Risk Factors For Prolonged Opioid Use After Spine Surgery

Trends of opioid use following anterior cervical discectomy and fusion: A 10-year longitudinal study of the Veterans Health Administration

Background

The United States Veteran Health Administration (VHA) cares for a substantial group of patients who are at higher risk of substance abuse in comparison to the general population. The purpose of this study was to (1) examine opioid consumption in the veteran population both pre- and postoperatively to anterior cervical discectomy and fusion (ACDF) and (2) understand the risk factors that are associated with sustained postoperative opioid use.

Methods

A retrospective database study was conducted using the Veterans Affairs Informatics and Computing Infrastructure database. Patients who underwent ACDF between 2010 and 2020 were identified and stratified into 3 groups based on their preoperative opioid usage prior to the procedure: opioid naïve, low preoperative opioid use (1-3 preoperative claims), and high preoperative opioid use (≥4 preoperative claims). Cumulative pre- and postoperative opioid usage for each patient was calculated in Morphine Milligram Equivalents (MME).

Results

A total of 7,894 patients were identified with 3,929 (49.7%) opioid naïve, 1,813 (23.0%) low preoperative opioid use, and 2,152 (27.3%) high opioid usage. The proportion of patients in the opioid-naïve cohort, low preoperative usage cohort, and high preoperative opioid usage cohort, that remained on opioids 1 year postoperatively was 13.1%, 31.3%, and 77.8%, respectively. At 1 year postoperatively, the median opioid MME significantly decreased pre- to postoperatively (25.0 vs. 0, p<.006). High preoperative opioid consumption was found to be the greatest risk factor for continued chronic opioid use (OR 17.1, p<.001).

Conclusions

Following ACDF procedures, opioid consumption significantly decreased; however, at 1 year, over one-third of patients remained on opioid therapy. A disproportionate number of patients who remained on chronic opioid therapy had high preoperative opioid consumption. Notably, increased scrutiny and policy changes regarding opioids, which began around 2017, resulted in a significant reduction in preoperative opioid use by 2020 compared to a decade earlier.

Opioid Use Following Spine Surgery in Ambulatory Surgical Centers Versus Hospital Outpatient Departments

Study DesignRetrospective cohort study.ObjectiveTo assess the association between undergoing spine surgery in an ambulatory surgical center (ASC) vs a hospital outpatient department (HOPD) and (a) perioperative opioid prescription patterns and (b) prolonged opioid use.MethodsData from the Merative MarketScan Database included patients aged 18-64 who underwent single-level or multilevel anterior cervical discectomy and fusion (ACDF) or lumbar decompression between January 2017 and June 2021. Primary outcomes included receipt of a perioperative opioid prescription, perioperative oral morphine milligram equivalents (MMEs), and prolonged opioid use (defined as opioid prescription 91-180 days post-surgery). Secondary outcomes included the number of perioperative opioid prescriptions filled (single/multiple) and type of initial perioperative opioid filled (potent/weak). Analysis of prolonged opioid use was limited to opioid-naive patients. Propensity score matching (1 ASC to 3 HOPD cases) and logistic regression models were used for analysis.ResultsThe study included 11,654 ACDF and 26,486 lumbar decompression patients. For ACDF, ASCs had higher odds of an initial potent opioid prescription (OR = 1.18, 95% CI 1.08-1.30, P < .001) and higher total adjusted mean MMEs (+21.14, 95% CI 3.08-39.20, P = .02). For lumbar decompression, ASCs had increased odds of an initial potent opioid (OR = 1.23, 95% CI 1.16-1.30, P < .001) but lower odds of multiple opioid prescriptions (OR = 0.90, 95% CI 0.85-0.96, P < .001). There was no significant association between the surgery setting and prolonged opioid use.ConclusionDifferences in perioperative opioid prescribing were observed between ASCs and HOPDs, but there was no increase in prolonged opioid use in ASCs. Further research is needed to optimize postoperative pain management in different outpatient settings.

