199 Protocolization of Post-transforaminal Lumbar Interbody Fusion Pain Control With Elimination of Benzodiazepines and Long-Acting Opioids

<sec><title>Study Design</title>Retrospective case-control study using prospectively collected data.</sec><sec><title>Purpose</title>Evaluate the impact of liposomal bupivacaine (LB) on postoperative pain management and narcotic use following standardized single-level low lumbar transforaminal lumbar interbody fusion (TLIF).</sec><sec><title>Overview of Literature</title>Poor pain control after surgery has been linked with decreased pain satisfaction and increased economic burden. Unfortunately, opioids have many limitations and side effects despite being the primary treatment of postoperative pain. LB may be a form of pre-emptive analgesia used to reduce the use of postoperative narcotics as evidence in other studies evaluating its use in single-level microdiskectomies.</sec><sec><title>Methods</title>The infiltration of LB subcutaneously during wound closure was performed by a single surgeon beginning in July 2014 for all single-level lumbar TLIF spinal surgeries at Landstuhl Regional Medical Center. This cohort was compared against a control cohort of patients who underwent the same surgery by the same surgeon in the preceding 6 months. Statistical analysis was performed on relevant variables including: morphine equivalents of narcotic medication used (primary outcome), length of hospitalization, Visual Analog Scale pain scores, and total time spent on a patient-controlled analgesia (PCA) pump.</sec><sec><title>Results</title>A total of 30 patients were included in this study; 16 were in the intervention cohort and 14 were in the control cohort. The morphine equivalents of intravenous narcotic use postoperatively were significantly less in the LB cohort from day of surgery to postoperative day 3. Although the differences lost their statistical significance, the trend remained for total (oral and intravenous) narcotic consumption to be lower in the LB group. The patients who received the study intervention required an acute pain service consult less frequently (62.5% in LB cohort vs. 78.6% in control cohort). The amount of time spent on a PCA pump in the LB group was 31 hours versus 47 hours in the control group (<italic>p</italic>=0.1506).</sec><sec><title>Conclusions</title>Local infiltration of LB postoperatively to the subcutaneous tissues during closure following TLIF significantly decreased the amount of intravenous narcotic medication required by patients. Well-powered prospective studies are still needed to determine optimal dosing and confirm benefits of LB on total narcotic consumption and other measures of pain control following major spinal surgery.</sec>

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Robot-guided versus freehand fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion: a single-institution, observational, case-control study

Neurosurgical FOCUS ◽

10.3171/2021.10.focus21514 ◽

2022 ◽

Vol 52 (1) ◽

pp. E9

Keyword(s):

Spinal Surgery ◽

Pain Control ◽

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Lumbar Interbody Fusion ◽

Single Institution ◽

Operative Blood Loss ◽

Short Term ◽

Guided Surgery ◽

Operative Duration

OBJECTIVE The use of robotics in spinal surgery has gained popularity because of its promising accuracy and safety. ROSA is a commonly used surgical robot system for spinal surgery. The aim of this study was to compare outcomes between robot-guided and freehand fluoroscopy-guided instrumentation in minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF). METHODS This retrospective consecutive series reviewed 224 patients who underwent MIS-TLIF from March 2019 to April 2020 at a single institution. All patients were diagnosed with degenerative pathologies. Of those, 75 patients underwent robot-guided MIS-TLIF, and 149 patients underwent freehand fluoroscopy-guided MIS-TLIF. The incidences of pedicle breach, intraoperative outcomes, postoperative outcomes, and short-term pain control were compared. RESULTS The patients who underwent robot-guided surgery had a lower incidence of pedicle breach (0.27% vs 1.75%, p = 0.04) and less operative blood loss (313.7 ± 214.1 mL vs 431.6 ± 529.8 mL, p = 0.019). Nonsignificant differences were observed in operative duration (280.7 ± 98.1 minutes vs 251.4 ± 112.0 minutes, p = 0.056), hospital stay (6.6 ± 3.4 days vs 7.3 ± 4.4 days, p = 0.19), complications (intraoperative, 1.3% vs 1.3%, p = 0.45; postoperative surgery-related, 4.0% vs 4.0%, p = 0.99), and short-term pain control (postoperative day 1, 2.1 ± 1.2 vs 1.8 ± 1.2, p = 0.144; postoperative day 30, 1.2 ± 0.5 vs 1.3 ± 0.7, p = 0.610). A shorter operative duration for 4-level spinal surgery was found in the robot-guided surgery group (388.7 ± 107.3 minutes vs 544.0 ± 128.5 minutes, p = 0.047). CONCLUSIONS This retrospective review revealed that patients who underwent robot-guided MIS-TLIF experienced less operative blood loss. They also benefited from a shorter operative duration with higher-level (> 3 levels) spinal surgery. The postoperative outcomes were similar for both robot-guided and freehand fluoroscopy-guided procedures.

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Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids

Neurosurgery ◽

10.1093/neuros/nyz232 ◽

2019 ◽

Vol 86 (5) ◽

pp. 717-723

Author(s):

Jason H Boulter ◽

Brian P Curry ◽

Nicholas S Szuflita ◽

Charles A Miller ◽

Joseph Spinelli ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Control ◽

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Opioid Use ◽

Postoperative Pain Control ◽

Single Level ◽

Pain Scores ◽

Control Regimen ◽

Long Acting

Abstract BACKGROUND The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (LAOs) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and LAOs from our postoperative pain control regimen. OBJECTIVE To evaluate the impact of removing benzodiazepines and LAOs on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. METHODS A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the + benzodiazepine cohort included scheduled diazepam with or without LAOs. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the −benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. RESULTS Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (−18.7%, 95% CI [−1.22%, −36.10%]), used less trigger medications (−1.55, 95% CI [−0.43, −2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the −benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P = .021) and 6 mo postoperatively (0% vs 13.2%, P = .039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P = .048). CONCLUSION Replacement of benzodiazepines and LAOs in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.

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Cost-effectiveness of minimally invasive midline lumbar interbody fusion versus traditional open transforaminal lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2019.6.spine1965 ◽

2020 ◽

Vol 32 (1) ◽

pp. 31-35

Author(s):

Mladen Djurasovic ◽

Jeffrey L. Gum ◽

Charles H. Crawford ◽

Kirk Owens ◽

Morgan Brown ◽

...

Keyword(s):

Cost Effectiveness ◽

Minimally Invasive ◽

Interbody Fusion ◽

Smoking Status ◽

Transforaminal Lumbar Interbody Fusion ◽

Direct Costs ◽

Lumbar Interbody Fusion ◽

Related Quality ◽

Health Related

OBJECTIVEThe midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.METHODSFrom a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.RESULTSOf 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).CONCLUSIONSCompared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

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Obesity may be associated with adjacent-segment degeneration after single-level transforaminal lumbar interbody fusion in spinopelvic-mismatched patients with a minimum 2-year follow-up

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20159 ◽

2021 ◽

Vol 34 (1) ◽

pp. 83-88

Author(s):

Ping-Guo Duan ◽

Praveen V. Mummaneni ◽

Minghao Wang ◽

Andrew K. Chan ◽

Bo Li ◽

...

Keyword(s):

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Adjacent Segment Degeneration ◽

Adjacent Segment ◽

Lumbar Interbody Fusion ◽

Inclusion Criteria ◽

Single Level ◽

Degenerative Lumbar Spondylolisthesis ◽

Surgery Rates

OBJECTIVEIn this study, the authors’ aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.METHODSPatients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters.RESULTSA total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24–135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49–0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05).CONCLUSIONSIn patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

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