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

Perioperative Methadone for Spine Surgery: A Scoping Review

Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.

Comparison between minimally invasive and open transforaminal lumbar interbody fusion for the treatment of multi‑segmental lumbar degenerative disease: A systematic evaluation and meta‑analysis

The present study aimed to compare the differences between minimally invasive transforaminal lumbar fusion (MIS-TLIF) and open transforaminal lumbar fusion (TLIF) for multi-segmental lumbar degenerative disease regarding intraoperative indices and postoperative outcomes. PubMed, Web of Science, Embase, CNKI, Wanfang and VIP databases were searched for literature on MIS-TLIF and open TLIF in treating multi-segmental lumbar degenerative diseases. Of the 1,608 articles retrieved, 10 were included for final analysis. The Newcastle-Ottawa Scale and Review Manager 5.4 were used for quality evaluation and data analysis, respectively. The MIS-TLIF group was superior to the open TLIF group regarding intraoperative blood loss [95% confidence interval (CI): -254.33,-157.86; P<0.00001], postoperative in-bed time (95%CI: -3.49,-2.76; P<0.00001), hospitalization time (95%CI: -5.14,-1.78; P<0.0001) and postoperative leg pain Visual Analog Scale score (95%CI: -0.27,-0.13; P<0.00001). The fluoroscopy frequency for MIS-TLIF (95%CI: 2.07,6.12; P<0.0001) was significantly higher than that for open TLIF. The two groups had no significant differences in operation time, postoperative drainage volume, postoperative complications, fusion rate, or Oswestry Disability Index score. In treating multi-segmental lumbar degenerative diseases, MIS-TLIF has the advantages of less blood loss, shorter bedtime and hospitalization time and improved early postoperative efficacy; however, open TLIF has a lower fluoroscopy frequency.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis

BACKGROUND

Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series.

OBJECTIVE

To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting.

METHODS

A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed.

RESULTS

There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery.

CONCLUSION

In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.

The Effect of Preoperative, Low-Dose Intrathecal Morphine on Patient Outcomes Following Lumbar Fusion Surgery: Can We Teach an Old Dog New Tricks?

BACKGROUND

Early pain control after lumbar fusion presents a challenge to patients and providers. Intrathecal morphine (ITM) has been used at the end of these procedures with limited benefit, but recent data suggest low-dose ITM at case initiation may be effective. This study aims to evaluate the use of preoperative ITM during lumbar fusion to determine whether there is a benefit for these patients.

METHODS

One hundred and eighty lumbar fusion patients between 1 January 2018 and 31 May 2022 were evaluated. Patients were grouped by whether they received preoperative, low-dose ITM or not. Outcomes of interest included hospital narcotic consumption, pain scores, opioid-related complications, and complications within the first 90 days.

RESULTS

Sixty-five study patients received 200 µg ITM at case initiation and 115 did not. No differences in length of stay, discharge disposition, or complications in the first 90 days were noted. ITM patients received fewer milligram morphine equivalents in the postanesthesia care unit (9.7 ± 31.23 vs 21.83 ± 21.07; P = 0.006) and on postoperative day 0 (18.60 ± 35.47 vs 35.47 ± 28.51; P = 0.001). Pain scores were lower in the ITM group both in the postanesthesia care unit and on postoperative day 0, with a decrease in extreme pain scores (>7; 35.4% vs 53.0%; P = 0.034).

CONCLUSIONS

ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction.

CLINICAL RELEVANCE

ITM appears to be safe and effective for reducing early pain and narcotic consumption on the day of surgery for lumbar fusion patients and may hold value for incorporation into rapid recovery protocols and for improving pain-related patient satisfaction.

LEVEL OF EVIDENCE: 3

Lateral versus posterior approaches to treat degenerative lumbar pathologies-systematic review and meta-analysis of recent literature

INTRODUCTION

The lateral lumbar interbody fusion arose as a revolutionary approach to treating several spinal pathologies because the techniques were able to promote indirect decompression and lordosis restoration through a minimally invasive approach allowing for reduced blood loss and early recovery for patients. However, it is still not clear how the technique compares to other established approaches for treating spinal degenerative diseases, such as TLIF, PLIF, and PLF.

MATERIAL AND METHODS

This is a systematic review and meta-analysis of articles published in the last 10 years comparing lateral approaches to posterior techniques. The authors included articles that compared the LLIF technique to one or more posterior approaches, treating only degenerative pathologies, and containing at least one of the key outcomes of the study. Exclusion articles that were not original and the ones that the authors could not obtain the full text; also articles without the possibility to calculate the standard deviation or mean were excluded. For count variables, the odds ratio was used, and for continuous variables, the standard means difference (SMD) was used, and the choice between random or fixed-effects model was made depending on the presence or not of significant (p < 0.05) heterogeneity in the sample.

