Search

Background Context Although lumbar disc herniation (LDH) classically presents with lower extremity radiculopathy, there are patients who have substantial associated back pain. Purpose The present study aims to determine if patients with LDH with substantial back pain improve with decompression alone. Study Design This is a longitudinal observational cohort study. Patient Sample Patients enrolled in the Quality and Outcomes Database with LDH and a baseline back pain score of ≥5 of 10 who underwent single- or two-level lumbar discectomy only. Outcome Measures Back and leg pain scores (0–10), Oswestry Disability Index (ODI), and EuroQoL 5D were measured. Methods Standard demographic and surgical variables were collected, as well as patient-reported outcomes at baseline and at 3 and 12 months postoperatively. Results The mean age of the cohort was 49.8 years and 1,195 (52.8%) were male. Mean body mass index was 30.1 kg/m2. About half of the patients (1,103, 48.8%) underwent single-level discectomy and the other half (1,159, 51.2%) had two-level discectomy. Average blood loss was 44 cc. Most of the patients (2,217, 98%) were discharged home with routine postoperative care. The average length of stay was 0.53 days. At 3 and 12 months postoperatively, there were statistically significant (p Conclusions Patients with LDH who have substantial back pain can be counseled to expect improvement in their back pain scores 12 months after a discectomy.

BACKGROUND CONTEXT Recent studies suggest as much as 25% of patients undergoing spine surgery are still on opioids two years later. In response, we developed protocols to minimize opioid consumption following elective spine surgery. Our goal was to evaluate patients undergoing single-level Anterior Lumbar Interbody Fusions (ALIF ± posterior fixation) on MMPC compared to patients who were not (nonMMPC). PURPOSE To determine if the combination of an oral preoperative pain cocktail with transverse abdominis plane (TAP) block (multi-modal pain control: MMPC) will reduce length of stay (LOS), ileus, and in-hospital opioid consumption. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions by a single-surgeon. OUTCOME MEASURES Length of stay (LOS), incidence of ileus and in-hospital opioid consumption. METHODS A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in technique. Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions were identified before and after initiation of the MMPC. The MMPC consisted of a preop oral regimen of cyclobenzaprine (10mg), gabapentin (600mg), acetaminophen (1g) and methadone (10mg). Postoperatively they received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivicaine. Our primary outcome was total, in-hospital opioid consumption (morphine milligram equivalents: MME). RESULTS There were 68 patients in the MMPC cohort and 39 in the nonMMPC cohort. There was no difference in baseline demographics such as sex, BMI, smoking, or preoperative opioid use between the two groups. The MMPC cohort was older (56.7 vs 51.1 years, p=0.026). Similar rates of ileus (4 vs 6, p=0.102), no difference in LOS (3.8 vs 4.5, p=0.246) and no difference in index hospital costs was found. Although there was no difference in day of surgery MMEs (58.5 vs 68.9, p=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs 314.8, p CONCLUSIONS The use of a MMPC regimen in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on POD 1, resulting in a cumulative reduction of 62%. Further research should strive to minimize opioid use and the downstream effects. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In attempts to expedite recovery by limiting muscle dissection, the midline interbody fusion (MIDLIF) has been described. More recently, we have developed a robotic-assisted MIDLIF (RA-MIDLIF) technique. Introduction of new technology can potentially be expensive and burdensome. PURPOSE The purpose of this study was to compare index episode of care parameters between patients undergoing either traditional open TLIF (tTLIF), MIDLIF, or RA-MIDLIF. STUDY DESIGN/SETTING Retrospective review of a prospective, multisurgeon, surgical database. PATIENT SAMPLE Consecutive patients undergoing 1- or 2- level RA-MIDLIF, tTLIF or MIDLIF. OUTCOME MEASURES Estimated blood loss (EBL), operative tme (OR Time), length of stay (LOS), total direct hospital cost. METHODS A retrospective review of a prospective, multisurgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level RA-MIDLIF for degenerative lumbar conditions were identified and propensity-matched based on age, sex, smoking status, BMI, ASA grade and levels fused to patients undergoing tTLIF or MIDLIF. LOS, EBL, OR Time and direct hospital cost for the index surgical admission were compared. RESULTS Of 55 RA-MIDLIF cases identified, 52 were successfully propensity-matched to patients undergoing tTLIF or MIDLIF. Consistent with propensity matching, there was no difference in age, sex, BMI, ASA