Abstract
Study Design:
Single-center, multi-surgeon, retrospective review.
Objective:
Evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes.
Summary of Background Data:
Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain.
Methods:
Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient reported outcome measures, return to drive, return to work and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days.
Results:
In total, 123 MI-L patients and 107 MI-TLIF patients were included. 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of 7 and 11 days. 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male gender (OR 3.57) and preoperative SF-12 PCS (OR 1.08) are associated with return to driving by 15 days. Male gender (OR 3.23) and preoperative SF-12 PCS (OR 1.07) are associated with return to work by 30 days. Preoperative VAS back was associated with decreased odds of discontinuing opioids by 15 days (OR 0.84).
Conclusion:
Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.
MINI ABSTRACT
This study found that not only do most patients return to drive, return to work and discontinue opioids following MI-L or MI-TLIF, there are certain preoperative factors like gender, preoperative physical function and preoperative pain that are associated with the timing of these outcomes.
INTRODUCTION
Postoperative recovery is a common discussion topic for patients during their preoperative counseling. Specifically, the timing of return to everyday activities following surgery can be a significant source of concern for many patients. While the term “everyday activities” can signify different meanings for patients, some of the more commonly analyzed activities in the literature include driving, working, and discontinuation of opioid pain medications. There is a paucity of data that reports on these parameters following minimally invasive spine surgery.1–6
As preoperative counseling and expectation-setting are important for optimizing postoperative outcomes and patient satisfaction,7,8 shedding light on this topic will allow spine surgeons to better guide their patients in a shared-decision making environment. The importance of “return-to-activities” is particularly salient for minimally invasive procedures as these procedures aim to minimize surgical morbidity in an attempt to speed postoperative recovery.9–21
This study sought to establish the timing of return to three commonly performed activities in patients undergoing one-level minimally invasive lumbar laminectomy (MI-L) and one-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). Additionally, we sought to evaluate preoperative factors associated with return to activities after these procedures.
MATERIALS & METHODS
Patient population
This was a retrospective review of prospectively collected data of patients that underwent primary, elective, single-level MI-L or MI-TLIF. Patients were included if at least 18 years of age, underwent these procedures for lumbar spinal stenosis with or without spondylolisthesis between April 2017 and October 2021 by one of three fellowship-trained spine surgeons, and if they had at least 3 months of follow-up. Patients who underwent non-elective or revision surgery, or surgery for trauma, tumor or fractures were excluded.22 All surgeries were performed using an MIS tubular approach, using surgical techniques previously described in the literature.23–25
Postoperative Guidelines
For return to driving, all three surgeons required patients to be off prescription pain medication and recommended 1–2 weeks as tolerated. For return to work, all three surgeons allowed remote work immediately but otherwise recommended return to work at the earliest at 1 week after MI-L and 4 weeks after MI-TLIF. One surgeon counseled patients that return to work around 6 weeks instead of 4 weeks after MI-TLIF was also acceptable. For both MI-L and MI-TLIF, prescriptions were typically 30 tabs of tramadol 50mg every 6 hours as needed (q6h PRN) or 20–30 tabs oxycodone 5mg q6h PRN with no refills. All surgeons aimed to discontinue opioids before 4 weeks, with 1 surgeon aiming for transition to NSAIDs by 2 weeks. The other two surgeons counseled patients that 1 month of opioid use is acceptable unless the patient had preoperative opioid use, which typically increased expected time until opioid discontinuation.
Data collection
Patient demographics and other baseline characteristics were obtained from electronic medical records. Patient reported outcome measures (PROMs) including Oswestry Disability Index (ODI), Visual Analog Scale (VAS) for back and leg pain, Short Form-12 physical and mental score components (SF-12 PCS and SF-12 MCS), and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), which have been validated for use in minimally invasive lumbar surgery, were collected preoperatively.26
In this study, the term ‘return-to-activities’ served as the umbrella phrase for return to driving, return to work, and discontinuation of opioids. Data were collected and managed using REDCap (Research Electronic Data Capture),27,28 which was hosted at the Weill Cornell Medicine Clinical and Translational Science Center and supported by the following grant: CTSC GRANT UL1 TR002384.