RESULTS

Twenty-four articles were included in the quantitative review. As for the intra-/perioperative variables, the lateral approaches showed a significant reduction in blood loss (SMD-1.56, p < 0.001) and similar operative time (SMD =  - 0.33, p = 0.24). Moreover, the use of the lateral approaches showed a tendency to lead to reduced hospitalization days (SMD =  - 0.15, p = 0.09), with significantly reduced odds ratios of complications (0.53, p = 0.01). As for the clinical outcomes, both approaches showed similar improvement both at improvement as for the last follow-up value, either in ODI or in VAS-BP. Finally, when analyzing the changes in segmental lordosis and lumbar lordosis, the lateral technique promoted significantly higher correction in both outcomes (p < 0.05).

CONCLUSION

Lateral approaches can promote significant radiological correction and similar clinical improvement while reducing surgical blood loss and postoperative complications.

Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 2: Assessment of Surgical Safety in Medicare Beneficiaries

(1) Background: The clinical benefits and procedural efficiencies of performing minimally invasive fusion procedures, such as transforaminal lumbar interbody fusion (TLIF), in the ambulatory surgery center (ASC) are becoming increasingly well established. Currently, Medicare does not provide reimbursement for its beneficiaries eligible for TLIF in the ASC due to a lack of evidence regarding procedural safety. However, the initiation of the Hospital Without Walls program allowed for traditional hospital procedures to be relocated to other facilities such as ASCs, providing a unique opportunity to evaluate the utility of TLIF in the ASC in Medicare-age patients. (2) Methods: This single-center, retrospective study compared baseline characteristics, intraoperative variables, and 30-day postoperative safety outcomes between 48 Medicare-age patients undergoing TLIF in the ASC and 48 patients having the same procedure as hospital in-patients. All patients had a one-level TLIF using the VariLift^®-LX expandable lumbar interbody fusion device. (3) Results: There were similar patient characteristics, procedural efficiency, and occurrence of clinical 30-day safety events between the two study groups. However, there was a marked and statistically significant difference in the median length of stay favoring TLIF patients treated in the ASC (23.9 h vs. 1.6 h, p = 0.001). All ASC-treated patients were discharged on the day of surgery. Postoperative visits to address adverse events were rare in either group. (4) Conclusions: These findings provide evidence that minimally invasive TLIF can be performed safely and efficiently in the ASC in Medicare-age patients. With same-day discharge, fusion procedures performed in the ASC offer a similar safety and more attractive cost-benefit profile for older patients than the same surgery undertaken in the traditional hospital setting. The Centers for Medicare and Medicaid Services should strongly consider extending the appropriate reimbursement codes (CPT ^® 22630, 22633) for minimally invasive TLIF and PLIF to the ASC Covered Procedure List so that Medicare-age patients can realize the clinical benefits of surgeries performed in this setting.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes

STUDY DESIGN/SETTING

Systematic review.

OBJECTIVE

The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion.

SUMMARY OF BACKGROUND

As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices.

MATERIALS AND METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes.

RESULTS

The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs.

CONCLUSION

There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis.

LEVEL OF EVIDENCE

Level III.

Protocolo multimodal farmacológico perioperatorio para la cirugía de columna en pediatría

Introducción: La cirugía de columna es uno de los procedimientos con mayor morbimortalidad dentro de la población pediátrica; el manejo farmacológico del dolor en dicha población aún no se encuentra estandarizado. La analgesia multimodal trata de responder a esta problemática. Objetivo: Sobre la base de una revisión sistemática de la bibliografía, desarrollar un detallado protocolomultimodal farmacológico para el manejo del dolor pre- y posoperatorio intra/extrahospitalario para la cirugía de columna en niños. Materiales y Métodos: Se realizó una revisión sistemática de textos completos en inglés o español en PubMed, Embase, Cochrane Library y LILACS Database publicados entre 2000 y 2021; se aplicó el diagrama de flujo PRISMA. Resultados: De 756 artículos preseleccionados, 38 fueron incluidos en la evaluación final. Dada la dificultad bioética de desarrollar trabajos en formato de ensayos clínicos con fármacos y combinaciones de ellos en la población pediátrica, desarrollamos un protocolo detallado de manejo del dolor pre- y posoperatorio por vía intravenosa/oral, intra- y extrahospitalario, para aplicar en niños sometidos a cirugía de columna. Conclusión: Logramos desarrollar un detallado protocolo multimodal farmacológico para el perioperatorio intra- y extrahospitalario de cirugía de columna en niños, sencillo y reproducible, tendiente a acelerar la recuperación funcional del paciente y disminuir los costos socioeconómicos globales.Nivel de Evidencia: II

Feasibility of outpatient robot assisted minimally invasive transforaminal lumbar interbody fusion

Introduction

Lumbar interbody fusion is a common spine procedure. 199,140 elective lumbar fusions were performed in the United States in 2015. Robot assisted (RA) pedicle screw placement has advanced minimally invasive spine surgery (MIS) making short stay transforaminal lumbar interbody fusions (TLIF) with same day or next day discharge a possibility for select patients.

