OBJECTIVES: To implement an integrated anesthesia and surgery protocol of improved postoperative pain control to facilitate transitioning of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) from a hospital to an ambulatory surgery center setting by lowering postoperative (in-facility) narcotic consumption and length of stay (LOS) transitioning from general to awake spinal anesthesia. METHODS: A retrospective cohort study of 180 patients who received awake or general anesthesia (GA) MI-TLIF from 2017 to 2023. RESULTS: Among 180 MI-TLIF patients, 101 (56 %) received awake protocol and 79 (44 %) received general anesthesia. Baseline characteristics (age, sex, Charlson comorbidity index (CCI), smoking status) were similar between groups except for body mass index (BMI) and height which was higher in the GA group. ASC patients had a significantly lower CCI (3.25 ± 1.55 vs. 1.33 ± 0.96
p <
0.001). Awake patients had shorter facility LOS and total LOS compared to GA group (Hospital LOS: 25.67 ± 1.77 hours vs 33.91 ± 2.7 hours, p <
0.05
p = 0.009). PACU LOS was shorter in a hospital setting (1.19 ± 0.04 hrs.) than in the ASC (6.68 ± 0.90 hrs.
p <
0.001) since patients could be transferred to a step-down unit after immediate postoperative recovery. The total facility LOS was also significantly extended in inpatients (33.81 ± 1.68 hrs.) versus ASC patients (6.68 ± 0.9045
p <
0.001). Awake patients required less narcotics during their entire post-operative stay compared to GA patients (155.83 ± 15.87 MME vs 258.27 ± 21.18 MME, p <
0.001). Additionally, the awake group had a shorter operative time compared to the GA group (2.43 ± 0.10 hours vs. 2.93 ± 0.05 hours, p <
0.001). CONCLUSION: Awake MI-TLIF procedure with spinal anesthesia is associated with shorter post-operative LOS, less post-operative narcotic use, and shorter operative time compared to MI-TLIF under GA. Awake spinal anesthesia facilitates performing MI-TLIF in an ASC due to lower narcotic requirements.