Limited health literacy does not adversely affect compliance with postoperative restrictions, 90-day emergency department return, or opioid use following shoulder arthroscopy

Background

Limited health literacy can negatively impact how patients process medical information, make medical decisions, and navigate the healthcare system. The literature with regards to health literacy and its impact on both postoperative compliance and healthcare utilization remains scant.

Methods

We retrospectively analyzed the records for patients who underwent elective shoulder arthroscopy with a minimum 90-day follow-up at a single academic institution. Demographic data including age, gender, prior ipsilateral shoulder arthroscopy, body mass index and age-adjusted Charlson Comorbidity Index were collected. A validated 9-item literacy in musculoskeletal problems questionnaire to assess musculoskeletal health literacy was administered preoperatively. Postoperative compliance with therapy and surgeon-directed immobilization restrictions, 90-day return to emergency department (ED), and the number of opioid prescriptions filled within 3 months postoperatively was recorded.

Results

There were 252 cases included in this study. Seventy-seven (31%) patients demonstrated adequate musculoskeletal health literacy (MHL). On multivariable analysis, limited MHL (LMHL) was not significantly associated with 90-day postoperative ED return, compliance with postoperative surgeon instructions regarding shoulder motion or therapy restrictions, or obtaining ≥2 postoperative opioid prescriptions.

Conclusions

LMHL is highly prevalent among patients undergoing elective shoulder arthroscopy. The lack of association between LMHL and postoperative compliance, 90-day ED return, or filling ≥2 postoperative opioid prescriptions suggests that further research is needed to identify more relevant modifiable risk factors that could reduce these negative clinical outcomes and healthcare utilization patterns.

Osteoporosis is not associated with reoperation or pseudarthrosis after anterior cervical discectomy and fusion through 4-years' follow-up: a retrospective cohort study of US academic health centers

BACKGROUND CONTEXT

Osteoporosis has been proposed as a risk factor for reoperation after anterior cervical discectomy and fusion (ACDF), yet this potential association has been understudied, with conflicting results to date.

PURPOSE

This study examines the hypothesis that adults with osteoporosis would have an increased risk of reoperation after ACDF compared to matched adults without osteoporosis.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Two matched cohorts (mean age: 62 years; 75% female), each with 1,019 patients, who underwent primary ACDF. Cohorts were determined by the presence or absence of a diagnosis of osteoporosis.

OUTCOME MEASURES

Incidence of reoperation occurring over 4 years postoperatively, with our primary outcome being the risk ratio (RR) of reoperation with 95% confidence intervals (CI). Secondary outcomes included risk and mean count of oral opioid prescriptions and risk of pseudoarthrosis.

METHODS

We utilized the TriNetX network to identify adults undergoing their first ACDF from 2004 to 2020, excluding those with serious pathology, and divided patients into 2 cohorts: osteoporosis and nonosteoporosis. Patients were propensity matched according to key risk factors for reoperation.

RESULTS

Patients with osteoporosis had no statistically significant or meaningful difference in risk of reoperation compared to nonosteoporotic patients over 4-years' follow-up [95% CI] (17.3% vs 16.5%; RR: 1.05 [0.86, 1.27]; p=.6361). Similarly, there were no significant differences in the risk of pseudoarthrosis (26.5% vs 29.1%; RR: 0.91 [0.79, 1.05]; p=.1820), oral opioid prescription (75.0% vs 76.0%; RR: 0.99 [0.94, 1.04]; p=.6067), or mean oral opioid prescription count (11.5 vs 11.8; p=.7040).

CONCLUSIONS

Compared to matched nonosteoporosis controls, osteoporosis was not associated with a statistically significant or clinically meaningful increase in risk of reoperation in adults over 4 years after ACDF. Furthermore, osteoporosis was not associated with a significant or meaningful risk of pseudoarthrosis or oral opioid prescription after ACDF, although more research is needed for corroboration. Additional research is needed to clarify whether those with osteoporosis have meaningful differences in pain and function compared to those without osteoporosis following ACDF.

