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

Clinical Outcomes for Workers' Compensation versus Commercially Insured Patients Following Ambulatory Lumbar Decompression: A Cohort Matched Analysis with Two-Year Follow-Up

OBJECTIVE

To evaluate outcomes for workers' compensation (WC) patients versus patients with commercial insurance (CI) undergoing lumbar decompression at an ambulatory surgical center.

METHODS

This is a retrospective cohort study utilizing propensity score matched groups. Patients undergoing elective lumbar decompression at an ambulatory surgical center with 2-year follow-up were identified and grouped based on insurance type (WC or CI). Other demographic, diagnostic, and patient-reported outcome (PRO) data were obtained as well. PROs included Patient-Reported Outcome Measurement Information System-Physical Function, Visual Analog Scale-Back, Visual Analog Scale-Leg, Oswestry Disability Index, 12-Item Veterans Rand (VR-12) Physical Composite Score, VR-12 Mental Composite Score, and 9-Item Patient Health Questionnaire (PHQ-9). PRO scores were obtained preoperatively and up to two years postoperatively. Rates of minimum clinically important difference were obtained. Multivariate regression was utilized to compare postoperative PROs.

RESULTS

Following propensity score matching, 153 patients remained in the CI group and 71 were in the WC group. At baseline through one year postoperatively, WC patients reported worse Oswestry Disability Index, PHQ-9, Patient-Reported Outcome Measurement Information System-Physical Function, VR-12 Physical Composite Score, and VR-12 Mental Composite Score (P ≤ 0.041, all). At two years, WC patients reported similar outcomes as CI patients. WC patients reported significantly greater minimum clinically important difference achievement for PHQ-9 (73.1% vs. 37.7% for CI patients, P = 0.008).

CONCLUSIONS

WC patients report inferior preoperative and postoperative outcomes in disability, mental health, and physical function compared to CI patients. However, WC patients were more likely to report clinically significant improvements in depressive burden. Surgeons can counsel WC patients on expected mental health improvements and recommend psychosocial and physical rehabilitation.

Temporal Trends of Improvement After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze temporal trends in improvement after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Although several studies have shown that patients improve significantly after MIS TLIF, evidence regarding the temporal trends in improvement is still largely lacking.

METHODS

Patients who underwent primary single-level MIS TLIF for degenerative conditions of the lumbar spine and had a minimum of 2-year follow-up were included. Outcome measures were: 1) patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS); 2) global rating change (GRC); 3) minimal clinically important difference (MCID); and 4) return to activities. Timepoints analyzed were preoperative, 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. Trends across these timepoints were plotted on graphs.

RESULTS

236 patients were included. VAS back and VAS leg were found to have statistically significant improvement compared to the previous timepoint up to 3 months after surgery. ODI and SF-12 PCS were found to have statistically significant improvement compared to the previous timepoint up to 6 months after surgery. Beyond these timepoints, there was no significant improvement in PROMs. 80% of patients reported feeling better compared to preoperative by 3 months. >50% of patients achieved MCID in all PROMs by 3 months. Most patients returned to driving, returned to work, and discontinued narcotics at an average of 21, 20, and 10 days, respectively.

CONCLUSIONS

Patients are expected to improve up to 6 months after MIS TLIF. Back pain and leg pain improve up to 3 months and disability and physical function improve up to 6 months. Beyond these timepoints, the trends in improvement tend to reach a plateau. 80% of patients feel better compared to preoperative by 3 months after surgery.

Comparison of the Safety of Inpatient Versus Outpatient Lumbar Fusion : A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The objective of this study is to synthesize the early data regarding and analyze the safety profile of outpatient lumbar fusion.

SUMMARY OF BACKGROUND DATA

Performing lumbar fusion in an outpatient or ambulatory setting is becoming an increasingly employed strategy to provide effective value-based care. As this is an emerging option for surgeons to employ in their practices, the data is still in its infancy.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that described outcomes of inpatient and outpatient lumbar fusion cohorts were searched from PubMed, Medline, The Cochrane Library, and Embase. Rates of individual medical and surgical complications, readmission, and reoperation were collected when applicable. Patient-reported outcomes (PROMs) were additionally collected if reported. Individual pooled comparative meta-analysis was performed for outcomes of medical complications, surgical complications, readmission, and reoperation. PROMs were reviewed and qualitatively reported.

RESULTS

The search yielded 14 publications that compared outpatient and inpatient cohorts with a total of 75,627 patients. Odds of readmission demonstrated no significant difference between outpatient and inpatient cohorts [OR=0.94 (0.81-1.11)]. Revision surgery similarly was no different between the cohorts [OR=0.81 (0.57-1.15)]. Pooled medical and surgical complications demonstrated significantly decreased odds for outpatient cohorts compared with inpatient cohorts [OR=0.58 (0.34-0.50), OR=0.41 (0.50-0.68), respectively]. PROM measures were largely the same between the cohorts when reported, with few studies showing better ODI and VAS Leg outcomes among outpatient cohorts compared with inpatient cohorts.

CONCLUSION

Preliminary data regarding the safety of outpatient lumbar fusion demonstrates a favorable safety profile in appropriately selected patients, with PROMs remaining comparable in this setting. There is no data in the form of prospective and randomized trials which is necessary to definitively change practice.