Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost.
The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center.
Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL.
The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.


Low back pain (LBP) is one of the most common reasons for visiting a physician in the United States.1 To put this into perspective, medical visits for LBP are second only to the common cold. In the US population, LBP is the most common reason for reductions in activities of daily living and work activity limitations in individuals younger than 45 years. Additionally, LBP is the third most common indication for all spine-related surgical procedures.2 Annual direct health care costs in the United States for spine disorders have been estimated at more than $85 billion, with indirect costs from lost work productivity resulting from LBP in the United States estimated to exceed $7 billion annually.3,4 Given the epidemiological data and health care costs, LBP is a significant issue for today’s health care system and society as a whole.
Similarities exist between the US population and the US military cohort across a multitude of health criteria. Similar to the general US population, LBP is also one of the most common forms of chronic pain in the US military population. Moreover, LBP has been associated with high rates of medical expenses and increased time to return to duty (RTD). Military duty presents a unique spectrum of intrinsic and extrinsic factors, not typical to the general population, that increase the risk factors associated with musculoskeletal disorders specific to spine-related pathologies. Recent research reported that within the military population, there is approximately 20% 6-mo prevalence of axial lower back pain necessitating medical evaluation.5 Active duty military service has been shown to result in a 2.4-fold increase in the prevalence of axial lower back pain resulting in a medical exam, whereas 70% and 46% of deployed active duty military members (with non-traumatic lumbar spine pain complaints) reported new radicular and axial pain symptoms, respectively.6
Although costs to train a single military serviceman/woman vary, ranges are estimated from $200,000 to $9,000,000. Due to the high cost of training and the extensive knowledge gained through the training, having military servicemen/women on active duty is critical. As such, the length in which it takes to have a military servicemen/women return to full duty post-surgery is a vital metric in surgical efficacy.5 RTD rates and length of time for spine pathology treatment protocols vary significantly in published research.57 Houghton et al (2016) presented a comprehensive review of RTD rates compared in the context of the treatments and reported RTD between 3 and 17 mo depending on treatment. Lunsford et al (2016) reported on the percentage of military service members RTD following elective lumbar spine surgery. The RTD rate following elective lumbar spine surgery is 64% within 1 year. When stratified by procedure type, isolated decompression procedures (63% RTD rate) and fusion procedures (66% RTD rate) displayed similar 1-year results.
Over the past decade, advancements in instrumentation, surgical access technology, and navigation have expanded the breadth of treatment applications for spine surgery. Specifically, the adoption of minimally invasive techniques has supplemented the practice of contemporary spine surgery. Minimally invasive spine surgery (MISS) has demonstrated comparable efficacy to traditional open procedures and has garnered popularity among surgeons. The limitations associated with open spine surgery, including extensive tissue dissection, muscle injury, blood loss, and greater hospital resource utilization have impacted patient outcomes.8,9
In addition to improvements in instrumentation and technology, outpatient surgery has seen a significant rise in utilization compared with the traditional hospital setting.10 Although outpatient surgery centers are freestanding or hospital-based with care extending 23 h, ambulatory surgery centers (ASC) are health care facilities focused on providing same-day surgical care of up to 23 h. Outpatient procedures represented over 60% of all surgeries in the United States in 2011, up from 19% in 1981.10 Outpatient surgery volume across both hospital-based and freestanding facilities grew by 64% between 1996 and 2011, according to the National Survey of Ambulatory Surgery.11
There is a breadth of research indicating the benefits of outpatient versus inpatient lumbar spine surgery and minimally invasive lumbar spine surgery techniques on patient-centric outcomes.1214 Benefits range from self-reported pain and disability improvement, blood loss, length of surgery, postoperative length of stay, and return to activities of daily living.15 More importantly in the context of this research, there is a paucity of literature examining these factors on the military population. Furthermore, to our knowledge, there is a gap in the literature investigating elective lumbar spine surgery and patient-centric outcomes in an ASC in the active duty military population. The objective of this research is to retrospectively examine surgical outcomes, RTD, and self-reported patient-centric outcomes at preoperative and 12 mo postoperative among active duty or reserve military patients who underwent an outpatient MISS Laminotomy Foraminotomy Decompression (LFD) for the treatment of lumbar spinal stenosis (LSS) in an ASC.