Parker J, Brennan JC, Johnson AH, Peterman MA, Turcotte JJ, Patton CM. Evaluation of an opioid-sparing protocol for spine surgeries performed in an ambulatory surgery center. World J Orthop 2026; 17(8): 122060 [DOI: 10.5312/wjo.122060]
Corresponding Author of This Article
Justin J Turcotte, PhD, Director, Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD 21401, United States. jturcotte@luminishealth.org
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Orthopedics
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Parker J, Brennan JC, Johnson AH, Peterman MA, Turcotte JJ, Patton CM. Evaluation of an opioid-sparing protocol for spine surgeries performed in an ambulatory surgery center. World J Orthop 2026; 17(8): 122060 [DOI: 10.5312/wjo.122060]
Jack Parker, Jane C Brennan, Andrea H Johnson, Matthew A Peterman, Justin J Turcotte, Chad M Patton, Luminis Health Orthopedics, Anne Arundel Medical Center, Annapolis, MD 21401, United States
Author contributions: Parker J, Brennan JC, Johnson AH, Peterman MA, Turcotte JJ, and Patton CM contributed to conceptualization, data curation validation, visualization, writing - original draft, writing - review and editing, formal analysis, investigation, methodology, project administration, resources, software; Turcotte JJ and Patton CM contributed to supervision. All authors have read and approved the final manuscript.
AI contribution statement: No artificial intelligence tools were used in the preparation of this manuscript.
Institutional review board statement: This study was deemed exempt by the Institutional Review Board (WCG IRB) and a waiver of informed consent was granted.
Informed consent statement: A HIPAA waiver of informed consent was granted for this retrospective study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The data used to perform this study is available from the authors upon reasonable request.
Corresponding author: Justin J Turcotte, PhD, Director, Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Annapolis, MD 21401, United States. jturcotte@luminishealth.org
Received: April 15, 2026 Revised: June 16, 2026 Accepted: July 14, 2026 Published online: August 18, 2026 Processing time: 128 Days and 13 Hours
Abstract
BACKGROUND
Data on opioid-sparing spine surgery is mostly limited to the hospital setting with a focus on perioperative outcomes. There is even less data available on ideal pain management approaches for spine surgery patients in an ambulatory surgery center (ASC) where same-day discharge is inherently required.
AIM
To evaluate the impact of an opioid-sparing protocol (OSP) on patients undergoing spine surgery at an ASC.
METHODS
A retrospective study of 290 patients undergoing 1-2 level surgeries from 2022-2024 was performed. All procedures were performed by one fellowship trained orthopedic-spine surgeon in a hospital-affiliated ASC. Procedures included anterior cervical discectomy/fusion, lumbar laminectomy/discectomy and posterior lumbar fusion. Patients were classified based on whether they were managed postoperatively as usual care (UC) or using an OSP consisting of oral ketorolac, acetaminophen, ibuprofen, gabapentin, diazepam, and tramadol for breakthrough pain. Differences in patient demographics, comorbidities, surgical details, postoperative pain management, and outcomes between the UC (n = 208) and OSP (n = 82) groups were assessed using univariate statistics.
RESULTS
There were no significant differences in patient demographics, comorbidities, number of operative levels, or rates of anterior cervical discectomy/fusion and lumbar laminectomy/discectomy between groups. Patients in the OSP group had a shorter length of stay, were prescribed opioids less frequently in the recovery room, and were prescribed significantly fewer postoperative morphine-milligram-equivalents at discharge [30.0 (30.0-30.0) vs 140.0 (105.0-210.0); P < 0.001] compared to those in the UC group. There were no statistically significant differences in 30-day postoperative outcomes between groups.
CONCLUSION
The use of an opioid-sparing multimodal analgesia protocol for ambulatory spine surgery patients resulted in significant reductions in postoperative opioid consumption without compromising quality outcomes or increasing postoperative resource utilization. Evaluation of similar protocols is warranted to confirm these findings, which suggest opioid-sparing approaches to ambulatory spine surgery are both safe and effective.
Core Tip: The use of an opioid-sparing multimodal analgesia protocol for ambulatory spine surgery patients resulted in significant reductions in postoperative opioid consumption without compromising quality outcomes or increasing postoperative resource utilization. Patients in the opioid-sparing group had a shorter length of stay, were prescribed opioids less frequently in the recovery room, and were prescribed significantly fewer postoperative morphine-milligram-equivalents at discharge compared to those in the usual care group. Opioid sparing multimodal analgesia protocols appear safe and effective for patients undergoing spine surgery in the ambulatory surgery center setting.