Patients were followed up at office visits or via email at 2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years postoperatively. At the first follow-up visit in which patients completed the return-to-activities questionnaire, they were asked if they were regularly driving and/or working before their surgery. If they answered “yes”, they were asked if they had returned to that activity after surgery, and the exact date of return. Patients were also asked whether they had discontinued opioids after surgery, and if so, to specify the date of opioid cessation. Return to work counted as the first date of returning to a full day of remote or in-person work. When applicable, patients were asked to grade their preoperative employment as sedentary, light, medium, or heavy. “Sedentary” work included secretary, typist, engineer, teacher, etc. “Light” work included jobs in administration, sales, business, and finance. Examples of “medium” work were waiter, cook, and mechanic, and examples of “heavy” occupations were farm operator, construction worker, and freight mover. The number of days it took for patients to return to each activity and to discontinue opioids were calculated.
Statistical analysis
Descriptive statistics, including the mean, standard deviations, median, and interquartile ranges (IQR), were calculated for demographic variables, PROMs and return-to-activity measures.
For patients who returned to activity, individual logistic regressions were conducted to identify factors associated with return to driving by 15 days, work by 30 days, and for discontinuing opioids by 15 days. 15-day (~ ½ month) and 30-day (1 month) cutoffs were chosen based on both what surgeons perceived as clinically meaningful for return to activity as well as existing literature.29–33 A composite group analysis was also performed for patients who were driving preoperatively, working preoperatively, used opioids postoperatively, and returned to all three activities. Regression was performed for return to all activities by 30 days using latest activity return date. Variables in the regression analyses included all patient demographics and preoperative PROMs (Appendix A). Variables with p<0.2 in the individual regression were included in multiple regressions. Stepwise elimination was performed in order to create a simple multivariate model without overfitting. Variables were eliminated if p>0.1. Age, gender, and type of surgery were kept in each regression to appropriately control for these variables. Stepwise elimination ended if the overall model reached statistical significance or until only the three control variables were remaining. Odds ratios were reported for each variable and the variance of the logistic model was reported using Nagelkerke R2.
The significance level for all statistical tests was 0.05. All analyses were performed using SPSS Statistics Version 24.0 (IBM Corp., Armonk, NY).
RESULTS
Patient Characteristics
Patient demographics are shown in Table 1. Among the 123 patients who received MI-L, 80/111 (72.1%) drove preoperatively, 62/113 (54.9%) worked preoperatively, 71/108 (65.7%) used opioids postoperatively, and 26/123 (21.1%) did all three. Notably, the MI-L cohort had more males and an average Charlson Comorbidity Index greater than 2. Among the 107 patients who received MI-TLIF, 83/102 (81.4%) subjects drove preoperatively, 63/101 (62.4%) worked preoperatively, 94/106 (88.7%) used opioids postoperatively, and 45/107 (42.1%) did all three. Preoperative PROMs are shown in Table 2, and the overall survey completion rates ranged from 84.6% to 96.1%.