Efficacy of Duloxetine for Postspine Surgery Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), is used to treat various health conditions, including major depressive disorder, generalized anxiety disorder, fibromyalgia, and off-label for chemotherapy-induced pain. We conducted this systematic review and meta-analysis aiming to test the current evidence regarding effectiveness and safety of duloxetine for postspine surgeries pain.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Scopus and Web of science databases for relevant articles up to March 2024. The following search terms were Used in combination using the Boolean operators ((Duloxetine Hydrochloride) AND ((Pain, Postoperative) OR (Postoperative Period) OR (Postoperative Cognitive Complications) OR (Delayed Emergence from Anesthesia) OR (Postoperative Care) OR (spine surgery)) without time constrain for the search. Meta-analysis was performed using Review Manager (RevMan version 5.4) on the extracted outcome data that present in at least 3 of the included studies. Mean difference (MD) was used as the effect size for continuous outcomes with a 95% confidence interval (CI) or standardized mean difference (SMD) in case of different outcome reporting scales.

RESULTS

Pooled analysis showed that duloxetine significantly reduces pain intensity after 24 h from the operation compared to placebo (SMD = -1.11, 95% CI [-2.16 to -0.07], p = 0.04) with no significant difference in pain after 2 and 48 h. Meta-analysis revealed that duloxetine shows a significant reduction in the amount of analgesic consumption after 24 h postoperative; (MD = -3.33, 95% CI [-5.53 to -1.13], p = 0.003). The analysis did not show any statistically significant difference between duloxetine and placebo in patients experiencing nausea or vomiting (RR = 1.37, 95% CI [0.62 to 3.00] CONCLUSION: The findings of this study suggest that duloxetine may be effective in reducing pain 24 h after spine surgery. Furthermore, there is a promising effect of duloxetine in treating chronic postoperative pain. However, it is important to acknowledge that further research is warranted to thoroughly evaluate the efficacy and safety of duloxetine for relieving chronic postoperative pain.

Opioid Prescribing Trends Following Lumbar Discectomy

BACKGROUND

Lumbar diskectomy is a common procedure, following which a brief course of narcotics is often prescribed. Nonetheless, increasing attention has been given to such prescribing patterns to limit adverse effects and the potential for abuse. This study investigated prescribing patterns of opioid within 90 days following lumbar diskectomy.

METHODS

Patients undergoing single-level lumbar laminotomy/diskectomy from 2011 to 2021 were identified in the PearlDiver Mariner161 database. Exclusion criteria included the following: additional same-day spine procedures, age less than 18 years, same-day diagnosis of neoplasm, trauma, or infection, prior diagnosis of chronic pain, records active for less than 90 days following surgery, and filled opioid prescription between 7 and 30 days before the surgery. Predictors associated with receiving opioid prescriptions and excess prescribed morphine milligram equivalents (MMEs) were assessed with multivariable regression analyses. Prescribing patterns over the years were then analyzed with simple linear regression and compared for 2011 and 2021.

RESULTS

A total of 271,631 patients met the inclusion criteria. Opioids were prescribed for 195,835 (72.1%) and were independently associated with lower age, female sex, higher Elixhauser Comorbidity Index, and geographic region (P < 0.0001 for each). Greater MMEs were independently prescribed to those who were younger, had higher Elixhauser Comorbidity Index, and lived in specific geographic regions (P < 0.0001 for each). The proportion of patients receiving opioid prescriptions slightly increased over time (69.0% in 2011 to 71.0% in 2021), whereas a decrease was observed in median MMEs prescribed (428.9 in 2011 to 225.0 in 2021, P < 0.0001) and mean number of prescriptions filled (3.3 in 2011 and 2.3 in 2021, P < 0.0001).

CONCLUSION

Following lumbar diskectomy, this study found clinical and nonclinical factors to be associated with prescribing opioids and prescribed MME. The decreased MME prescribed over the years was encouraging and the decreased number of prescriptions filled suggests that patients are not needing to return for more prescriptions than prior.

