62. Multimodal analgesic management for lumbar decompression surgery in the ambulatory setting clinical case series and review of the literature

Abstract

BACKGROUND CONTEXT Patient selection and new anesthetic techniques, such as the refined multimodal analgesic (MMA) protocol, aide in performing lumbar decompression surgery procedures in the ambulatory surgical center (ASC) setting. PURPOSE To characterize a case series of patients who underwent lumbar decompression (LD) in the ASC setting with the use of an MMA protocol. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 499 patients who underwent single or multilevel LD. OUTCOME MEASURES Visual analog scale (VAS) pain, length of stay, oral morphine equivalents (OME). METHODS A prospective surgical registry was retrospectively assessed for patients who were eligible for this study. The senior author performed all procedures and had extensive experience operating in an ASC. Observation in excess of 23 hours was not permitted at the ASC. All patients were required to be discharged the same day. Consecutive patients were identified who underwent single or multilevel LD in the ambulatory setting between May 2013 until August 2019. Procedures were conducted using the aforementioned MMA protocol. Baseline characteristics were recorded including patient demographics such as: age, gender, body mass index (BMI), smoking status, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, preoperative chronic medical conditions, and spinal diagnoses. Intraoperative characteristics were collected, including operative level, operative location, operative time (time from skin incision to skin closure), and estimated blood loss (EBL). Postoperative characteristics were recorded, including surgery center length-of-stay, patient-reported VAS pain scores prior to discharge, and the quantity of narcotic medications administered to patients prior to discharge were converted into units of oral morphine equivalents (OME) and summed across all types of narcotic medications prescribed. Postoperative complications while in the surgical center were also recorded. RESULTS A total of 499 patients who underwent lumbar decompression procedures were identified between April 2013 and September 2019. Of the total patients, 86.0% (429) underwent a single-level decompression procedure, 13.8% (69) underwent a two-level, and 0.2% (1) underwent a three-level procedure. Of the patients in this study, 83.6% (417) underwent a primary LD and 14.0% (70) underwent a revision decompression. The longest surgical case was 105 minutes with a mean of 44.1±13.3 minutes. The mean length of stay was 2.5±1.1 hours, with the longest was 7.6 hours. All other patients were discharged within 7.6 hours of the procedure end. CONCLUSIONS With the 499 patients in this ASC study on MMA protocol, this is the largest clinical case series focused on lumbar decompression procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing lumbar decompression surgery in an ASC with proper patient selection, surgical technique and a multimodal analgesia protocol. Postoperative pain was controlled for all patients, and all were discharged from the surgical center on the same day of surgery. Overall, the reduction in VAS and the rapidly treated yet minor postoperative complications suggest that lumbar decompressions can be safely performed in the ASC setting with an MMA protocol. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.