Methods

This study is a retrospective case series of a single surgeon's experience with RA MIS TLIF using the Globus ExcelsiusGPS system. Patients undergoing RA MIS TLIF at an outpatient surgery center between August 2020 and February 2021 were included in the study.

Results

Twenty-three patients met inclusion criteria. Ninety-six RA pedicle screws and 25 interbody cages were placed. 96/96 (100%) pedicle screws and 25/25 (100%) interbodies were found to be in satisfactory position using intraoperative x-ray. None of the instrumentation required re-placement or revision intraoperatively. 20/23 (87%) patients were able to discharge within 24 hours of the procedure. 2/23 (8.7%) patients discharged on the day of surgery. One patient of 23 (4.3%) required discharge to an inpatient rehabilitation facility post operatively. 0/23 (0%) patients required readmission for pain control.

Conclusions

Our study demonstrates the safety and feasibility of outpatient RA MIS TLIF for select patients. Future directions include a larger study to elucidate characteristics of the best candidates for outpatient RA MIS TLIF.

Application and thinking of minimally invasive transforaminal lumbar interbody fusion in degenerative lumbar diseases

Background

This study sought to investigate the clinical efficacy and safety of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lumbar degenerative diseases.

Methods

The clinical data of 55 patients with lumbar degenerative diseases treated at our hospital from January 2018 to January 2020 were analyzed retrospectively. Of the 55 patients, 35 who underwent MIS-TLIF were included in the MIS-TLIF group, and 20 who underwent posterior lumbar interbody fusion (PLIF) were included in the PLIF group. The visual analogue scale (VAS) score, Oswestry disability index (ODI) score, operation time, incision length, intraoperative bleeding, postoperative drainage, postoperative landing time, postoperative hospital stay, postoperative interbody fusion rate, and complications were compared between the two groups.

Results

The patients in both groups were followed-up for at least 1.5 years (range, 18–30 months; with an average of 27.5±2.6 months). There was no significant difference in the operation time, incision length, intraoperative bleeding, VAS score for low back and leg pain, ODI score, interbody fusion rate, hospitalization expenses, and complication rate between the two groups (P>0.05). One patient had nail failure in the MIS-TLIF group, 1 patient in each group had nerve root irritation, and 1 patient in each group had superficial incision infection and local suture dehiscence. The postoperative drainage volume, postoperative landing time, and postoperative hospital stay of the MIS-TLIF group were less than those of the PLIF group (P<0.05).

Conclusions

Compared to PLIF, the use of MIS-TLIF in the treatment of lumbar degenerative diseases has a number of advantages, including more complete intraoperative hemostasis, less postoperative drainage, earlier landing, and faster discharge, and also significantly improves postoperative lumbar discomfort.

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

INTRODUCTION

Both transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) are suitable for achievement of lumbar arthrodesis. Comparative studies have observed complications and outcomes without stratification by lumbar level. This study aims to assess patient-reported outcome measures (PROMs) and recovery in TLIF and LLIF at L4-5.

METHODS

Patients undergoing primary, elective, single-level, TLIF or LLIF procedures at L4-5 were grouped. Demographics, perioperative characteristics, and postoperative complication rates were collected. PROMs included Patient-Reported Outcome Measurement Information System Physical Function, visual analog scale (VAS) back and leg, Oswestry Disability Index, and 12-Item Short-Form Physical Component Summary, and Mental Component Summary and were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year time points. Delta values and recovery ratios (RRs) were calculated for all PROMs at all time points. Demographics, perioperative characteristics, and postoperative complications were compared using chi-squared and Student t-test for categorical and continuous variables, respectively. Differences in mean PROMs, delta values, and RR at each time point were evaluated using unpaired Student's t-test.

RESULTS

Three hundred sixty TLIF and 46 LLIF patients were included. Most (54.3%) were men, mean age 56.3 years, and mean body mass index 30.8 kg/m2. Body mass index and insurance significantly differed (P ≤ 0.045, all). TLIF showed significantly greater mean operative time, length of stay, and postoperative narcotic consumption (P < 0.033, all) and greater postoperative nausea/vomiting (P = 0.004). No preoperative PROMs significantly differed. TLIF cohort had significantly greater VAS back at 6 months and VAS leg at 12 weeks and 6 months (P < 0.034, all). No mean delta PROMs or RRs significantly differed.

DISCUSSION

LLIF demonstrated significantly reduced length of stay, postoperative narcotic consumption, and postoperative nausea/vomiting and significantly improved VAS back at 6 months and VAS leg at 12 weeks and 6 months versus TLIF. Although 2-year PROMs and RRs did not significantly differ, our findings may suggest improved midterm follow-up pain scores for LLIF patients.