What factors contribute to delays in first versus non-first case operating room starts for patients undergoing elective anterior cervical discectomy and fusion?

Background: Anterior cervical discectomy and fusion (ACDF) is a common spine procedure with standardized steps, making it well-suited for examining inefficiencies in the operating room (OR). This study evaluated the causes and durations of surgical delays in elective ACDFs at a single academic center, focusing on differences between first and non-first case starts. Methods: We retrospectively reviewed 385 elective ACDF procedures performed from 2021 to 2022. Surgical delays were defined as cases that started more than 10 min late. Delay causes were extracted from OR records and categorized into operational themes. First versus non-first case starts were compared using descriptive statistics, Chi-square testing, and Welch's Results: Surgical delays occurred in 48.8% of cases, most commonly due to prior case delays (46.3%, mean delay 121.9 min) and preoperative team coordination issues (25.5%, mean delay 43.1 min). First case starts experienced significantly fewer delays (24.2%) than non-first case starts (85.7%, Conclusions: This study underscores a clear first case advantage in elective ACDFs, with earlier starts experiencing fewer and shorter delays. Targeted measures including preoperative planning, turnover optimization, and surgeon engagement may enhance OR efficiency.