Table 1.
Patient Demographics
| MI-L (n = 123) | MI-TLIF (n = 107) | |||||||
|---|---|---|---|---|---|---|---|---|
| Driving | Work | Opioids | Composite | Driving | Work | Opioids | Composite | |
| N analyzed | 80 (65%) | 62 (50.4%) | 71 (57.7%) | 26 (21.1%) | 83 (77.6%) | 63 (58.9%) | 94 (87.9%) | 45 (42.1%) |
| Not applicable* | 31 (25.2%) | 51 (41.5%) | 37 (30.1%) | 97 (78.9%) | 19 (17.8%) | 38 (35.5%) | 12 (11.2%) | 62 (57.9%) |
| No response | 12 (9.8%) | 10 (8.1%) | 15 (12.2%) | 0 (0%) | 5 (4.7%) | 6 (5.6%) | 1 (0.9%) | 0 (0%) |
| Age | 67.6 ± 10.2 | 63.3 ± 12.4 | 64.6 ± 12.6 | 62.1 ± 8.7 | 61 ± 11.6 | 59 ± 11.7 | 61 ± 11.4 | 58.4 ± 11.7 |
| Gender | ||||||||
| Female | 26 (32.5%) | 18 (29%) | 29 (40.8%) | 5 (19.2%) | 42 (50.6%) | 28 (44.4%) | 55 (58.5%) | 18 (40%) |
| Male | 54 (67.5%) | 44 (71%) | 42 (59.2%) | 21 (80.8%) | 41 (49.4%) | 35 (55.6%) | 39 (41.5%) | 27 (60%) |
| BMI | 26.7 ± 4.09 | 26.9 ± 4.58 | 27.3 ± 5 | 27.1 ± 5.16 | 28 ± 6.1 | 28.2 ± 5.27 | 27.7 ± 6.24 | 28.7 ± 5.81 |
| Race | ||||||||
| Non-Caucasian | 9 (11.3%) | 6 (9.7%) | 9 (12.7%) | 3 (11.5%) | 11 (13.3%) | 15 (23.8%) | 14 (14.9%) | 8 (17.8%) |
| Caucasian | 71 (88.8%) | 56 (90.3%) | 62 (87.3%) | 23 (88.5%) | 72 (86.7%) | 48 (76.2%) | 80 (85.1%) | 37 (82.2%) |
| Insurance Type | ||||||||
| Non-Commercial | 38 (47.5%) | 18 (29%) | 30 (42.3%) | 5 (19.2%) | 25 (30.1%) | 15 (23.8%) | 30 (31.9%) | 10 (22.2%) |
| Commercial/Private | 42 (52.5%) | 44 (71%) | 41 (57.7%) | 21 (80.8%) | 58 (69.9%) | 48 (76.2%) | 64 (68.1%) | 35 (77.8%) |
| Charlson Combined Age-Comorbidity Score | 2.93 ± 1.69 | 2.34 ± 1.65 | 2.51 ± 1.88 | 2.36 ± 1.80 | 0.65 ± 1.06 | 0.47 ± 0.84 | 0.48 ± 0.94 | 0.45 ± 0.82 |
| Current smoker | ||||||||
| No | 66 (94.3%) | 54 (93.1%) | 51 (92.7%) | 24 (96%) | 78 (96.3%) | 60 (96.8%) | 85 (94.4%) | 43 (97.7%) |
| Yes | 4 (5.7%) | 4 (6.9%) | 4 (7.3%) | 1 (4%) | 3 (3.7%) | 2 (3.2%) | 5 (5.6%) | 1 (2.3%) |
| Duration of symptoms | ||||||||
| ≤1 year | 41 (51.9%) | 30 (48.4%) | 35 (49.3%) | 9 (34.6%) | 33 (41.8%) | 30 (50.8%) | 38 (42.7%) | 22 (52.4%) |
| >1 year | 38 (48.1%) | 32 (51.6%) | 36 (50.7%) | 17 (65.4%) | 46 (58.2%) | 29 (49.2%) | 51 (57.3%) | 20 (47.6%) |
| Type of occupation | ||||||||
| Sedentary | - | 23 (39%) | - | 11 (44%) | - | 19 (31.7%) | - | 13 (31%) |
| Light | - | 29 (49.2%) | - | 12 (48%) | - | 30 (50%) | - | 21 (50%) |
| Medium | - | 5 (8.5%) | - | 1 (4%) | - | 6 (10%) | - | 4 (9.5%) |
| Heavy | - | 2 (3.4%) | - | 1 (4%) | - | 5 (8.3%) | - | 4 (9.5%) |
| Preoperative opioid use | ||||||||
| No | 51 (73.9%) | 42 (72.4%) | 36 (65.5%) | 16 (64%) | 67 (82.7%) | 50 (80.6%) | 72 (80%) | 35 (79.5%) |
| Yes | 18 (26.1%) | 16 (27.6%) | 19 (34.5%) | 9 (36%) | 14 (17.3%) | 12 (19.4%) | 18 (20%) | 9 (20.5%) |
Reported as mean ± SD. BMI, body mass index. MI-L, Minimally invasive lumbar laminectomy. MI-TLIF, Minimally invasive transforaminal lumbar interbody fusion. Preoperative opioid use defined as any active opioid prescriptions noted at the last office visit.
Not applicable includes patients who were not driving preoperatively, not working preoperatively or never took opioid pain medication postoperatively.
Table 2.
