Postoperative Opioid Consumption: A Comparison between Anterior and Direct Lateral Lumbar Interbody Fusion

Presented at SMISS Annual Forum 2014
By Islam Elboghdady
With Kern Singh MD, Sreeharsha Nandyala BA, Alejandro Marquez-Lara MD, Eric Sundberg MD, Hamid Hassanzadeh MD, Anton Jorgensen MD, Khaled Aboushaala MD, Junyoung Ahn ,

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, Hamid Hassanzadeh MD None, Anton Jorgensen MD None, Khaled Aboushaala MD None, Junyoung Ahn None,

Introduction:
There is considerable interest in evaluating the safety, efficacy, and outcomes associated with minimally invasive approaches to achieve lumbar arthrodesis. Although often overlooked, the narcotic requirements following these less invasive techniques are extremely important to consider.

Aims/Objectives:
To compare the immediate postoperative narcotic consumption between anterior (ALIF) and direct lateral (DLIF) lumbar interbody fusions

Methods:
A prospectively maintained database was retrospectively reviewed for patients undergoing a single-level, stand-alone, lumbar interbody fusion. The selected cohort was further stratified based upon the surgical approach: ALIF vs DLIF. Patient demographics, comorbidity burden (CCI), intra-operative parameters, and in-hospital complications, were assessed. Cumulative and daily in-hospital oral morphine equivalent (OME) doses (mg) were recorded and assessed with regards to the postoperative day (POD) 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: Of the 65 patients included in this analysis, 50 underwent an ALIF and 15 underwent a DLIF. DLIF-treated patients were older (61.6±11.9 vs 44.9±11.9, p<0.05) and demonstrated a greater comorbidity burden (CCI: 3.36±2.09 vs 1.44±1.34, p<0.05), than ALIF patients. There were no significant differences in surgical times, length of hospitalization, or in-hospital complications between the two cohorts. Patients discharged on POD 3 following an ALIF demonstrated greater daily narcotic consumption on POD 2 compared to ALIF-treated patients discharged on that day. In addition, ALIFs were associated with greater cumulative narcotic requirements compared to the DLIF technique regardless of the day of discharge. However, this was only significant between patients discharged on POD 3 (63.7±48.5 vs 120.4±52.8, p<0.05).

Conclusions:
The two approaches assessed in this study demonstrated comparable intraoperative parameters, length of hospitalization, and rates of in-hospital complications. However, the less invasive DLIF approach was associated with lower narcotic requirements than the open anterior approach for a single-level, stand-alone lumbar arthrodesis. Although further large-scale studies are warranted, these findings suggest that a minimally invasive approach to the lumbar spine may result in less narcotic consumption compared to an open approach.