Opioid Use Following Open Reduction and Internal Fixation of Mandibular Fractures

A mandible fracture is a common traumatic craniofacial injury for which surgery is sometimes indicated. Post-fracture and postoperative pain are often controlled through prescribed narcotics, which have received increased attention for potential abuse. The current work identified 90-day opioid prescribing patterns following surgically treated mandible fractures. Patients who underwent open reduction and internal fixation to treat a closed mandible fracture between 2011 and 2021 were identified in the PearlDiver Mariner165 database. Exclusion criteria included: (1) patients with records active for fewer than 180 days before the injury and 90 days post-fracture, (2) age younger than 18, and (3) those with long bone fracture within 30 days of mandible fracture. Variables associated with filling an opioid prescription and utilizing excess morphine milligram equivalents (MMEs) were identified through multivariate regression. Prescribing patterns between 2011 and 2021 were analyzed using simple linear regression. A total of 15,049 patients were identified. Of these patients, opioid prescriptions were filled by 10,389 (69.0%). Greater MMEs were filled for those with greater age, prior opioid use, and history of chronic pain ( P < 0.01 for all). The proportion of patients who received opioids decreased from 2011 to 2021 (73.3% versus 61.9%) during which declines were also seen for median MMEs (225.0 versus 128.4) and mean number of filled prescriptions (4.1 versus 2.8). The present work identified age and preexisting risk factors as significantly associated with excess MMEs following open reduction and internal fixation-treated mandible fracture. The decreasing proportion of patients receiving opioids along with decreasing MMEs suggests more refined practice with regard to their use.

Complex regional pain syndrome after distal radius fracture: A survey of current practices

INTRODUCTION

Complex regional pain syndrome (CRPS) is a common complication following distal radius fractures that is difficult to diagnose and can lead to permanent disability. While various proposed prophylaxis and treatment modalities exist, high-quality evidence guiding practice is limited. This survey of Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA) members was conducted with the primary aim of assessing practice patterns in distal radius fractures complicated with CRPS.

METHODS

An electronic survey was distributed to practicing orthopaedic surgeons in the COA and OTA. Questions assessed practice setting, preference in management of distal radius fractures and CRPS, comfort level in managing CRPS, and identification of gaps in management. Responses were anonymized and collected over 8 months. Response data was analyzed using descriptive statistics; thematic analysis was used on free text response.

RESULTS

134 survey responses were completed. 84% of respondents felt the incidence of CRPS in distal radius fractures was 1-10%, while 15% felt it was closer to 11-20%. 24% of respondents utilized the "Budapest Criteria" to diagnose CRPS. 40% offered prophylaxis in patients felt to be at high risk of developing CRPS. 66% of surgeons felt neutral, uncomfortable, or very uncomfortable managing CRPS in distal radius fractures. When asked to consider adopting a prophylactic therapy, 38% of surgeons indicated that a therapy that reduced the absolute risk of CRPS by 6-10% would change their practice. Gaps in current practice included lack of evidence-based treatment and prevention strategies and diagnostic uncertainty.

CONCLUSION

This study identified that amongst orthopaedic surgeons in the COA and OTA, diagnosis, treatment, and prophylaxis strategies for CRPS in distal radius fractures are heterogeneous. Surgeons are not confident in their treatment of CRPS. Future studies using rigorous research methods are warranted to improve management.

Classifying High-Risk Patients for Persistent Opioid Use After Major Spine Surgery: A Machine-Learning Approach

BACKGROUND

Persistent opioid use is a common occurrence after surgery and prolonged exposure to opioids may result in escalation and dependence. The objective of this study was to develop machine-learning-based predictive models for persistent opioid use after major spine surgery.

METHODS

Five classification models were evaluated to predict persistent opioid use: logistic regression, random forest, neural network, balanced random forest, and balanced bagging. Synthetic Minority Oversampling Technique was used to improve class balance. The primary outcome was persistent opioid use, defined as patient reporting to use opioids after 3 months postoperatively. The data were split into a training and test set. Performance metrics were evaluated on the test set and included the F1 score and the area under the receiver operating characteristics curve (AUC). Feature importance was ranked based on SHapley Additive exPlanations (SHAP).