Pre-operative Patient Reported Outcome Measures
| MI-L (n=123) | MI-TLIF (n=107) | |||||||
|---|---|---|---|---|---|---|---|---|
| Driving | Work | Opioids | Composite | Driving | Work | Opioids | Composite | |
| N | 80 | 62 | 71 | 26 | 83 | 63 | 94 | 45 |
| ODI | 34.3 ± 17.2 | 34.4 ± 16.6 | 42 ± 16.8 | 34.6 ± 15.6 | 37.8 ± 19.5 | 37.4 ± 17.8 | 38.1 ± 18.7 | 36.7 ± 19.7 |
| VAS Back | 4.31 ± 2.9 | 4.33 ± 3.15 | 5.68 ± 2.71 | 4.85 ± 2.88 | 5.51 ± 3.07 | 5.41 ± 2.97 | 5.33 ± 3.09 | 5.27 ± 3.05 |
| VAS Leg | 5.59 ± 2.99 | 5.46 ± 3.2 | 5.96 ± 2.96 | 5.46 ± 3 | 5.5 ± 3.35 | 5.46 ± 3.41 | 5.49 ± 3.32 | 4.87 ± 3.59 |
| SF12 PCS | 33.6 ± 8.81 | 34.3 ± 8.87 | 31.1 ± 7.71 | 34.5 ± 8.36 | 32.4 ± 8.81 | 33.6 ± 8.87 | 32.3 ± 8.81 | 34 ± 9.63 |
| SF12 MCS | 49.5 ± 11.7 | 47.6 ± 12.1 | 44.7 ± 11.4 | 46.1 ± 13.1 | 51.8 ± 10.9 | 50.7 ± 10.3 | 50.6 ± 11 | 52 ± 10.6 |
| PROMIS PF | 37.4 ± 7.68 | 37.6 ± 8.28 | 35.1 ± 8.74 | 40.1 ± 9.1 | 36.7 ± 6.96 | 37.2 ± 7.46 | 36.1 ± 6.7 | 37.5 ± 7.09 |
| Overall Survey Completion Rate | (89%) | (87.4%) | (89%) | (84.6%) | (94%) | (95.8%) | (96.1%) | (95.6%) |
Reported as Mean ± SD. MI-L, Minimally invasive lumbar laminectomy. MI-TLIF, Minimally invasive transforaminal lumbar interbody fusion. ODI, Oswestry Disability Index. VAS, Visual Analog Scale. SF12 PCS, Short Form Physical Component Score. SF12 MCS, Short Form Mental Component Score. PROMIS, Patient-Reported Outcomes Measurement Information System.
Return to Driving
Eighty MI-L patients and 83 MI-TLIF patients drove preoperatively. 71 (88.8%) subjects in the MI-L group, and 80 (96.4%) of the MI-TLIF group returned to driving. The median number of days taken to return to driving was 11 [IQR 5–25] days for MI-L patients and 18.5 [IQR 14–30] days for MI-TLIF patients (Table 3). Male patients were more likely to return to driving at 15 days (OR 3.57, 95CI [1.64,7.69], p=0.001) (Table 4). The odds ratio for a 1 unit increase in preoperative SF-12 PCS was 1.08 (95CI [1.02, 1.12], p=0.004).
Table 3.
Return to Activities
| MI-L (n=123) | MI-TLIF (n=107) | |||||||
|---|---|---|---|---|---|---|---|---|
| Driving | Work | Opioids | Composite | Driving | Work | Opioids | Composite | |
| N | 80 | 62 | 71 | 26 | 83 | 63 | 94 | 45 |
| RTA | 71 (88.8%) | 57 (91.9%) | 63 (88.7%) | 25 (96.2%) | 80 (96.4%) | 54 (85.7%) | 87 (92.6%) | 45 (100%) |
| Median (days) | 11 | 14 | 7 | 27 | 18.5 | 25 | 11 | 31 |
| IQR (days) | 5–25 | 4.5–32 | 4–17 | 14–53.5 | 14–30 | 14–49.75 | 5–18 | 18.5–49 |
| Range (days) | 1–880 | 1–880 | 1–365 | 3–880 | 2–133 | 1–150 | 1–727 | 2–150 |
MI-L, Minimally invasive lumbar laminectomy. MI-TLIF, Minimally invasive transforaminal lumbar interbody fusion. IQR = interquartile range (25th-75th percentile).
Table 4.
