Minimally Invasive Lumbar Fusion: Is It Actually Less Painful? | #544

Hello and welcome to The Evidence-Based Chiropractor. I'm your host, Dr. Jeff Langmaid. This week we are back with more great research, and this is a really cool study. This one is going to be all about surgical intervention, specifically what's going on, the different approaches, how it affects a patient. I think there's a lot of really important information in this study for patients that might be pre-surgery, maybe they're looking at it, and definitely for all those patients that come in post-surgery, so you have a clearer understanding of what they're dealing with maybe right now and also what they've dealt with post-surgically. So fantastic study, we're going to dive into it and much more on today's episode. Big shout out to some partners before we get started. Leander Tables, you can still save $1,000 off their Series 950. That is going to be changing on June 1st and go to saving $750. So So for maximum savings, connect with their team ASAP. Let them know you're a listener. Use the code EBC2026. You can save $1,000. Additionally, Shockwave Centers of America, $500 off one of their shockwave units and a free cart. $1,500 in savings right there for being a listener. I'm gonna drop those links down in the show notes. But as I talked about at the top, today's episode, all about research. And this is really like kind of what lumbar fusion research can teach us as chiropractors about pain recovery and better patient conversations. I'm gonna drop a link to the study in the show notes as always. It is titled Comparative Analysis of Acute Postoperative Pain and Opioid Use Between Lateral, Transsoas, Anterior, and Transforaminal Lumbar Interbody Fusions. So you probably have heard of minimally invasive surgery. I used to practice and I was actually the director of Total Spine Care at the world's largest outpatient elective minimally invasive spine surgery company. And you might be wondering, okay, is, is this actually better for the patient? Minimally invasive sounds good, but what does that actually mean? Sounds great on the surface. It sounds smaller, sounds faster, sounds easier. But does minimally invasive always mean less pain? And that's where today's research is going to get really interesting. This study came out in 20— 25. And again, they looked at 3 different lumbar fusion approaches. So all these were fusions, um, a TLIF, an ALIF, a lateral transverse fusion, and, uh, which you'll later hear called an XLIF or a DLIF. So TLIF, ALIF, lumbar interbody fusion is the LIF. The first letter, TA or X, are the approaches. So, you know, you might think, well, I'm a chiropractor, I'm not performing lumbar surgery. Exactly. And that's why this episode matters so much, because your patients— if you've been in practice more than a week, your patients are going to start asking you questions about spine surgery. They're seeing spine surgeons, they're Googling spine procedures, they're hearing terms advertised— billboards, television, radio, internet, you name it— minimally invasive, fusion, disc space, stenosis, spondylolisthesis, degenerative changes. And often they're pretty scared. Now, we and you don't need to act like their surgeon. Uh, they need you to help understand, help them understand what questions to ask, so important, how to think about their options, and why conservative care and your care still has such an important role in really the broad spine care ecosystem. And this study, I think, gives us a really great reminder that the approach Matters, the anatomy matters, the patient matters, and less invasive does not always equal less painful in the short term. So today we're gonna talk about this all in plain English. You know, this is really a practical look at what the research found, why it matters, and how you can use it to become the best communicator possible with your patients. The study compared acute postoperative pain and opioid use among patients who underwent, again, lumbar interbody fusion, LIF, LIF, through 3 different approaches: TLIF, transforaminal, ALIF, anterior, and what they call an XLIF, which they interchange with a DLIF, which is lateral trans psoas. So that means the surgeon accessed lumbar spine from, uh, side, of course, traversing and traveling through the psoas muscle. And that last part is really important. The lateral trans psoas approach has become popular because it can spare the posterior spinal muscles and avoid some of the vascular structures that really become super challenging when going anterior. So on paper it seems like a win, but as with everything in life, there's really big trade-offs. To get to the spine laterally, surgeon has to go through the psoas muscle, and the lumbar plexus lives directly in that neighborhood. So there's a, there's a known risk of temporary thigh pain, groin symptoms, sensory issues, hip flexor weakness after those types of procedures. So the study authors wanted to answer a specific question. That question is, does psoas and lumbar plexus manipulation actually translate into higher pain scores or higher opioid use after surgery? I say manipulation, I mean relative to the surgery, not relative to the chiropractic care. So It's a very practical question, 'cause in modern spine surgery, there's a really big emphasis on enhanced recovery after surgery. Protocols focus on better pain control, earlier movement, shorter hospital stays, and reduced opioid exposure. So if there's an approach that helps get patients out of the hospital faster, but require more opioids while they're there, it's worth knowing for all of us. So this was a retrospective cohort study with, uh, 17 spine surgeons. They looked at patients between 18 and 89 years old, um, who went a elective 1 or 2 level lumbar interbody fusion between 2020, uh, 2018, excuse me, and 2023. They included cases for degenerative spinal pathology, spinal stenosis, spondylolisthesis, degenerative disc disease. They excluded procedures relative to trauma, infection, malignancy, or revision. In total, they analyzed just under 