Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series.

PURPOSE: Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery. METHODS: A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity. RESULTS: Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted. CONCLUSION: 95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

Video-assisted ALIF with cage and anterior plate fixation for L5-S1 spondylolisthesis.

INTRODUCTION: Spondylolysis and spondylolisthesis grade 0, 1, and 2 are mainly asymptomatic but with aging process and different factors some back pain can occur and lead to chronic low back pain. The conservative treatment with physiotherapy and steroid injection is the gold standard but in some cases is not efficient enough and a surgical treatment is proposed. OBJECTIVES: The goal of this study is to propose a new technique to treat grade 0, 1, and 2 spondylolisthesis with an anterior video-assisted fusion and stabilization. METHODS: Twenty patients with chronic low back pain since more than 2 years and resistant to conservative therapy were included in this protocol. Clinical signs and radicular pain were noted. They were evaluated preoperatively and postoperatively until the last follow up using Oswestry score and visual analog score (VAS) for leg and back pain. X-rays showed grade 0 (8 cases), 1 (10 cases), and 2 (2 cases) spondylolisthesis according to Meyerding classification with disc collapse (bulging disc). MRI showed in all cases a disc degeneration with at least black disc and/or endplates changes with Modic I or II. All patients were operated using an anterior video-assisted retroperitoneal approach, with discectomy and fusion using an anterior impacted cage filled with autologous cancellous bone from the iliac crest and an anterior fixation with a triangular plate (Pyramid, Medtronic, Memphis). The follow up at 3, 6, 12, and 24 months was done with clinical and radiologic evaluation. In case of problem a computed tomography scan was performed. RESULTS: There were 11 women and 9 men, with and average age of 39 years old and a BMI of 25.6. All spondylolistheses occurred at level L5. The average slippage was 19%. All L5S1 discs were black, 8 had a Modic I changes in the endplates and 2 had Modic II. The shape of L5 vertebra was abnormal (trapezoidal) in 7 cases. All anterior approaches were performed without vascular, urologic, or digestive complication. Blood loss was inferior to 100 mL. All patients had a soft brace for 8 weeks postoperatively. There was no retrograde ejaculation for the 9 men and no sexual dysfunction reported by the women. One patient had no pain relief and was reoperated for posterior pedicular screw fixation. It was obvious that there was a pseudarthrosis even after the posterior fixation and an anterior transperitoneal revision was performed with the removal of the interbody device and iliac crest bone graft packing alone. A propioni bacterium acnes germ was found responsible for the anterior nonunion. This revision surgery with antibiotics treatment was successful. One of the patients with grade 2 had an additional posterior screw fixation with a minimally invasive pedicle screw system (Sextant, Medtronic, Memphis). Nineteen patients had a good fusion at 2 years follow-up (95%), mean Oswestry score improved from 74% preoperative to 21% postoperative at the last follow-up. Visual analog score (VAS) for back pain improved from 6.5 to 2.7 and VAS for leg pain improved from 6.2 to 3.4. Satisfaction rate was 90%. All active patients except two, were back to work at an average of 5.5 months (6 wk to 1 y). The 2 patients still not working were the nonunion and a work compensation. CONCLUSIONS: The results of this technique compare favorably with posterior stabilization and fusion (posterior lumbar interbody fusion and postero-lateral fusion) reported in the literature. Unlike posterior lumbar interbody fusion, however, it seems that the complication rate due to the approach is much lower, the fusion rate is similar. Grade 2 SPL is the limitation of the technique. The main advantage of the technique is to avoid posterior muscle damage and a quick recovery with no blood loss. Preservation of adjacent level disease can be assessed only after long-term follow-up.