Logistic Regression for Return to Activities
| Outcome | Variable | Odds Ratio | 95% CI | p value | Model performance |
|---|---|---|---|---|---|
| Return to drive by 15 days | Age | 1.03 | [1, 1.08] | 0.065 |
p < 0.001 R2 = 0.289 Accuracy = 72.5% |
| Male (vs Female) | 3.57 | [1.64, 7.69] | 0.001 | ||
| MI-L (vs MI-TLIF) | 2.08 | [0.95, 4.54] | 0.066 | ||
| Pre-operative SF-12 PCS | 1.08 | [1.02, 1.12] | 0.004 | ||
| Return to work by 30 days | Age | 1.04 | [1, 1.08] | 0.051 |
p < 0.001 R2 = 0.282 Accuracy = 73.5% |
| Male (vs Female) | 3.23 | [1.27, 8.2] | 0.014 | ||
| MI-L (vs MI-TLIF) | 2.58 | [1, 6.64] | 0.049 | ||
| Pre-operative SF-12 PCS | 1.07 | [1.01, 1.13] | 0.029 | ||
| Discontinuation of opioids by 15 days | Age | 1.00 | [0.97, 1.03] | 0.783 |
p = 0.057 R2 = 0.087 Accuracy = 70.4% |
| Male (vs Female) | 1.30 | [0.62, 2.73] | 0.493 | ||
| MI-L (vs MI-TLIF) | 1.56 | [0.72, 3.37] | 0.256 | ||
| Pre-operative Back VAS | 0.84 | [0.73, 0.96] | 0.011 | ||
| Return to all activities by 30 days | Age | 1.02 | [0.97, 1.08] | 0.379 |
p = 0.028 R2 = 0.209 Accuracy = 65.6% |
| Male (vs Female) | 2.92 | [0.95, 9.01] | 0.062 | ||
| MI-L (vs MI-TLIF) | 1.91 | [0.59, 6.17] | 0.278 | ||
| Pre-operative SF-12 PCS | 1.06 | [1, 1.13] | 0.064 |
CI, Confidence Interval. MI-L, Minimally invasive lumbar laminectomy. MI-TLIF, Minimally invasive transforaminal lumbar interbody fusion. VAS, Visual Analog Scale. SF12 PCS, Short Form Physical Component Score.
Return to Work
Sixty-two MI-L patients and 63 MI-TLIF patients were working preoperatively. 57 (91.9%) subjects in the MI-L group, and 54 (85.7%) of the MI-TLIF group returned to work. The median number of days taken to return to work was 14 [IQR 4.5–32] days for MI-L patients and 25 [IQR 14–49.75] days for MI-TLIF patients (Table 3). Male patients were significantly more likely to return to work by 30 days (OR 3.23, 95CI [1.27,8.2], p=0.014) (Table 4). The odds ratio for a 1 unit increase in preoperative SF-12 PCS was 1.07 (95CI [1.01,1.13], p=0.029). Also, MI-L was significantly associated with return to work by 30 days (OR 2.58, 95CI [1,6.64], p=0.049).
Discontinuation of Opioids
Of 108 total MI-L patients, 37 (34.3%) patients did not take any opioids postoperatively, while the remaining 71 (65.7%) did. Similarly, 12/106 (11.3%) MI-TLIF patients did not take any opioids postoperatively, while 94/106 (88.7%) did. The 71 MI-L patients and 94 MI-TLIF patients who required opioids postoperatively were included for analysis. 63 (88.7%) subjects in the MI-L group, and 87 (92.6%) of the MI-TLIF group discontinued opioids. The median number of days taken discontinue opioids was 7 [IQR 4–17] days for MI-L patients and 11 [IQR 5–18] days for MI-TLIF patients (Table 3). The odds ratio for a 1 unit increase in preoperative Back VAS was OR 0.84 (95CI [0.73,0.96], p=0.011).
Return to All Activities
Twenty-six MI-L patients and 45 MI-TLIF patients were driving preoperatively, working preoperatively, and taking opioids postoperatively. 25 (96.2%) subjects in the MI-L group and 45 (100%) of the MI-TLIF group returned to all three activities. The median number of days was 27 [IQR 14–53.5] days for MI-L patients and 31 [IQR 18.5–49] days for MI-TLIF patients (Table 3). No variables demonstrated statistical significance.
DISCUSSION
There is a paucity of data on the timing of return to activity following commonly performed minimally invasive surgery. This study assessed the number of days to return to driving, return to work, and discontinue opioids in patients undergoing elective, single-level MI-L and MI-TLIF. This study found that MI-L patients returned to driving, returned to work, and discontinued opioids by 11, 14 and 7 days, respectively. MI-TLIF patients returned to driving, returned to work, and discontinued opioids by 18.5, 25 and 11 days, respectively. MI-L and MI-TLIF are presented here as a case series as they are not interchangeable procedures, and each have their own indications.
