Implementation of Enhanced Recovery After Surgery (ERAS) Program for Patients Undergoing Same Day Outpatient Elective Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS TLIF).

Presented at SMISS Annual Forum 2019
By Samuel Joseph MD
With Uhuru Smith MD, Ashley Urso BS,

Disclosures: Samuel Joseph MD B; Osseus, Arthrex, Alphatec Spine, MiRus. D; Osseus, MiRus. F; Osseus, Alphatec Spine. Uhuru Smith MD None, Ashley Urso BS None,


Enhanced recovery after surgery (ERAS) programs for improving spinal fusion surgery are possible and necessary. To date no programs have been described for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) to allow for same day discharge in a safe and effective manner.


In this report, the authors review the development of an outpatient ERAS program for MI TLIF, with a focus on multimodal analgesia combined with pre-induction spinal anesthesia and local infiltration prior to emergence.


A prospective review of the first 30 consecutive patients in which the ERAS program was implemented for elective 1 and 2-level MIS TLIF with bilateral pedicle screw instrumentation. A synergistic protocol including multimodal preoperative analgesics, intrathecal anesthesia, combined general and local anesthesia, and postoperative medication was implemented. Data collection was performed by review of medical records. Data included number of levels fused, age, operative time, Body Mass Index (BMI), ASA Physical Status Classification, time to discharge, visual analog pain (VAS) level at discharge, readmission rate, after hours calls to office, wound complications, postoperative narcotic use till first postoperative visit, and rates of postoperative urinary retention.


A total of 20 1-level and 10 2-level MI TLIFs were performed. Patients consisted of 17 females and 13 males. Mean age was 49 years (range, 34-64), mean BMI was 33 (range, 26-44), mean ASA was 2 (range, 1-3), mean operative time was 109 minutes (range, 44-227), mean time to discharge was 161 minutes (range, 65-321), mean VAS was 4.5 (range, 1-10). There was no premature refill of narcotic, no readmission, no premature return or call to office due to pain, no postoperative urinary retention, and no wound complications at latest follow-up.


Inadequate pain control after surgery has been shown to prolong rehabilitation and opioid use, increase morbidity, impair quality of life, and increase health care costs. We employed the use of multimodal analgesia to achieve adequate pain control while decreasing the use of opioids and their potential for respiratory depression and postoperative operative cognitive dysfunction. This report describes the first ERAS protocol for MIS TLIF. Pre-, intra-, and postoperative interventions were associated with no complications and no readmissions.

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