Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol

Abstract

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.