Outpatient Lumbar Research Articles

Worse Preoperative 12-Item Veterans Rand Physical Component Scores Prognosticate Inferior Outcomes Following Outpatient Lumbar Decompression.

Retrospective Review. Evaluate the influence of the 12-Item veterans Rand (VR-12) physical component score (PCS) on patient-reported outcome measures (PROMs) in an outpatient lumbar decompression (LD) cohort. The influence of baseline VR-12 PCS on postoperative clinical outcomes has not been evaluated in patients undergoing outpatient LD. Patients undergoing primary, elective, 1/2-level outpatient LD with baseline VR-12 PCS scores were retrospectively identified from a prospectively maintained single-surgeon database. Cohorts were preoperative VR-12 PCS<30 and VR-12 PCS≥30. Patient/perioperative characteristics and preoperative/postoperative 6-week/final follow-up (FF) PROMs were collected. Physical health PROMs included the VR-12 PCS, 12-Item Short Form (SF-12) PCS, patient-reported outcome measure information system-physical function (PROMIS-PF), visual analog scale (VAS)-back/leg, and Oswestry disability index (ODI). Mental health PROMs included the VR-12/SF-12 mental component score (MCS) and the patient-health questionnaire-9 (PHQ-9). Average FF was 13.8±8.9 months postoperatively. PROM improvements at 6 weeks/FF and minimal clinically important difference (MCID) achievement rates were determined. χ 2 analysis and the Student's t tests compared demographics, perioperative data, and preoperative PROMs. Multivariate linear/logistic regression compared postoperative PROMs, PROM improvements, and MCID achievement rates. Six weeks postoperatively, VR-12 PCS<30 reported worse baseline PROMs ( P ≤0.042, all) and worse scores except VR-12/SF-12 MCS ( P ≤0.043, all). Compared with VR-12 PCS≥30, VR-12 PCS<30 had worse FF VR-12 PCS, SF-12 PCS/MCS, PROMIS-PF, PHQ-9, and VAS-Back ( P ≤0.033, all). VR-12 PCS<30 experienced greater 6-week improvements in VR-12/SF-12 PCS, PHQ-9, VAS-Back, and ODI ( P ≤0.039, all). VR-12 PCS<30 had greater FF improvements in VR-12/SF-12 PCS, PHQ-9, and ODI ( P ≤0.001, all) and greater overall MCID achievement in VR-12 PCS/MCS, SF-12 PCS, PHQ-9, and ODI ( P ≤0.033, all). VR-12 PCS<30 patients-reported worse baseline/postoperative mental/physical health scores. However, they reported greater improvements in physical function, depressive burden, back pain, and disability by 6 weeks and FF and experienced greater MCID achievement for physical functioning, mental health, and disability scores.

P271. Mental and physical health outcomes of outpatient lumbar decompression for patients with severe baseline disability

P271. Mental and physical health outcomes of outpatient lumbar decompression for patients with severe baseline disability

Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series.

Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery. A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity. Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted. 95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

Risk Factors for Surgical Site Complications After Outpatient Lumbar Spine Surgery.

Background: With the recent increase of minor lumbar spine surgeries being performed in the outpatient setting, there is a need for information on factors that contribute to post-operative complications for these surgeries. Patients and Methods: This was a prospective observational study examining risk factors for self-reported post-operative drainage in patients who underwent lumbar spine surgery. Patient surveys and the hospital's electronic medical records were used to collect data on patient demographic, patient lifestyle, and surgical variables. Univariable and multivariable analyses in addition to a random forest classifier were performed. Results: A total of 146 patients were enrolled in the study with 111 patients included in the final analysis. The average age and body mass index (BMI) of these patients was 66 and 27.8, respectively. None of the 146 patients in this study developed surgical site infection. Older age, no steroid use, no pet ownership, and spine surgery involving two or more levels were all found to be risk factors for wound drainage. Conclusions: This study evaluated lifestyle, environmental, and traditional risk factors for surgical site drainage that have not been explored cohesively related to outpatient orthopedic surgery. Consistent with the existing literature, outpatient spine surgery involving two or more levels was most strongly associated with surgical site drainage after surgery.

Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis

BACKGROUND CONTEXTAlthough spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting. PURPOSETo assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures. STUDY DESIGNRetrospective analysis using national administrative claims database. PATIENT SAMPLEA total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery. OUTCOME MEASURESPatients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users. METHODSWe utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors. RESULTSA total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient. CONCLUSIONOur results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification. LEVEL OF EVIDENCELevel III Prognostic Study. MINI ABSTRACTWe utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture

Introduction Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results 141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). Conclusion 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Risk stratification of patients undergoing outpatient lumbar decompression surgery

BACKGROUND CONTEXTReimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSETo prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTINGRetrospective single-institution cohort. PATIENT SAMPLEA total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURESPostoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODSPatients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTSA total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONSUtilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.

Caliber and type of needle are associated with the risk of spontaneously reported post-dural punction headache

Introduction&#x0D; Post-dural punction headache (PDH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in hypovolemia and CSF hypotension. The risk factors for PDH are not yet fully understood. &#x0D; Objective&#x0D; To evaluate the risk of spontaneously reported PDH according to the size and type of spinal tap needle.&#x0D; Methods&#x0D; A total of 4589 patients undergoing outpatient lumbar puncture were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone the onset of orthostatic headache during the first 7 days after the puncture to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. &#x0D; Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. &#x0D; Comparisons of the percentages of spontaneous reports of PDH were made using the chi-square test.&#x0D; Results&#x0D; 141 patients (3.07%) reported PHD to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of greater than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). &#x0D; Conclusion&#x0D; 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD. &#x0D; Key-words:&#x0D; Post-dural punction headache, Spinal Tap, Spinal Tap Needle.

Advanced Technologies for Outpatient Lumbar Fusion: Barriers and Opportunities.

In recent years, there has been increasing interest in outpatient spine surgery. Minimally invasive techniques have created an opportunity for ambulatory lumbar fusion, and these techniques increasingly involve advanced technologies such as navigation and robotics. To explore the barriers, advantages, and future predictions for such technology in the context of outpatient lumbar fusions. This is a narrative review of studies examining the advantages, limitations, and cost-effectiveness of navigation and spinal robotics in conjunction with the outcomes and costs of outpatient lumbar fusion. Outpatient lumbar fusion is a growing trend with ample evidence of its safety, favorable patient outcomes, and cost savings. Navigation and spinal robotics are associated with improved instrumentation accuracy and fewer complications, and the long-term cost savings can make these technologies financially practical in the outpatient setting. Future capabilities with robotics will only increase their value. Advanced technologies such as navigation and robotics are strategic long-term investments in the context of outpatient lumbar fusion. The favorable outcomes and costs associated with navigation and robotics will be relevant to any spine surgeon interested in developing an outpatient lumbar fusion program.

MIS TLIF, EndoTLIF, and the Ability of Navigation/Robotics to Enable Spinal Surgery in an Ambulatory Care Setting.

Study DesignTechnical Report.ObjectivePerforming surgeries in the ambulatory surgery center affords improved efficiencies in terms of cost and speed. However, ambulatory surgery is only successful if complications, re-admissions, and re-operations are avoided. This report describes the San Diego Outpatient Lumbar Fusion Program, a culmination of cumulative incremental improvements in patient selection and patient education, meticulous peri-operative management, minimally invasive techniques together with navigation/robotics.MethodsRetrospective review of prospectively collected data on 1–2 level minimally invasive transforaminal lumbar interbody fusions (MIS TLIF).ResultsHealthy patients (age 72 years old or less, BMI less than 50, ASA 1 or 2) with good social support and reasonable pre-operative function (ODI 50 or less) treated with the MIS TLIF technique can be discharged home in less than 1 midnight with good clinical results.ConclusionsRelatively young, healthy patients can safely and effectively undergo 1–2 level lumbar fusion surgery in the ASC setting when using contemporary minimally invasive techniques and computer-assisted navigation/robotics.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting.

Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Cost effectiveness of outpatient lumbar discectomy

BackgroundMicrodiscectomy is the most commonly performed spine surgery and the first transitioning for outpatient settings. However, this transition was never studied, in what comes to cost-utility assessment. Accordingly, this economic study aims to access the cost-effectiveness of outpatient lumbar microdiscectomy when compared with the inpatient procedure.MethodsThis is a cost utility study, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy Quality-adjusted life-years were calculated from Oswestry Disability Index values (ODI). ODI was prospectively assessed in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. A probabilistic sensitivity analysis was performed and incremental cost-effectiveness ratio (ICER) calculated.ResultsOutpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135,753 to €345,755/QALY, higher than the predefined threshold of €60,000/QALY gained. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group.ConclusionThis is the first economic study on cost-effectiveness of outpatient lumbar microdiscectomy, showing a significant reduction in costs, with a similar clinical outcome, proving it cost-effective.