Citation: Parker J, Brennan JC, Johnson AH, Peterman MA, Turcotte JJ, Patton CM. Evaluation of an opioid-sparing protocol for spine surgeries performed in an ambulatory surgery center. World J Orthop 2026; 17(8): 122060
Evolving surgical techniques and approaches to postoperative care have allowed for enhanced recovery after surgery care pathways that emphasize early mobility. Clinical and economic factors have simultaneously led to a substantial shift of spine surgery to the outpatient environment, whether in a hospital outpatient department or an ambulatory surgery center (ASC)[1]. Within our health system, approximately 30% of total spine surgical volume has shifted out of the hospital to an ASC. Successful same-day discharge relies on adequate postoperative analgesia and early mobilization[2]. Combined with healthcare economic pressures and policy changes, spine surgeons now face a clinical dilemma to deliver a growing number of outpatient procedures while meeting patient expectations for postoperative pain control, enabling safe mobilization and discharge, and minimizing postoperative complications including readmissions.
In the United States, multi-modal analgesia (MMA) remains a key concept to enhanced recovery pathways and typically includes perioperative alternatives to opioids. Despite clear benefits of MMA to lowering opioid consumption after surgery[3-5], uncontrolled pain remains the second most common reason for 30-day unplanned readmissions following lumbar spine surgery[6]. Surgeons have historically relied on opioids for uncontrolled pain[7], and spine surgery has one of the highest rates of opioid prescribing[7-9]. Concerningly, it is estimated that 15%-18% of spine surgery patients develop an opioid use disorder and up to 45% of filled opioid prescriptions remain unused at 90 days after surgery[6,10].
Compared to the United States, other countries appear to de-emphasize the role of opioids in the postoperative setting. For example, patients undergoing common outpatient procedures in the United States have a seven-fold higher likelihood of receiving an opioid prescription compared to patients in Sweden undergoing the same surgery and at much higher doses and quantity per prescription[11]. Meanwhile, a meta-analysis of randomized trials suggests no difference in acute postoperative pain control between opioids and non-opioids for patients undergoing minor and moderate-extent surgical procedures, including orthopedic surgery[12]. These discrepancies call into question both the culture and approach to managing pain in the United States specifically.
Data on opioid-sparing spine surgery is mostly limited to the hospital setting with a focus on perioperative outcomes. For example, limited data suggests that opioid-sparing anesthesia may positively impact total opioid consumption, recovery room times, and non-home discharge[13]. There is even less data available on ideal pain management approaches for spine surgery patients in an ASC where same-day discharge is inherently required. In the ambulatory setting, studies have shown that MMA approaches to pain management after lumbar decompression are feasible, and do not result in failure to discharge on the day of surgery[14]. Others have evaluated specific MMA protocol elements, such as the efficacy of intravenous vs oral acetaminophen[15], yet no studies directly comparing the outcomes of spine surgeries performed in the ASC setting using opioid-sparing vs usual care (UC) protocols have been conducted, to the authors’ knowledge. The aim of this study was to pragmatically evaluate the impact of an opioid-sparing protocol (OSP) on patients undergoing spine surgery at an ASC. We hypothesized that an opioid-sparing approach could provide adequate postoperative analgesia as measured by 30-day rates of patient calls regarding uncontrolled pain, additional opioid prescriptions, and readmissions or emergency department (ED) visits for uncontrolled pain.
MATERIALS AND METHODS
This study was deemed exempt by the institutional review board (WCG IRB) and a waiver of informed consent was granted.
Study population
A retrospective observational study of 290 patients undergoing one- or two-level spinal surgery for degenerative pathologies from February 2022 to December 2024 was performed. All procedures were performed by one fellowship trained orthopedic spine surgeon in a hospital-affiliated ASC. Procedures performed included anterior cervical discectomy and fusion (ACDF), lumbar laminectomy/discectomy and posterior lumbar fusion (PLF). Patients were classified into groups based on whether they were managed postoperatively as UC or using an OSP. Convenience sampling was used to establish the sample sizes in this study. Data were extracted via manual review of the institutions’ electronic medical record.
UC postoperative pain management
Patients were typically discharged with a 7-day prescription of an opioid medication (oxycodone, hydrocodone, or tramadol), with the specific medication and dose determined by the surgeon based on clinical judgement, the extent of the procedure, and prior opioid use. Adjuvants such as a muscle relaxant or a gabapentinoid were often considered in addition to an opioid. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) were advised as needed in the absence of a fusion procedure or a past medical history of renal impairment or gastric reflux/ulcer.
