Enhanced Recovery After Surgery Pathway for Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Decreases Length of Stay and Opioid Consumption

Neurosurgery. 2021 Feb 16;88(3):648-657. doi: 10.1093/neuros/nyaa493.


Background: Opioid requirements in the perioperative period in patients undergoing lumbar spine fusion surgery remain problematic. Although minimally invasive surgery (MIS) techniques have been developed, there still remain substantial challenges to reducing length of hospital stay (LOS) because of postoperative opioid requirements.

Objective: To study the effect of implementing an enhanced recovery after surgery (ERAS) pathway in patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF) at our institution.

Methods: We implemented an ERAS pathway in patients undergoing an elective single-level MIS TLIF for degenerative changes at a single institution. Consecutive patients were enrolled over a 20-mo period and compared with a pre-ERAS group prior to the implementation of the ERAS protocol. The primary outcome was LOS. Secondary outcomes included reduction in morphine milligram equivalent units (MME), pain scores, postoperative urinary retention (POUR), and incidence of postoperative delirium. Patients were compared using the chi-square and Welch's 2-sample t-tests.

Results: A total of 299 patients were evaluated in this study: 87 in the ERAS group and 212 in the pre-ERAS group. In the ERAS group, there was a significant reduction in LOS (3.13 ± 1.53 vs 3.71 ± 2.07 d, P = .019), total admission MME (252.74 ± 317.38 vs 455.91 ± 498.78 MME, P = .001), and the number of patients with POUR (48.3% vs 65.6%, P = .008). There were no differences in pain scores.

Conclusion: This is the largest ERAS MIS fusion cohort published to date evaluating a single cohort of patients in a generalizable manner. This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period. There is further work to be done to evaluate patients undergoing other complex spine surgical interventions.

Keywords: Enhanced recovery; Fast track; Length of stay; MIS transforaminal lumbar interbody fusion (TLIF); Morphine milligram equivalent; Opioid intake; Urinary retention.

MeSH terms

  • Aged
  • Analgesics, Opioid / administration & dosage*
  • Cohort Studies
  • Enhanced Recovery After Surgery*
  • Female
  • Humans
  • Length of Stay / trends*
  • Lumbar Vertebrae / surgery*
  • Male
  • Middle Aged
  • Minimally Invasive Surgical Procedures / methods
  • Minimally Invasive Surgical Procedures / trends*
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Spinal Fusion / methods
  • Spinal Fusion / trends*
  • Treatment Outcome


  • Analgesics, Opioid