Postoperative Narcotic Consumption between Anterior and Anterior-Posterior Lumbar Fusion Surgery

Presented at SMISS Annual Forum 2014
By Islam Elboghdady
With Kern Singh MD, Sreeharsha V. Nandyala BA, Alejandro Marquez-Lara MD, Eric Sundberg MD, Abbas Naqvi BS, Hamid Hassanzadeh MD, Anton Jorgensen MD,

Disclosures: Islam Elboghdady None Kern Singh MD A; CSRS Resident Grant. B; DePuy, Zimmer, Stryker, CSRS, ISASS, AAOS, SRS, Vertebral Column - ISASS. D; Avaz Surgical, LLC, Vital 5, LLC. F; Zimmer, Stryker, Pioneer, Lippincott Williams & Wilkins, Th, Sreeharsha Nandyala BA None, Alejandro Marquez-Lara MD None, Eric Sundberg MD None, Abbas Naqvi BS None, Hamid Hassanzadeh MD None, Anton Jorgensen MD None,

Introduction:
The thought that posterior instrumentation enhances fusion by providing additional fixation strength to the affected lumbar spine level has been subject to debate. Regardless, the additional surgical time and surgical incisions required to execute this circumferential technique may be associated with greater postoperative pain and higher narcotic consumption than stand-alone procedures.

Aims/Objectives:
To assess the impact of additional posterior instrumentation on the postoperative narcotic requirements in patients undergoing a single-level anterior lumbar interbody fusion (ALIF).

Methods:
A prospectively maintained surgical database was retrospectively analyzed for patients undergoing a single level lumbar interbody fusion. 49 patients who underwent an ALIF procedure were compared to 22 patients who underwent an anterior-posterior lumbar interbody fusion (APLF). All posterior instrumentation was performed percutaneously (pedicle screws and rods), and only primary cases performed for degenerative spinal conditions were included in the analysis. Patient demographics, comorbidity burden, smoking status, intraoperative parameters, rates of in-hospital complications, and length of hospitalization were assessed. Cumulative and daily (postoperative day (POD)) in-hospital narcotic consumption (expressed in oral morphine equivalent (OME) doses) were assessed with regards to the day of discharge. Statistical analysis was performed with a chi-squared test for categorical variables and Student-Test for continuous variables. OME means were compared utilizing non-parametric analysis to adjust for skewedness. A p-value of <0.05 denoted statistical significance.

Results:
Patients who underwent an APLF procedure were significantly older (51.1±13.2 vs 44.4±11.3 years, p<0.05) than ALIF-treated patients. However, the comorbidity burden, rate of peri-operative complications, or length of hospitalization did not vary between cohorts. APLF procedures were associated with longer operative times (173.6±65.9 vs 91.2±26.7 min, p<0.05) and slightly higher blood loss (92.9±35.8 vs 79.7±75.9 cc, p=0.44) compared to ALIF procedures. Posterior instrumentation did not significantly impact the cumulative opioid requirements regardless of the day of discharge (POD 1: 35.0 vs 51.3±32.9 mg; POD 2: 76.3±47.3 vs 73.4±38.1 mg, p=0.92; POD 3: 106.7±60.2 vs 120.4±52.8 mg, p=0.79).

Conclusions:
This analysis demonstrated that additional percutaneous posterior instrumentation for lumbar arthrodesis is not associated with greater narcotic consumption compared to a stand-alone technique. Despite the longer operative time and slightly greater blood loss incurred by patients who underwent additional posterior percutaneous instrumentation, achieving adequate postoperative pain control may not require greater narcotic administration compared to patients undergoing a stand-alone single-level ALIF.