Opioid sparing postoperative pain management
Use of the OSP began on October 1, 2023. All patients were counseled preoperatively about the potential adverse effects of opioids. After surgery, patients received a 5-10 days regimen consisting of scheduled oral ketorolac (10 mg three times daily for 72 hours), scheduled over-the-counter acetaminophen, and gabapentin (100 mg nightly for 5-10 days). After completing ketorolac, patients were instructed to transition to over-the-counter NSAIDs. Diazepam (5 mg daily as needed) was prescribed for postoperative muscle spasm. All patients were advised to contact a spine surgery nurse navigator to report uncontrolled pain, intolerable side effects, or refill requests. In the early phase of the protocol, some patients received a very limited supply of tramadol (50 mg, quantity 3-5 tablets) for breakthrough pain during non-business hours. In the later phases, no tramadol was prescribed. Patients with a past medical history of renal impairment, gastric reflux or ulcer, or adverse effects from NSAIDs were excluded from this protocol and received UC.
Perioperative care
All patients underwent a standardized medical evaluation in a pre-anesthesia testing clinic and received pre- and postsurgical education by both the surgeon and a spine surgery nurse navigator. In all cases except ACDF, a weight-based volume of 0.25% bupivacaine with epinephrine (1 mL/kg) was infiltrated into the surgical field soft tissues. At the discretion of the anesthesiologist and recovery room nurse, patients were eligible to receive any combination of intravenous opioid, ketorolac, dexamethasone; oral valium or opioid; and cryotherapy prior to discharge from the facility.
Independent variables
The demographics and comorbidities of interest included age, gender, body mass index, race, American Society of Anesthesiologist score, Charlson Comorbidity Index (CCI) score, preoperative depression/anxiety, chronic opioid use (defined as > 90 days preoperatively), and smoking status. Surgical details evaluated included surgery type and the number of operative levels.
Outcome measures
The primary outcome of interest was the total oral morphine milligram equivalents (MMEs) prescribed at discharge for postoperative pain management. Secondary outcomes included rates of calls for pain management concerns, ED return, readmission, ED return or readmission for pain control, and whether additional opioids were prescribed. All outcomes were assessed within 30-days postoperatively. Additionally, perioperative ASC outcomes including intraoperative MMEs received, minutes in the operating room, post anesthesia care unit (PACU) opioids received, PACU MME, and length of stay (LOS) were evaluated.
Overall, the average patient age was 55.1 ± 13.5 years old, body mass index was 28.6 ± 5.1 kg/m2, and CCI score was 1.0 (0.0-2.0). The patients were 54.5% male and 45.5% female, most patients were White (84.8%) and had an American Society of Anesthesiologist score of 2 (66.6%) or 3 (26.2%). Preoperatively, 45.2% of patients had depression/anxiety, 5.2% had chronic opioid use, 11.7% were current smokers and 27.6% were former smokers. The most commonly performed procedure was lumbar laminectomy/discectomy (65.5% patients), followed by ACDF (23.8%), and PLF (10.7%). The majority of procedures (84.1%) involved 1-level, with 15.9% involving 2-levels (Table 1).
Table 1 Patient demographics, comorbidities, and surgical details.
Of the 290 patients included in this study, 82 (28.3%) were in the OSP group while 208 (71.7%) were in the UC group. Use of the OSP increased over time, accounting for 13% and 70% of patients in 2023 and 2024, respectively. There were no significant differences in patient demographics, comorbidities, number of operative levels, or rates of ACDF and lumbar laminectomy/discectomy between groups. However, the OSP group had a lower rate of PLF (3.7% vs 13.5%; P = 0.019) than the UC group (Table 2).
Table 2 Patient demographics, comorbidities and surgical details by protocol, n (%)/mean ± SD.
Intraoperatively, there were no differences in MMEs received or minutes in the operating room between groups. However, in the PACU, the OSP group received opioids less frequently (54.9% vs 70.7%; P = 0.015) and received fewer MMEs [5.0 (0.0-5.0) vs 5.0 (0.0-12.5); P < 0.001] than the UC group. Additionally, OSP patients had a shorter LOS (4.1 ± 1.7 hours vs 4.9 ± 1.9 hours; P < 0.001) (Table 3). At ASC-discharge, patients in the OSP were more frequently prescribed tramadol (84.1% vs 4.3%; P < 0.001) compared to those in the UC group. Overall, patients in the OSP group were prescribed significantly fewer postoperative MMEs at discharge [30.0 (30.0-30.0) vs 140.0 (105.0-210.0); P < 0.001] compared to those in the UC group. A full list of medications used in each group is presented in Table 4.
