been debated, and current guidelines are inconclusive.

The authors reviewed all ACDF cases performed at a UK tertiary neurosurgical center between 2013 and 2023. Drains were used at the surgeon’s discretion. Patient characteristics were assessed. Outcomes included reoperation for postoperative hematoma (POH), surgical site infection (SSI), and postoperative length of stay (LOS). POH was defined as significant swelling or hematoma requiring either conservative or surgical management, while SSI was characterized by the administration of antibiotics with or without returning to the operating room.

In total, 1,938 patients were included; 1,614 (83.3%) received a drain and 324 (16.7%) did not. Patient demographics differed between the groups: the drain cohort was slightly older, more often male, and more likely to smoke, drink alcohol, and have hypertension. There was no statistically significant difference between groups in reoperation for hematoma (0.68% with drains vs 0.31% without, p = .43), SSI (1.12% vs 1.23%, p = .85), or LOS (48.8 vs 51.4 hours, p = .18).

These findings align with prior studies that similarly failed to demonstrate reductions in hematoma, infection, or length of stay with drain usage. Notably, the hematoma reoperation rate in this cohort (0.62%) was within the range published in prior literature (0.4 - 2.4%). The authors point out that half of the hematomas occurred within hours of surgery despite the presence of a drain, and the remainder occurred after drain removal, suggesting that drain placement did not eliminate risk.

The other factor of significance was that the drain group did not have a prolonged length of stay. It is conceivable that tracking of drain outputs could have delayed discharge, but this was not identified to be the case.

While this study reinforces previous literature, it has some limitations that should be taken into consideration. Most notably, the drains were placed at the discretion of the treating surgeon. If the drains were only placed in the most dry and simple of the surgeries, related outcomes might not apply equally to the rest of the cases. To that end, the retrospective nature of the study carries inherent limitations. Finally, the single-center design limits generalizability.

Overall, the reviewed retrospective, single-cohort study found that surgical drain placement after ACDF did not provide measurable benefit in reducing hematoma, infection, or add to length of stay. In the end, the study suggests that the minority of cases that were found appropriate to be left without surgical drain did not have worse outcomes and that this practice is likely appropriately considered in correctly selected patients.