115. Preoperative factors associated with outpatient lumbar decompression surgery

115. Preoperative factors associated with outpatient lumbar decompression surgery

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

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.

Fast-Track Eligibility and Hospital Discharge for Outpatient Lumbar Discectomy

Fast-Track Eligibility and Hospital Discharge for Outpatient Lumbar Discectomy

Microdiscectomía lumbar ambulatoria en el hospital de Puerto Montt: segura, alta satifacción usuaria y menor costo

Desde julio de 2007 el tratamiento quirúrgico de radiculopatías por hernia del núcleo pulposo (HNP) lumbares formó parte del sistema de garantías explícitas de salud (GES). Objetivo: Comparar de forma retrospectiva los resultados de dos cohortes de pacientes con indicación de cirugía discal lumbar seleccionados por el protocolo del Hospital de Puerto Montt para microdiscectomía lumbar ambulatoria (MLA). Métodos: Se incluyeron todos los pacientes seleccionados por el protocolo, que se operaron de microdiscectomía lumbar (ML) entre julio de 2015 hasta febrero de 2017. Se comparó de forma retrospectiva la homogeneidad de la cohorte de pacientes ambulatorios con la de hospitalizados. Se analizó: alivio del dolor, complicaciones, días camas, tiempo de espera a la cirugía, costos y satisfacción usuaria. Resultados: 253 pacientes operados de ML desde el inicio del protocolo hasta febrero de 2017, 126 fueron seleccionados para MLA por el protocolo, de estos 41 fueron efectivamente ambulatorios y 85 requirieron hospitalización, generándose dos cohortes homogéneas. La tasa total de complicaciones para ambos grupos fue de 4,9% y 16% respectivamente, no hubo complicaciones mayores. En los pacientes ambulatorios se ahorraron $3.145.110 pesos chilenos y se liberaron 82 días camas. El tiempo de espera para ser operados fue significativamente menor en el grupo ambulatorio. La satisfacción usuaria fue similar en ambos grupos. Conclusiones: El realizar MLAha sido seguro para nuestros pacientes sin mayores complicaciones o cambios en la satisfacción usuaria. El protocolo ha disminuido el número de días cama, los costos y el tiempo de espera para acceder a la cirugía.

Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning.

Outpatient lumbar spinal fusion surgery has the potential for improved patient satisfaction, speed of recovery, and economic advantages when compared to inpatient surgery. Despite the rise in the number of these procedures performed annually, the literature on this topic remains scarce. As such, there is a need for a comprehensive review of current concepts in indications and management. The current review will present the most recent literature regarding pre-operative, intra-operative, and post-operative considerations when performing outpatient lumbar spinal fusion surgery.

143. Chiropractors treating patients with acute lower back pain in a spine treatment pathway model: a five-year prospective cohort study

BACKGROUND CONTEXT Patient access to current best evidence primary care treatment for acute lower back remains highly problematic. Treatment pathway models have the potential to improve patient access to care, provide seamless transitions from one form of treatment to another, optimize clinical outcomes, improve cost-effectiveness and reduce progression to chronic illness /pain. A standardized protocol of hospital-based outpatient clinic chiropractic lumbar spinal manipulative therapy (CSMT) as a component of care for patients with acute lower back pain (ALBP) has been previously validated. PURPOSE To determine the feasibility and patient satisfaction of a community-based standardized chiropractic treatment protocol as a component of a primary care spine treatment pathway in the treatment of patients with ALBP. STUDY DESIGN/SETTING Feasibility prospective cohort study. PATIENT SAMPLE Inclusion: Patients with ALBP without radiculopathy of less than 24 weeks; Exclusion: Red flag conditions; SPECT scan positive facet arthropathy; > Grade IV Thompson lumbar disc degeneration at one or more levels; relevant DSM 5 diagnoses; third-party insurer involvement. OUTCOME MEASURES Willingness to participate of ALBP patients and community chiropractors. Rate of compliance with a standardized treatment protocol in community-based chiropractors. Patient wait times, satisfaction scores, pre- and post-VAS and ODI scores, need for additional imaging, rate of discharge from hospital outpatient clinic. METHODS Community-based chiropractors from three British Columbia Provincial Health Regions agreed to accept referrals from a hospital-supervised primary care spine program to treat ALBP patients with a standardized protocol comprised of a maximum four-week course of lumbar spine CSMT only and a lumbar spine flexibility instruction exercise program. Participating patients were seen for follow-up in the hospital spine outpatient clinic at four and eight weeks post-treatment. RESULTS Over the five-year duration of the study, 368/380 (97%) of eligible patients and 21/26 (81%) of community-based chiropractors agreed to participate. Seventeen of 21 chiropractors (81%) consistently administered treatment within the boundaries of the standardized research study protocol. VAS and ODI scores improved significantly in 320/368 (87%) patients. The average wait time for access to treatment was 7.4 days. Eighty-two percent of patients reported high satisfaction scores. The rate of required additional diagnostic imaging was 3%. Rates of discharge from the hospital spine program outpatient clinic with no requested follow-up by six months was 86%. CONCLUSIONS A standardized protocol of CSMT and flexibility exercise instruction administered by community-based chiropractors to a specific cohort of patients with ALBP is a feasible component of a primary care spine treatment pathway. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