Table 3 Perioperative ambulatory surgery center outcomes by protocol, mean ± SD/median (25th-75th percentile).
Within the 30-day postoperative period, 29.7% of patients called with pain management concerns, 10% returned to the ED, 4.1% were readmitted, 3.4% returned to the ED or were readmitted for pain management concerns specifically, and 13.1% required additional opioid prescriptions. There were no statistically significant differences in postoperative outcomes between groups (Table 5). In the subgroup analysis of ACDF and laminectomy/discectomy patients, similar trends in outcomes were observed. For each procedure, significant reductions in PACU and postoperative opioid use occurred, with no impact on postoperative outcomes (Tables 6 and 7).
Table 5 30-day postoperative outcomes by protocol, n (%).
The results of this study highlight the feasibility of an opioid-sparing approach to pain management in patients undergoing same-day spine surgery in the ASC setting. Patients in the OSP received significantly fewer postoperative MMEs, fewer PACU MMEs, and had a shorter LOS than patients managed under UC. The rates of call backs for pain, ED return, readmission, return/readmission for pain-related reasons, and additional opioid prescriptions were not significantly different in patients in the OSP group as compared to patients in the UC group. These outcomes were consistent when examining ACDF and laminectomy/discectomy procedures separately. The findings of this study suggest that an opioid-sparing approach can be successfully implemented in the majority of ASC-based spine surgery patients without an adverse impact on quality measures.
The use of MMA within enhanced recovery pathways has consistently shown that alternative pain management approaches can safely reduce opioid consumption, decrease LOS, and adequately control pain after spine surgery[16-21]. All three of these outcomes were mirrored in our study, without an increase in postoperative utilization of resources for pain management issues. As protocols continue to evolve, more recent studies have highlighted the potential for opioid-sparing or opioid-free spine surgery. Segebarth et al[22] conducted a randomized clinical trial of 50 1-2 level ACDF patients, comparing opioid-free to opioid-containing regimens. After an opioid-free preoperative and intraoperative regimen, patients in the opioid-free cohort were prescribed meloxicam, gabapentin, and acetaminophen at discharge. The opioid-free regimen yielded lower pain scores within 24 hours of surgery, and similar pain levels at 2 and 6-week follow up without a reduction in patient satisfaction or quality of life. Similarly, Berkman et al[23] demonstrated that opioid-free elective spine surgery is feasible, especially for opioid-naive patients. In a study of 244 patients undergoing a variety of hospital-based spinal procedures, including lumbar fusion, the authors evaluated a regimen that included NSAIDs, acetaminophen, ketorolac, gabapentin, muscle relaxants, early ambulation, and frequent application of ice. In the first phase of the study, which included pro re nata opioid orders for breakthrough pain, 47% of patients took no opioids from PACU discharge to 1-month follow up. In the second phase, which removed the pro re nata order and used opioids only for breakthrough pain, 88% of patients took no opioids over the same period. Opioids were not routinely included in discharge orders in either phase. Notably, the authors highlighted that patients taking opioids preoperatively had a nearly five-fold increase in the odds of postoperative opioid use, regardless of procedural invasiveness[23].
Importantly, our results build upon these prior hospital-based studies, demonstrating that an opioid-sparing approach is also feasible for procedures performed in the ASC setting. This finding is of critical importance as the shift of spine surgeries to ambulatory facilities accelerates[1]. To date, evaluations of OSPs for ASC-based spine surgeries are sparse. However, a recent database study of 11654 ACDF and 26486 lumbar decompression patients compared perioperative opioid prescribing trends between outpatient procedures performed in ASCs vs hospital outpatient departments[24]. While no association between surgery setting and prolonged opioid use was found for either procedure, ACDFs performed in the ASC had higher odds of an initial potent opioid prescription and higher total MMEs prescribed; lumbar decompressions performed in the ASC had higher odds of initial potent opioid prescription but lower odds of multiple opioid prescriptions. These results suggest surgeons may default to stronger opioid prescriptions in the ASC setting in an effort to enable patients to independently manage their pain and reduce the need for immediate follow-up care and pain management[24]. However, our results indicate that this approach may not be necessary, as patients in the OSP displayed lower absolute, but statistically similar, rates of calls for pain management, ED returns, readmissions, returns/readmissions for pain control, and additional opioid prescriptions than those treated under UC.
