Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting

Abstract

Background: The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.Methods: Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.Results: Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.Conclusions: The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.Level of Evidence: 4. Clinical Relevance: The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Single-level TLIF Versus LLIF at L4-5: A Comparison of Patient-reported Outcomes and Recovery Ratios

“…[28][29][30] In the study by Parrish et al, a novel MMA protocol was established and validated for both TLIF and LLIF patients in an outpatient setting. 18 Given notable differences in postoperative narcotic consumptions and PONV between cohorts, our study may suggest the need for procedure specific MMA protocols in MIS fusion.…”

“…Although our study reported no significant differences in postoperative recovery through RRs, previous literature has identified patients undergoing LLIF to have a faster initial recovery. 3,18 Moreover, no difference in t1-year rates of arthrodesis and postoperative complications with exception of PONV were noted. The lack of significant differences in longterm clinical outcomes between TLIF and LLIF agreed with existing studies.…”

“…10 In addition, epidemiological studies of disk degeneration have consistently reported the prevalence of disk degeneration and disk herniation to be highest in the lumbar spine, with the rates at L4-5 found to much higher than those at L1-2, L2-3, L3-4, and L5-S1. 13,15,18 As a result, the most commonly operated on level during lumbar fusion is L4-5, followed by L5-S1. Optimizing surgical outcomes requires curating surgical approaches based on anatomy and preoperative characteristics of patients.…”

Response to Letter to the Editor by Soffin et al.

“…As such, use of tramadol, which is a known weak l-opioid receptor agonist, was implemented to minimize the use of more potent opioids (oxycodone). While our protocol does incorporate the use of some narcotic medications, their use, as described in the study of discussion, 23 is at half dosage, as recommended by the FDA, 5 and is primarily for breakthrough pain in the postoperative recovery room as well as for patients discharged on postoperative day 0. Furthermore, there is sufficient evidence that controlling acute pain after surgery can reduce chronic pain.…”

Letter to the Editor: “Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting”

“…We read with great interest the work by Dr Parrish and colleagues describing their package of multimodal analgesia (MMA) for lumbar surgery in the ambulatory setting. 1 We applaud their efforts to highlight the importance of adequate analgesia on rapid recovery after spine surgery.…”