Comparative analysis of acute postoperative pain and opioid use between lateral transpsoas, anterior, and transforaminal lumbar interbody fusions.

BACKGROUND

The lateral transpsoas lumbar interbody fusion is associated with transient postoperative anterior thigh and inguinal dysesthesias and hip flexor weakness from manipulation of the psoas and interposed lumbar plexus. However, it remains unclear whether this translates to higher pain scores and opioid requirements.

METHODS

Patients who had undergone one- or two-level extreme/direct (XLIF/DLIF), anterior (ALIF), or transforaminal lumbar interbody fusion (TLIF) between January 2018 and December 2023 for degenerative spinal pathology were included. All cases were further classified as standalone or pedicle screw-fixated, and pedicle screw-fixated was included as a covariate. Outcomes were assessed using multivariable linear or binary logistic regression and included length of stay (LOS), inpatient daily maximum pain scores, inpatient morphine-equivalent daily dosage, and total inpatient morphine milligram equivalents, 30- and 90-day complications, emergency department visits, return to operating room, and readmission, and 90-day and 1-year Oswestry Disability Index (ODI) and EuroQuol-5 Dimension (EQ5D).

RESULTS

A total of 936 patients were assessed, including 90 (9.6%) XLIF/DLIFs, 587 (62.7%) TLIFs, and 259 (27.6%) ALIFs. Pedicle screw fixation differed significantly between approaches (TLIF: 100%, ALIF: 51.0%, XLIF/DLIF: 51.1%; p<.001). The XLIF/DLIF approach had the shortest operative time compared to ALIF and TLIF (p<.003). Furthermore, XLIF/DLIF approach was associated with lower 90-day ODI than TLIF (=-21.185; p=.002) and ALIF (=-9.275; p=.043), higher 90-day EQ5D than TLIF (=+27.389; p<.001) and ALIF (=+13.897; p=.001), higher morphine-equivalent daily dosage than TLIF (=+29.115; p<.001) and ALIF (=+11.959; p=.006), and shorter LOS than TLIF (=-45.500 hours; p=.014) and ALIF (=-24.447 hours; p=.049). No significant differences were observed in maximum pain scores, total inpatient morphine milligram equivalents, complications, readmissions, or return to operating room.

CONCLUSIONS

Despite a shorter operative time, shorter LOS, and better 90-day ODI and EQ5D, the lateral transpsoas lumbar interbody fusion is associated with higher postoperative inpatient opioid consumption than TLIF and ALIF.

LEVEL OF EVIDENCE

III.