RESULTS

After exclusion (patients with missing follow-up data), 2611 patients were included in the analysis, of which 1209 (46.3%) continued to use opioids 3 months after surgery. The balanced random forest classifiers had the highest AUC (0.877, 95% confidence interval [CI], 0.834-0.894) compared to neural networks (0.729, 95% CI, 0.672-0.787), logistic regression (0.709, 95% CI, 0.652-0.767), balanced bagging classifier (0.859, 95% CI, 0.814-0.905), and random forest classifier (0.855, 95% CI, 0.813-0.897). The balanced random forest classifier had the highest F1 (0.758, 95% CI, 0.677-0.839). Furthermore, the specificity, sensitivity, precision, and accuracy were 0.883, 0.700, 0.836, and 0.780, respectively. The features based on SHAP analysis with the highest impact on model performance were age, preoperative opioid use, preoperative pain scores, and body mass index.

CONCLUSIONS

The balanced random forest classifier was found to be the most effective model for identifying persistent opioid use after spine surgery.

Opioid alternatives in spine surgeries

PURPOSE OF REVIEW

The escalating opioid crisis has intensified the need to explore alternative pain management strategies for patients undergoing spine surgery. This review is timely and relevant as it synthesizes recent research on opioid alternatives for perioperative management, assessing their efficacy, side effects, and postoperative outcomes.

RECENT FINDINGS

A systematic search was conducted to capture articles from the past 18 months that examined opioid-sparing strategies. Findings indicate that multimodal analgesia, incorporating nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, lidocaine, gabapentinoids, N-methyl-D-aspartate (NMDA) antagonists, dexmedetomidine, and emerging regional block techniques like the erector spinae block and TLIF (thoraco lumbar interfascial block), can significantly reduce opioid consumption without compromising pain relief. Additionally, these approaches reduce opioid-related side effects such as postoperative nausea, vomiting, and prolonged hospital stays.

SUMMARY

The use of multimodal analgesia aligns with current pain management guidelines and addresses public health concerns related to opioid misuse. While effective, these alternatives are not without side effects, and the ultimate outcome depends on balancing benefits and risks. Future research should focus on the long-term outcomes of opioid alternatives, their effectiveness across diverse populations, and further validation and optimization of these strategies.

The impact of mental health on shoulder arthroplasty and rotator cuff repair: a meta-analysis

BACKGROUND

The aim of this study was to evaluate the impact of mental health attributes, such as the presence of psychiatric comorbidities or psychological comorbidities (low resilience), on outcomes after rotator cuff repair (RCR) and total shoulder arthroplasty (TSA).

METHODS

PubMed, Cochrane, and Google Scholar (results pages 1-20) were searched up to November 2023. Mental health problems of interest included the presence of psychiatric comorbidities (depression, anxiety) or indicators of poor psychological functioning, such as low resilience or the presence of distress. Patients were assigned to poor or good mental health groups in this study based on their grouping in the original study.

RESULTS

Fourteen studies were included in the meta-analysis. Patients with good mental health had greater improvements in postoperative American Shoulder and Elbow Surgeons and Simple Shoulder Test scores in the TSA cohort (P=0.003 and P=0.01), RCR cohort (P<0.001), and the combined TSA and RCR cohort (P<0.001). No difference was found in visual analog scale score, satisfaction, external rotation, or flexion between the two mental health groups. Patients with poor mental health undergoing RCR experienced higher rates of adverse events and transfusions (P<0.001). Patients with poor mental health also had greater rates of revision and emergency department visits in the TSA cohort (P<0.001), RCR cohort (P=0.05 and P=0.03), and combined cohort (P<0.001). Patients with poor mental health undergoing TSA had a higher rate of re-admission (P<0.001).