Regardless of setting, a consistent theme across studies of opioid reduction strategies is the importance of managing patient expectations around postoperative pain[22,23,25]. In each of the aforementioned opioid-free protocols, preoperative counseling regarding pain management strategies and the risks of opioids were identified as critical elements of the programs’ success[22,23]. We echo this sentiment based on our experience implementing the OSP in the ambulatory setting. The surgeon directly counseled patients about the role and expectations of the ASC for their surgery and the benefits of non-opioid medications in their acute postoperative recovery. While this discussion does add to preoperative visit time, it is our opinion that this is an indispensable aspect of the protocol, and that the positive outcomes observed justify this investment of time. Moving forward, we aim to evaluate alternative approaches to preoperative pain education through modalities that may be delivered both synchronously and asynchronously across multiple platforms. Although studies into novel approaches to preoperative education have shown promising results and hold the potential to drive efficiencies in care delivery[26-29]. We cannot overstate the fundamental importance of physician-patient conversations and the development of trust to successfully perform opioid-sparing spine surgery.
If proven to be replicable, the findings of this study show that a paradigm shift in the management of post-surgical pain to one that minimizes reliance on opioids is feasible for ambulatory spine surgery patients. Across a variety of orthopedic and non-orthopedic surgeries, opioid-free and OSPs have proven successful at managing postoperative pain without adversely affecting quality outcomes[12,30-32]. Furthermore, large multinational studies have repeatedly shown that surgical patients in the United States are more likely to receive opioids and are prescribed higher opioid doses for postoperative pain management than those treated internationally, yet this practice does not translate to improved post-surgical pain control[33-36]. The potential drivers of increased opioid prescribing among United States surgeons are multifactorial, including differences in physician training and comfort with alternative pain management strategies, patient expectations of pain management after surgery, and broad structural factors such as regulation and drug marketing practices[11]. While changes in each of these dimensions will be required to truly shift the culture of pain management across the United States healthcare system, our results demonstrate that alternative opioid-sparing approaches are both safe and feasible to implement.
The results of this study should be considered in the context of its limitations. As it was a retrospective investigation conducted at a single institution, the findings may not be representative of the broader ambulatory spine surgery population due to small sample size and selection bias. Notably, the study population of patients treated in the ASC limits the generalizability of our findings to this subset of generally younger, healthier spine surgery patients. In addition, it is likely that unmeasured patient and surgery-specific factors influenced our results. Further, we were unable to assess how many opioids were actually taken by patients, limiting our analysis to the MMEs of prescriptions written. Moreover, this study was limited by a relatively short follow-up period of 30 days and focused primarily on postoperative pain management and resource utilization. Further study is needed to assess the relationship between OSP use and long-term patient-reported outcomes and satisfaction. Finally, as an observational study of an MMA protocol, we cannot discern the impact of specific protocol elements on postoperative pain levels. The findings of this study also highlight the need for further research into the topic of opioid minimization strategies for spine surgery patients. Based on the promising results of single-center observational studies such as our own, we suggest prospective multicenter studies of alternative OSPs are warranted. Further, investigations into the transferability of the protocols across sites of care (i.e., hospital, hospital outpatient departments, and ASC) and the effects of additional and/or alternative analgesics, alternative patient selection approaches, and patient education modalities on protocol outcomes are needed. Given the complex, multifactorial nature of pain management, evaluation various OSPs for spine surgery patients should remain an area of focus.
CONCLUSION
The use of an opioid-sparing MMA protocol for ambulatory spine surgery patients resulted in significant reductions in postoperative opioid consumption without compromising quality outcomes or increasing postoperative resource utilization. Evaluation of similar protocols is warranted to confirm these findings, which suggest opioid-sparing approaches to ambulatory spine surgery are both safe and effective.
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Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Orthopedics
Country of origin: United States
Peer-review report’s classification
Scientific quality: Grade B, Grade C
Novelty: Grade C, Grade C
Creativity or innovation: Grade C, Grade C
Scientific significance: Grade B, Grade C
P-Reviewer: Arslan M, MD, Professor, Türkiye; Ekong AH, PhD, Post Doctoral Researcher, Researcher, Senior Researcher, Nigeria S-Editor: Hu XY L-Editor: A P-Editor: Zhao YQ