Return to Driving
MI-L patients returned to driving within 2 weeks and MI-TLIF patients returned to driving within 3 weeks. Male patients had greater odds of returning to drive by 15 days. The association with gender echoes findings from a previous study, which found that females were more likely than males to significantly reduce driving under certain adverse conditions and for certain elective purposes.34
Additionally, a patient with a higher preoperative SF-12 PCS was more likely to return to driving by 15 days. Although there are no previous studies that reported similar findings in minimally invasive surgery, this finding is intuitive since it is expected that better physical health would allow for faster time to return to driving. One prospective study with 30-day follow-up found that both sequestrectomy and conventional microdiscectomy for lumbar disc herniation had a positive effect on braking response time and improvement in pain.6 Our study adds to this literature and aims to provide patients and surgeons with some expectation on ability to drive and time to return to driving in the context of minimally invasive spine surgery. Other preoperative variables were not associated with return to driving. However, with larger sample sizes and a broader patient population, there may be significant predictor variables. Return to driving may not be applicable to patients in certain demographics, but for patients who need to drive, this data can provide more detailed expected outcomes.
Return to Work
MI-L patients returned to work within 2 weeks postoperatively, and MI-TLIF patients returned to work within 4 weeks postoperatively. This higher median justified using 30 days as the outcome variable since it would create a more meaningful model for the majority of our patient population. One prospective study by Parker et al. found MI-TLIF patients returned to work in a median of 7 days compared to 11 days for open TLIF patients.16 Their findings are not consistent with our results and not easily explained by any reported differences in patient demographics. One explanation would be the difference in the level of social support or socioeconomic status between our patient populations. Alternatively, our surgeons counseled return to work around 4 weeks, but Parker et al. reported their surgeons recommended as early as 3 weeks. Our study time period also overlapped with the COVID-19 pandemic which could have played a role.
There are limited data that identify specific factors that are associated with time to return to work after minimally invasive surgery.2–4,19 Previous studies have generally been retrospective with limited sample sizes and have not reported regression analyses. A previous retrospective analysis on a national prospective outcomes registry described a predictive model for return to work after elective, open surgery for lumbar degenerative disease, and found patients with manual labor as an occupation, higher preoperative ODI score, female sex, African American race, history of diabetes, lower education level, among other variables, to have lower likelihood to return to work by 3 months.22 Our study adds to this body of literature by focusing on time to return to work after two minimally invasive procedures, as well as by including physical function (SF-12 PCS) as a predictor.
Patients with a higher preoperative SF-12 PCS were more likely to return to work by 30 days. Again, this may be attributable to the fact that patients with higher SF-12 PCS are likely in better overall physical health preoperatively and may thus experience faster recovery. This pattern is consistent with our observations but has not been quantitatively described. Most patients in both the MI-L and MI-TLIF groups described their occupation status as sedentary or light, which may be associated with jobs that allow for longer medical leaves or partial return to work, compared to more intensive occupations. Less than 20% in both groups had medium- and heavy-type. Although these frequencies may adequately reflect our patient population, it may not be generalizable to others. Another limitation from this analysis is that we did not distinguish whether patients had physically returned to work or returned to remote work. The COVID-19 pandemic has altered work culture, and it is unclear whether this national trend would lead to our patients returning to work earlier or later than expected postoperatively.
Discontinuation of Opioids
Previous retrospective studies have aimed to predict length of postoperative opioid use after lumbar surgery. Cook et al. retrospectively reviewed a nationwide insurance claims database to explore the duration and magnitude of postoperative opioid prescriptions following open spine surgery.35 Among the opioid-naïve patients, they found that 63% of lumbar decompression patients and 68% of transforaminal/posterior interbody fusion patients filled an opioid prescription postoperatively, compared to our 57.7% and 87.9%, respectively. Their survival curve also demonstrated ~25 and ~50 days until 50% cessation, for decompression and fusion respectively, but included long-term users, whereas our reported medians exclude patients using opioids past 3 months.
In a prospective study of opioid-naïve patients who underwent one-level lumbar decompression or microdiscectomy, Lovecchio et al. found that the average length of opioid use was 8.7 ± 6.9 days and at 6 weeks, only 8.2% of patients were still taking opioids.36 Our median of 7 days to opioid cessation in the MI-L group is comparable, but 11.3% of MI-L patients were still taking opioids at 3 months. This could be explained by our inclusion of patients with preoperative opioid use.