CONCLUSIONS

Patients with poor preoperative mental health showed inferior patient-reported outcome scores and increased rates of adverse events, revisions, and re-admissions. Level of evidence: III.

Opioid Use Increases the Rate of Pseudarthrosis and Revision Surgery in Patients Undergoing Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective Cohort.

OBJECTIVES

To (1) quantify the risk opioids impart on pseudarthrosis development, (2) analyze the effect of pseudarthrosis on clinical outcomes, and (3) identify if the amount of opioids prescribed are predictive of pseudarthrosis revision.

METHODS

Patients who underwent ACDF at a single institution between 2017-2019 were retrospectively identified. Postoperative dynamic cervical spine radiographs were reviewed to assess fusion status. Logistic regression models measured the effect of morphine milligram equivalents (MME) prescribed on the likelihood of pseudarthrosis development. Receiver operating characteristic (ROC) curves were generated to predict the probability of surgical revision based on MME prescribed.

RESULTS

Of 298 included patients, an average of 2.01 ± 0.82 levels were included in the construct and 121 (40.9%) patients were diagnosed with a pseudarthrosis. However, only 14 (4.7%) required a pseudarthrosis revision. Patients requiring pseudarthrosis revision had worse one-year postoperative Δ PCS-12 (-1.70 vs. 7.58, P = 0.004), Δ NDI (3.33 vs. -15.26, P = 0.002), and Δ VAS Arm (2.33 vs. -2.48, P = .047). Multivariate logistic regression analyses found the three-month postoperative (OR=1.00, P = .010), one-year postoperative (OR=1.001, P = 0.025), and combined pre- and postoperative MME (OR=1.000, P = .035) increased the risk of pseudarthrosis. ROC analysis identified cutoff values to predict pseudarthrosis revision at 90.00 (area under the curve (AUC): 0.693, confidence interval (CI): 0.554-0.832), 132.86 (0.710, CI: 0.589-0.840), 224.76 (0.687, CI: 0.558-0.817) and 285.00 (0.711, CI: 0.585-0.837) MME in the preoperative, three-month postoperative, one-year postoperative, and combined pre-and postoperative period.

CONCLUSION

Increased prescription of opioid medications following ACDF procedures may increase the risk of pseudarthrosis development and revision surgery.

LEVEL OF EVIDENCE

Therapeutic Level III.

Prognostic Value in Preoperative Veterans RAND-12 Mental Component Score on Clinical Outcomes for Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion

OBJECTIVE

To evaluate the effect of Veterans RAND 12-item health survey mental composite score (VR-12 MCS) on postoperative patient-reported outcome measures (PROMs) after undergoing lateral lumbar interbody fusion.

METHODS

Retrospective data from a single-surgeon database created 2 cohorts: patients with VR-12 MCS ≥ 50 or VR-12 MCS < 50. Preoperative, 6-week, and final follow-up (FF)- PROMs including VR-12 MCS/physical composite score (PCS), 12-item Short Form health survey (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), visual analogue scale (VAS)-back/leg pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected. ∆6-week and ∆FF-PROMs were calculated. Minimal clinically important difference (MCID) achievement rates were determined from established cutoffs from the literature. For intercohort comparison, chi-square analysis was used for categorical variables, and Student t-test for continuous variables.

RESULTS

Seventy-nine patients were included; 25 were in VR-12 MCS < 50. Mean postoperative follow-up time was 17.12 ± 8.43 months. The VR-12 MCS < 50 cohort had worse VR-12 PCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, and ODI scores preoperatively (p ≤ 0.014, all), worse VR-12 MCS/PCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-week postoperatively (p ≤ 0.039, all), and worse VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, VAS-LP, and ODI scores at FF (p ≤ 0.046, all). The VR-12 MCS < 50 cohort showed greater improvement in VR-12 MCS and SF-12 MCS scores at 6 weeks and FF (p ≤ 0.005, all). The VR-12 MCS < 50 cohort experienced greater MCID achievement for VR-12 MCS, SF-12 MCS, and PHQ-9 (p ≤ 0.006, all).