grade, smoking status or levels fused. The mean direct hospital cost was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) compared to either MIDLIF (2.71 days) or TLIF (3.58 days). Both MIDLIF and RA-MIDLIFs had lower EBL and less OR time compared to both tTLIF. CONCLUSIONS Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of our first 52 robotic-assisted MIDLIF surgeries compared to tTLIF and MIDLIF showed promising results for reducing OR time, EBL, LOS and without increasing cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the post-discharge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE To identify factors associated with being discharged to a non-home location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES Non-home discharge. METHODS Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p CONCLUSIONS Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT In 2016 alone, 19,413 deaths were attributed to prescription opioid overdoses. Understanding the drivers of opiate consumption in postoperative lumbar spinal fusion patients is a high priority. PURPOSE To determine if surgical invasiveness and/or preoperative opiate use influences immediate postoperative opiate consumption. STUDY DESIGN/SETTING Propensity matched longitudinal cohort. PATIENT SAMPLE Patients from a multi-surgeon, single spine specialty center with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). OUTCOME MEASURES Oswestry Disability Index, morphine equivalent doses (MED) from postoperative day (POD) #0 through POD #4. METHODS A single-center, multi-surgeon, retrospective review identified patients with degenerative lumbar pathology who underwent an instrumented posterior lumbar decompression and interbody fusion (MIDLIF or TLIF). Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. MED POD #0 through POD #4 were calculated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS Of 214 MIDLIF and 281 TLIF patients undergoing surgery, 33 patients in each cohort were successfully propensity matched with no differences in baseline characteristics. There was no difference in immediate postoperative mean total MED between the cohorts (MIDLIF=370, TLIF=302, p=.398). Forty-three (65%) of patients were taking opiates prior to surgery. Opiate-naive patients required less narcotics (MED=248) compared to nonopiate naive patients (MED=383, p=.071) but this was not significant. Patients taking opiates preop had worse baseline ODI (56.5 vs. 47.2, p=.023) and 1-year postop ODI (46.3 vs. 30.9, p=.015). CONCLUSIONS Neither surgical invasiveness nor preoperative opiate use have an impact on immediate postop opiate consumption. This is likely secondary to non-individualized prescribing patterns. Patients taking preop narcotics have worse baseline, 1-year, and improvement in ODI following 1- and 2-level MIDLIFs or TLIFs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior instrumented lumbar fusions are commonly performed utilizing interbody fusions. Recently, a minimally invasive technique of midline exposure with cortical bone trajectory screw fixation has been described (MIDLIF). The goal is to limit muscle dissection, decreasing surgical morbidity and expedite recovery. PURPOSE The purpose of this study was to compare index episode of care (iEOC) cost between patients undergoing MIDLIF versus tTLIF. STUDY DESIGN/SETTING Multi-surgeon single-center spine specialty tertiary practice. PATIENT SAMPLE Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. OUTCOME MEASURES Index episode of care cost data for surgical and hospital stay parameters and included actual, direct, hospital cost. METHODS A retrospective review of a prospective, multi-surgeon, surgical database was utilized. Consecutive patients undergoing 1- or 2-level MIDLIF or tTLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity-matched based on age, sex, smoking status, BMI, diagnosis, ASA grade and levels fused. iEOC cost data was collected for surgical and hospital stay parameters and included actual, direct, hospital cost for the index surgical visit. RESULTS Of 214 and 281 patients undergoing MIDLIF or tTLIF, respectively, 105 cases in each cohort were successfully propensity-matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA score, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. The mean total iEOC was $706 ($16,604 vs. $17,310) lower for MIDLIF versus tTLIF. There was no difference in implant (p=.193) or biologic (p=.145) cost but blood utilization (p=.000), OR supplies (p=.000), hospital room/board (p=.000), pharmacy (p=.010), and therapy (p=.009) costs were all significantly lower in MIDLIF. Additionally, mean LOS was decreased for MIDLIF (2.97 vs. 4.02, p=.000). CONCLUSIONS Compared to traditional open tTLIF, patients undergoing MIDLIF have several cost parameters of the iEOC that are significantly lower as well as a shorter length of stay. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.