37. Outpatient minimally invasive lumbar fusion using multimodal analgesic management in the ambulatory surgery setting

Abstract

BACKGROUND CONTEXT 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 a lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol. PURPOSE To present a clinical case series of patients who underwent either a MIS transforaminal lumbar interbody fusion (TLIF) or a lateral lumbar interbody fusion (LLIF) in the ambulatory surgery setting while using an enhanced MMA protocol. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 50 patients who underwent MIS TLIF or LLIF with percutaneous pedicle screw fixation with direct decompression. OUTCOME MEASURES Postoperative pain, postoperative narcotics, postoperative complications. METHODS Consecutive patients who underwent outpatient 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 senior surgeon performing the cases had extensive experience, operating in an ambulatory surgical center. Patient demographics and baseline characteristics were recorded, including age, sex, smoking status, Charlson Comorbidity Index (CCI), and body mass index (BMI). Perioperative characteristics, postoperative pain scores and narcotics administered to patients prior to discharge from the ASC were recorded including any complications. RESULTS A total of 50 consecutive patients were identified from September 2016 to July 2019, of which 41 patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). The LLIF procedures involved percutaneous posterior pedicle screw instrumentation and direct tubular posterior decompression. All patients in our study population were discharged home on the day of surgery from the surgical center. The mean length of stay was 4.5±1.6 hours and 3.8±1.6 hours for the TLIF and LLIF cohorts respectively. There was an outlier of 8.8 hours following a TLIF procedure. This patient reported a high VAS pain score of 9 immediately following surgery that needed to be adequately controlled prior to discharge. Our review of medical records revealed no postoperative complications following either the TLIF or LLIF procedures. CONCLUSIONS To our knowledge, the present study of 50 consecutive patients is the largest clinical series of patients who underwent outpatient lumbar fusion procedures in a stand-alone ambulatory surgery setting with no extended postoperative observation capability. Our study of patients who underwent outpatient MIS TLIF or LLIF procedures in the ambulatory surgery setting while using a well-developed multimodal analgesia protocol demonstrated no postoperative complications. Postoperative pain was adequately controlled and all patients were discharged from the ambulatory surgical center on the day of surgery approximately 4.5 (TLIF) and 3.8 (LLIF) hours after the procedure. The findings suggest that with proper preoperative patient selection, an enhanced MMA protocol can lead to discharge of patients from a surgical center and minimize admission to a hospital. Preventing these complications may help increase the likelihood of timely discharge facilitating the performance of lumbar fusion procedures in the ambulatory setting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.