Despite the type of surgery, efficient use of opioids and postoperative pain management are critical aspects of surgical intervention. In this study, we aimed to provide better quantitative data behind two minimally invasive spine surgeries with the broader goal of creating a clearer postoperative picture for patients. Preoperative opioid use was not associated with a greater number of days to discontinue opioids. This finding differs from previous studies have shown that preoperative use of opioid is associated with longer duration of opioid use postoperatively both in lumbar decompression and in fusion patients.37,38
Return to All Activities
For patients looking to return to driving, work and to discontinue opioids, male gender and a higher preoperative SF-12 PCS were not statistically significant. This composite analysis may be isolating a group of particularly healthy patients, and the success of these patients may be attributable to factors not controlled for in this study. Also, the composite analysis only applied to 26 (MI-L) and 45 (MI-TLIF) patients so the sample size was small. Another limitation in analyzing the composite groups is that driving, working and discontinuation of opioids are not independent activities. For example, for a patient who is still taking opioids, they may not be able to drive, which is preventing them from driving to work. Another example would be if a patient cannot return to work, they may try to limit costs by reducing medications.
Limitations
The study was a retrospective review which introduces selection bias. This was a single-institution study, limiting the external validity. The minimum follow-up was 3 months, so patients with delayed return to activity may not have been captured. Although the analysis was not stratified by surgeon, the return to activtiy guidelines between the three surgeons were largely similar. The reasons for failure to return to an activity were not collected. For return to work, baseline socioeconomic status or level of social support are not accounted for. Additionally, most patients had sedentary or light occupations, so our finidngs are less generalizable to medium or heavy type jobs. Larger sample sizes to stratify by occupation type are required in future studies. For opioid discontinuation, duration or quantity of preoperative opioid use were not collected as well as the quantity of postoperative opioids used.
Conclusions
MI-L patients returned to driving, work, and discontinued opioids within 2 weeks postoperatively, and MI-TLIF patients did so within 4 weeks. Male gender and a high SF-12 PCS are associated with for return to driving by 15 days and work by 30 days. A lower Back VAS is associated with opioid discontinuation by 15 days. These return to activity findings may serve as an important compass for preoperative counseling and may be integrated with perioperative data to ultimately build a classification system.21 Larger studies are warranted to confirm our results with greater confidence and identify other factors that may be associated with patient recovery.
KEY POINTS.
Over 85% of MI-L and MI-TLIF patients return to drive, return to work, and discontinue opioids.
Following MI-L and MI-TLIF, patients returned to each activity in no more than a median of 2 and 4 weeks respectively.
Male gender and a higher preoperative SF-12 PCS are associated with return to drive by 15 days.
Male gender and a higher preoperative SF-12 PCS are associated with return to work by 30 days.
A lower preoperative VAS back is associated with discontinuation of opioids by 15 days.
Source of Funding:
No direct funding was received for this study. However, the study used REDCap (Research Electronic Data Capture) hosted at Weill Cornell Medicine Clinical and Translational Science Center supported by the National Center For Advancing Translational Science of the National Institute of Health (NIH) under award number: UL1 TR002384.