1,000 patients, about 580 TLIFs, almost 250 ALIFs, and 90 XLIFs. So this was not a tiny study. The lateral group was of course smaller, as we just highlighted, but the overall data set was definitely strong enough to really provide some meaningful comparisons for us. So they looked at several outcomes including length of stay, inpatient daily pain scores, opioid use, uh, morphine milligram equivalents, complications, ER visits, etc. And they really were trying to see how much pain did patients report, how many— how much opioid medication did they need, how long did they stay in the hospital, what were some of those complications, and how was the function afterward as well. So a really practical set of questions. So if we get into some of the headline findings, again, 936 patients 62% were TLIFs, 27% ALIFs, and just, just under 10% as those XLIFs. The XLIF group had the shortest operative time. Surgeon duration averaged 3.2 hours for the XLIFs compared to 3.4 for the ALIFs and 3.6 for the TLIFs. So that's an interesting fact because it supports the idea that the lateral approach is, is efficient from a surgical perspective. The ex— the XLIF group lateral approach also had the shortest length of stay at 61 hours compared to 65 for the TLIF and 67 for the ALIF. Now, the XLIF group had the highest daily inpatient opioid consumption. Average inpatient morphine equivalent dose was 31 for XLIFs compared to 26 for ALIFs and 24 for TLIFs. So the lateral psoas group had shorter surgeries and shorter hospital stays, but they required a pretty significant amount more opioid medication per day in the hospital. So did they report higher pain scores? Not significantly. The average maximum inpatient pain scores were 7.8 for XLIFs, 7.7 for ALIFs, and 7.5 for TLIFs. So the differences there were not statistically significant. Patients in the XLIF group were not necessarily reporting significantly higher pain scores, but they were receiving significantly more opioids per day. So we'll dive into that in a moment here. So compared to TLIFs, XLIFs were associated with an increased morphine equivalent daily dose of 29 compared to ALIFs associated with an increase of nearly 12. The lateral group also had a significantly shorter stay after care was given. So really, really interesting findings. And the simple version is this, that the lateral psoas approach was faster, it was associated with shorter hospital stays, and it actually even showed better early function at 90 days. But it did require daily opioid medication immediately postoperative during that inpatient period. So that's kind of the tension in this study, and it's also what makes it really clinically useful for us. So, you know, kind of highlighting anatomy briefly, that lateral psoas approach goes through the psoas muscle, as we discussed. That muscle is not just like a random piece of meat, as we know. It's a major hip flexor, and it's intimately related to lumbar biomechanics. And the lumbar plexus runs, runs through it and in and around it. So when the surgical corridor passes through the psoas, even if the incision is smaller and if the posterior musculature is spared, there can still be a lot of tissue irritation, muscle disruption, Nerve issues, temporary neurologic symptoms, all of that. So this paper notes that prior literature has reported transient postoperative thigh or inguinal pain in 62% of patients. So that's a big deal. Now, the word transient also is important. These symptoms are often temporary and may resolve shortly, but sometimes that can be months long. So if you're a— if the patient is experiencing thigh pain, groin symptoms, or hip flexors after surgery, temporary still feels really meaningful in that moment. It could be months before that goes away. And that may explain why opioid use was actually higher in this group, even though their pain scores were not significantly different.

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So, you know, two different people can report a 7 out of 10, but one might require a lot more medication to be able to function, sleep, and all of the things that they want to do post-surgically. Also, inpatient pain management is influenced by provider behavior. Important to remember surgical expectations, nursing protocols, all of those things can change quite a bit. Another important point, the complications were pretty low across all groups, uh, 6% in TLIF, a little bit under 6% in ALIF, and 2% in XLIF. So the differences were not clinically significant or statistically significant, excuse me. But again, still, you're looking at— this is not 1 in a million for a complication, you know, 2% to 6% in this study. And I've seen complication rates typically in the 20 to 30% range. So, you know, what's the difference? Why is there such a gap between 2%, 6%, and then a 20 to 30%? Often it's because what are you considering a complication, right? If you make a complication be a significantly severe adverse event, it's probably going to fall to 2 to 6%. If you include— if you're a little more generous in what you call a complication, could be 20 to 30%. So really, really important. Um, and when you look at, uh, 30-day and 90-day ER visits, readmissions, and return to the operating room, we're not significantly different between the different groups as well. So this is, you know, it's not one approach necessarily is better than the other, and that's a, it's a good thing. This is about trade-offs, it's about patient selection, and it's really about matching the right approach to the right person at the right time. So, you know, spine surgery is not just defined by procedure, it's really about the details of that procedure. And to me, that's one of the most important take-home messages of this study, is that, you know, regardless of the approach that somebody's taking, a surgery is still a surgery. People are still going under— in most cases, most of the time, they're still going under anesthesia. I don't care how minimally invasive a surgery is, there still is an incision happening. There is muscle disruption happening. There