305. Differences between postoperative narcotic prescriptions in outpatient lumbar spine surgery between the United States and France

BACKGROUND CONTEXT The United States is currently undergoing a major opioid crisis that has recently started to decrease its population's life expectancy due to over-mortality of its young citizens by drug overdose. Among the listed causes, physician narcotic prescriptions for both acute and chronic medical conditions are often pointed out as the main culprit for this crisis. PURPOSE We investigated the differences between discharge prescriptions following outpatient lumbar spine surgery between a French and a US spine surgery department. STUDY DESIGN/SETTING Multicenter comparative observational study. PATIENT SAMPLE A total of 100 age and sex-matched patients: 50 patients in the American center, 50 in the French center. OUTCOME MEASURES Amount of narcotics in MED (morphine equivalent dose) in the discharge prescription. Number of postoperative visits to the emergency room for inadequate pain control. METHODS Demographics, comorbidities, operative data, current prescriptions and discharge prescriptions were compared between the two groups. Narcotic consumption was converted in milligrams of morphine equivalent dose (mg MED). RESULTS A total of 25 American patients (50%) consumed narcotics preoperatively vs 4 French patients (8%). Only 22% of Americans were opioid naive. Postoperatively, all French patients had a narcotic-free prescription while all American patients were prescribed a significant amount of narcotics (617.04mg ± 345.16mg MED). One American patient returned to the emergency department for inadequate pain control while none of the French did. French patients were never prescribed steroids but had systematic nonsteroid inflammatory drugs while 41.4% of American patients were prescribed postoperative steroid tapers following a postoperative telephone call. CONCLUSIONS For identical surgeries, all American patients were prescribed postoperative narcotics while none of the French were. Cultural beliefs from both patients, physicians and the industry probably represent the most significant barrier against the implementation of a narcotic-free culture in our practice. Reducing narcotic prescriptions in our practice is not only feasible but also highly desirable. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Trends in Ambulatory Laminectomy in the USA and Key Factors Associated with Successful Same-Day Discharge: A Retrospective Cohort Study.

Laminectomy is commonly used in the treatment of lumbar spine pathology. Laminectomies are increasingly being performed in outpatient settings, but patient safety concerns remain. We aimed to describe trends in outpatient lumbar laminectomy between 2008 and 2016 and to identify factors associated with successful same-day discharge. We identified patients who underwent single-level lumbar laminectomy between 2008 and 2016 in the American College of Surgeons' National Surgical Quality Improvement Program database and divided them into two groups according to their admission status, either inpatient or outpatient. Inpatient and outpatient groups were further divided according to actual length of stay (LOS): did not remain in the hospital overnight (LOS = 0) or stayed in the hospital overnight or longer (LOS ≥ 1). We then analyzed patient characteristics and complications for significance and to identify factors associated with successful same-day discharge. We identified 85,769 patients, 41,149 classified as outpatient status and 44,620 as inpatient status. Between 2008 and 2016, the proportion of procedures performed on an outpatient basis increased from 24.1 to 56.74%. Overall, 27.3% of all patients were discharged on the day of surgery, representing 52.8% of outpatients and 3.8% of inpatients. Older age and longer duration of surgery predicted that patients were less likely to havesame-day discharge. Patients with a primary diagnosis other than intervertebral disk disorder, Hispanic ethnic background, or an American Society of Anesthesiologists physical status classification of III were less likely to achieve same-day discharge. Patients under the care of orthopedic surgeons (as opposed to neurosurgeons) were more likely to be discharged on the day of surgery. We also found an association between sex and day of discharge, with female patients being less likely to be discharged on the day of surgery. Laminectomy is increasingly being performed in the outpatient setting. Younger, healthier non-Hispanic male patients undergoing uncomplicated surgery have a higher likelihood of successful same-day discharge.