Conflicts of Interest and Source of Funding:
The manuscript submitted does not contain information about medical device(s)/drug(s)
Appendix A. Univariate (Individual) Regression
| Return to Driving by 15 days | Return to Work by 30 days | Discontinuation of Opioids by 15 days | Return to All Activities by 30 days | |||||
|---|---|---|---|---|---|---|---|---|
| Variable | Odds Ratio (95% CI) | p value | Odds Ratio (95% CI) | p value | Odds Ratio (95% CI) | p value | Odds Ratio (95% CI) | p value |
| Age | 1.04 (1.01, 1.07) | 0.009 | 1.05 (1.01, 1.09) | 0.006 | 1 (0.97, 1.03) | 0.962 | 1.03 (0.99, 1.08) | 0.190 |
| Male (ref: Female) | 3.56 (1.8, 7.04) | <0.001 | 3.26 (1.43, 7.41) | 0.005 | 1.48 (0.74, 2.95) | 0.267 | 3.02 (1.07, 8.55) | 0.037 |
| BMI | 1 (0.93, 1.08) | 0.927 | 0.97 (0.88, 1.06) | 0.489 | 0.95 (0.88, 1.03) | 0.196 | 0.97 (0.88, 1.08) | 0.613 |
| Caucasion race (ref: non-caucasion) | 2.22 (0.79, 6.29) | 0.131 | 2.75 (0.99, 7.69) | 0.053 | 0.6 (0.21, 1.76) | 0.354 | 0.92 (0.25, 3.36) | 0.903 |
| Commercial/private insurance (ref: non-commercial) | 0.52 (0.27, 1.01) | 0.053 | 0.44 (0.16, 1.21) | 0.112 | 0.66 (0.32, 1.39) | 0.276 | 0.69 (0.22, 2.21) | 0.533 |
| CCI Age | 1.34 (1.08, 1.67) | 0.008 | 1.35 (1, 1.81) | 0.050 | 1.18 (0.9, 1.54) | 0.222 | 1.28 (0.89, 1.85) | 0.179 |
| Current Smoker (ref: no) | 1.05 (0.2, 5.38) | 0.957 | 0.87 (0.14, 5.43) | 0.879 | 1.16 (0.22, 6.25) | 0.861 | -- | -- |
| Preoperative ODI | 0.98 (0.96, 1) | 0.022 | 0.97 (0.95, 1) | 0.045 | 0.99 (0.97, 1.01) | 0.143 | 0.98 (0.95, 1.01) | 0.167 |
| Pre-operative Back VAS | 0.88 (0.78, 0.98) | 0.022 | 0.93 (0.81, 1.06) | 0.291 | 0.84 (0.74, 0.96) | 0.011 | 0.82 (0.68, 0.98) | 0.028 |
| Pre-operative Leg VAS | 0.93 (0.84, 1.04) | 0.187 | 1.01 (0.89, 1.14) | 0.869 | 0.93 (0.83, 1.04) | 0.215 | 0.97 (0.84, 1.12) | 0.678 |
| Pre-operative SF-12 PCS | 1.07 (1.02, 1.11) | 0.003 | 1.06 (1.01, 1.12) | 0.020 | 1.04 (1, 1.09) | 0.071 | 1.06 (1, 1.12) | 0.051 |
| Pre-operative SF-12 MCS | 1.01 (0.98, 1.04) | 0.661 | 1.01 (0.97, 1.05) | 0.690 | 0.99 (0.96, 1.02) | 0.452 | 0.99 (0.95, 1.03) | 0.523 |
| Pre-operative PROMIS PF | 1.04 (0.99, 1.09) | 0.152 | 1.04 (0.98, 1.11) | 0.182 | 1.04 (0.99, 1.1) | 0.116 | 1.03 (0.97, 1.11) | 0.340 |
| Duration of symptoms > 1yr (ref: ≤ 1yr) | 1.05 (0.55, 2.02) | 0.874 | 0.62 (0.28, 1.39) | 0.246 | 0.92 (0.45, 1.87) | 0.818 | 1.31 (0.5, 3.45) | 0.582 |
| Pre-operative Opioid Use (ref: no) | 1.04 (0.47, 2.29) | 0.925 | 0.49 (0.2, 1.24) | 0.131 | 0.59 (0.26, 1.35) | 0.209 | 0.5 (0.17, 1.5) | 0.217 |
| Education level (ref: less than highschool) | 1.43 (1.03, 1.98) | 0.032 | 1.15 (0.78, 1.69) | 0.478 | 1.4 (1.02, 1.92) | 0.036 | 1.06 (0.68, 1.64) | 0.801 |
| MI-L (vs MI-TLIF) | 3.07 (1.58, 5.96) | <0.001 | 2.24 (1.01, 4.97) | 0.047 | 1.38 (0.69, 2.79) | 0.364 | 2.03 (0.74, 5.55) | 0.167 |
| Type of Occupation (ref: sedentary) | -- | -- | 0.86 (0.59, 1.25) | 0.423 | -- | -- | 0.97 (0.68, 1.39) | 0.890 |
Bolded values indicate p < 0.2 and were included in multivariate regression. BMI, Body Mass Index. CCI Age, Charlson Comorbidity Index Age Adjusted. SF-12 PCS, Short Form 12 Physical Component Score. SF-12 MCS, Short Form 12 Mental Component Score. MI-L, Minimally Invasive Laminectomy. MI-TLIF. Minimally Invasive Transforaminal Lumbar Interbody Fusion. PROMIS, Patient-Reported Outcomes Measurement Information System Physical Function.
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