Association between postoperative ketorolac use and pseudarthrosis following anterior lumbar interbody fusion: retrospective analysis of a multicenter national database.

OBJECTIVE: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac (Toradol) after spinal fusion surgery remains controversial due to concerns about increased pseudarthrosis rates. However, no prior studies have specifically examined this outcome in anterior lumbar interbody fusion (ALIF). The aim of this study was to investigate whether postoperative ketorolac is associated with pseudarthrosis after ALIF. The authors hypothesized that short-term ketorolac use does not significantly increase pseudarthrosis risk. METHODS: The TriNetX database was queried from 2003 to 2023 for adults (≥ 18 years) undergoing primary ALIF (Current Procedural Terminology code 22558) with ≥ 6 months of follow-up. Patients were grouped by postoperative ketorolac or acetaminophen (control) administration within 48 hours. Propensity score matching controlled for demographics, comorbidities, medication use, and surgical indications. Baseline characteristics were compared using t-tests and chi-square tests as appropriate. Outcomes were assessed using relative risk (RR) with 95% confidence intervals; significance was considered at p < 0.05. RESULTS: There were 2408 patients per cohort who met criteria after matching. After 2 years of follow-up, there was no increase in pseudarthrosis rate with exposure to ketorolac; in fact, ketorolac appeared to have a protective effect on this outcome (3.99% vs 5.44% control; RR 0.733 [95% CI 0.567-0.948], p = 0.017). There was no difference in reoperation rate (4.82% vs 5.31%; RR 0.906 [0.709-1.158], p = 0.430). At 90 days postoperatively, no patients in either group experienced severe postoperative bleeding, postoperative hematoma/seroma, acute surgical site infection, or postoperative ileus. There was no significant difference in bowel regimen utilization. There was no difference in risk of oral opioid prescriptions (21.7% vs 21.8%; RR 0.998 [0.897-1.111], p = 0.972) or in mean narcotic prescription count (mean number of instances at 90 days 0.61 vs 0.62, p = 0.87). CONCLUSIONS: Ketorolac is a safe adjunct to pain control following ALIF. Administration was not found to be associated with increased pseudarthrosis or reoperation rates at the 2-year follow-up. There were no significant differences in acute postoperative events at 90 days postoperatively. Further studies are warranted to evaluate the effect of postoperative NSAIDs on outcomes in anterior lumbar fusion surgery.