is stitching happening. And it's, it's a, it's a significant change. It's a change to the anatomy. The goal literally is a permanent change to the anatomy. So I don't think we could take— we should take that for granted. Just because somebody says minimally invasive doesn't mean that it's always better. Now, on the flip side, Often minimally invasive is a better procedure than a large-scale open procedure, which tend to have way longer anesthesia times, which is a really important thing. Way higher complication rates, a lot more muscle disruption. I mean, to get down to a lamina to, you know, to do a fusion, you're screwing rods into, into bone. I mean, let's just make no mistake about this. You are accessing an area as, you know, theoretically as little as you need to access, but you still need a portal of entry. Whether you're going minimally invasive through a scope, 8mm, 10mm, 12mm, whatever scope size that is, or you're doing an open procedure with retractors, one way or the other, you are having to get down to an area where you are then using power tools essentially to take out bone. You are scraping away disc. You are maybe using a heat element to cauterize the edge of that disc. These are on purpose, purposeful anatomical changes. And that is really important. Now, when somebody has been struggling with pain, when somebody has been struggling with functional disability, often the alternative permanent anatomical change sounds like a good idea. And sometimes it is. But elective surgeries, in my opinion, are dramatically overdone in the United States or overdone worldwide. In the United States, not even close. They're dramatically overdone. And do not be fooled when it's like, well, you know, yeah, they— of course they're a candidate. They had to check the box that they've exhausted conservative care. I've practiced in groups. I know how this works. And often the check the box is let's check the box as quickly as possible. The surgeon wants to do surgery. I'm not saying they're unethical. I'm not saying that they're, you know, taking advantage of people. But what I am saying is it's often the minimum viable amount. And quite often the minimal viable amount is what does the insurance say the patient needs to have had done before they come into surgery, and they're trying to just meet that threshold. They are not Sherlock Holmes on the case. They're not trying to figure out every single opportunity to help somebody avoid surgery, otherwise they'd be doing a lot less surgeries. So I think it's really important to keep in mind, while We don't need to be surgeons. We don't need to become experts in minimally invasive surgery or open surgeries. We do need to become experts in guiding and directing our patients to what's best by understanding their anatomy, by understanding their health goals and their examination, and by being a voice of reason. Because it's the journey of professional indifference that I often talk about, um, live, uh, when I teach. And the journey of professional indifference is somebody goes into a primary care with structural low back pain. They get prescribed a medication. The medication, of course, does not take care of the problem because there's a structural issue. Well, what happens next? What happens next? They get an MRI to confirm a structural issue, which should have been obvious based upon exam, which didn't happen. Once that comes back, it's off to get pain management doctor to get shots. The shots don't take care of the issue because there's a structural challenge. And guess what? It is the fast track to surgery. This is happening like 1 million, 2 million times per year. It's happening in your town. It's happening to some of your patients. That doesn't mean nobody should ever have surgery, but what it does mean is I believe that the onus is on us to step up, to lean in, to understand more about what's going on outside of our practice, and be able to appropriately— not through scare tactics, not by nevers— but ultimately by letting people know the truth of the decision-making process that they're going through by helping them understand every process takes time. And that often, you know, there have been plenty of studies out there showcasing that post-surgical, when you look longitudinally, those individuals post-surgically, whether, you know, if they had surgery, didn't have surgery with disc issues, tend to end up about the same. In other words, the surgery does not correct the issue. Now, this was a fusion procedure— excuse me, a fusion, uh, study. Infusions do have different criteria. So of course, if somebody is on stable. Of course, if somebody has red flags, these are the individuals who need to have the surgery, but those are often not elective surgery. So a lot to unpack, a little bit of a longer episode, a lot more I could unpack, and maybe I will unpack in the future. But a cool study. If you want to dive in more, I'll drop that link down below. And shout out to our partners here at the end. RehabFix Hybrid Program enables you to stretch your care beyond the four walls of your practice. Uh, Grant's doing a great job over there, with RehabFix hybrid-based program. Don't need to change anything within your practice. You can generate a lot more income, help people beyond your circle of practice. I'll drop a link down below. The NovoPulse OA Recovery Program. Osteoarthritis is walking through your door each and every day. Do you have a program to help those people? If not, the OA Recovery Program with NovoPulse is a great opportunity to do so, as well as type 2 diabetes, the Diabetes Reversal Group. Type 2 diabetes is walking through your door each and every day, no questions asked. Type 2, uh, type 2 diabetes, massive issue. Diabetes Reversal Group makes it easy to refer that patient to them, and everybody wins. You can watch the video, learn more at the link down in the show notes. Other than that, thank you so much for tuning in this week. Have a fantastic week in practice, and I will talk to you soon.

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