Study Design. Retrospective review of prospectively collected data. Objective. To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). Summary of Background Data. Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. Materials and Methods. Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. Results. Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. Conclusions. Unavailability of PT, surgery after 1 pm, orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. Level of Evidence. 4.

Objective: The purpose of our study was to develop and provide an initial internal validation of a novel classification system that can help surgeons and patients better understand their postoperative course following the particular minimally invasive surgery (MIS) and approach that is utilized.Summary of Background Data: Surgeons and patients are often attracted to the option of minimally invasive spine surgery because of the perceived improvement in recovery time and postsurgical pain. A classification system based on the impact of the surgery and surgical approach(es) on postoperative recovery can be particularly helpful.Methods: Six hundred thirty-one patients who underwent MIS lumbar/thoracolumbar surgery for degenerative conditions of the spine were included. Perioperative outcomes-operative time, estimated blood loss, postsurgical length of stay (LOS), 90-day complications, postoperative day zero narcotic requirement [in Morphine Milligram Equivalent (MME)], and need for intravenous patient-controlled analgesia (IV PCA).Results: Postoperative LOS and postoperative narcotic use were deemed most clinically relevant, thus selected as primary outcomes. Type of surgery was significantly associated with all outcomes (P < 0.0001), except intraoperative complications. Number of levels for fusion was significantly associated with operative time, in-hospital complications, 24 hours oral MME, and the need for IV PCA and LOS (P < 0.0001). Number of surgical approaches for lumbar fusion was significantly associated with operative time, 24 hours oral MME, need for IV PCA and LOS (P < 0.001). Based on these parameters, the following classification system ("Qureshi-Louie classification" for MIS degenerative lumbar surgery) was devised: (1) Decompressiononly; (2) Fusion-1 and 2 levels, 1 approach; (3) Fusion-1 level, 2 approaches; (4) Fusion-2 levels, 2 approaches; (5) Fusion-3+ levels, 2 approaches. Conclusions:We present a novel classification system and initial internal validation to describe the perioperative expectations following various MIS surgeries in the degenerative lumbar spine. This initial description serves as the basis for ongoing external validation.

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Objective: To evaluate outcomes of cervical disc replacement (CDR) in patients with nonlordotic alignment. Methods: Patients who underwent CDR were retrospectively reviewed and divided into 3 cohorts: (1) neutral/lordotic segmental and C2-7 Cobb angle (L), (2) nonlordotic segmental Cobb angle, lordotic C2-7 Cobb angle (NL-S), and (3) nonlordotic segmental and C2-7 Cobb angle (NL-SC). Radiographic and patient-reported outcomes (PROMs) were compared. Results: One-hundred five patients were included