CONCLUSION

VR-12 MCS < 50 yielded worse mental health, physical function, pain and disability postoperatively, yet reported greater improvements in magnitude and MCID achievement for mental health.

Postoperative Opioid Use and Prescribing Patterns among Patients Undergoing Cervical Laminectomy with Instrumented Fusion versus Cervical Laminoplasty with Reconstruction

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare patterns in opioid usage and prescriptions between patients who undergo cervical laminectomy with instrumented fusion (LF) vs cervical laminoplasty with reconstruction (LP) within single surgeon and national database cohorts.

METHODS

We identified patients with cervical myelopathy undergoing primary LF or LP in both a single-surgeon series cohort (2004-2018) and a nationally representative cohort drawn from the IBM® Marketscan® database (2014-2016). We recorded opioid usage within 6 months of surgery and identified differences in unadjusted opioid use rates between LF and LP patients. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative opioid use.

RESULTS

Without adjusting for covariates, LF patients had a higher rate of 6-month opioid use in the single-surgeon cohort (15.7% vs 5.1%, P = .02). After adjusting for covariates, LF patients had higher odds of 6-month postoperative opioid use (OR 2.8 [95% CI 1.0-7.7], P = .04). In the national cohort, without adjusting for covariates, there was no significant difference in 6-month opioid use between LF and LP patients. Even after adjusting for covariates, we found no significant difference in odds.

CONCLUSIONS

Findings from a single-surgeon cohort reveal that LF is associated with a higher rate of 6-month opioid use than LP. This is at odds with findings from a national database cohort, which suggested that LP and LF patients have similar rates of opioid usage at 6-months postoperatively. To prevent overuse of narcotics, surgeons must consider the distinct pain requirements associated with different procedures even in treatment of the same condition.

The Drivers of Persistent Opioid Use and Its Impact on Healthcare Utilization After Elective Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence of and risk factors for persistent opioid use after elective cervical and lumbar spine procedures and to quantify postoperative healthcare utilization in this patient population.

METHODS

Patients were retrospectively identified who underwent elective spine surgery for either cervical or lumbar degenerative pathology between November 1, 2013, and September 30, 2018, at a single academic center. Patients were split into 2 cohorts, including patients with and without opioid use at 180-days postoperatively. Baseline patient demographics, underlying comorbidities, surgical variables, and preoperative/postoperative opioid use were assessed. Health resource utilization metrics within 1 year postoperatively (ie, imaging studies, emergency and urgent care visits, hospital readmissions, opioid prescriptions, etc.) were compared between these 2 groups.

RESULTS

583 patients met inclusion criteria, of which 16.6% had opioid persistence after surgery. Opioid persistence was associated with ASA score ≥3 (P = .004), diabetes (P = .019), class I obesity (P = .012), and an opioid prescription in the 60 days prior to surgery (P = .006). Independent risk factors for opioid persistence assessed via multivariate regression included multi-level lumbar fusion (RR = 2.957), cervical central stenosis (RR = 2.761), and pre-operative opioid use (RR = 2.668). Opioid persistence was associated with higher rates of health care utilization, including more radiographs (P < .001), computed tomography (CT) scans (.007), magnetic resonance imaging (MRI) studies (P = .014), emergency department (ED) visits (.009), pain medicine referrals (P < .001), and spinal injections (P = .003).

CONCLUSIONS

Opioid persistence is associated with higher rates of health care utilization within 1 year after elective spine surgery.

The Relationship Between Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity Scores and Early Postoperative Pain and Opioid Consumption After Lumbar Fusion

Background The Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and pain intensity measures quantify separate dimensions of pain from the patient's perspective. This study aimed to assess differences in these outcomes and to evaluate whether baseline PROMIS pain scores could be used as a leading indicator of increased pain and opioid consumption during early recovery after lumbar fusion. Methods A retrospective review of 199 consecutive patients undergoing posterolateral fusion (PLF) at a single institution was performed. All patients underwent one to three level lumbar PLF and preoperatively completed the PROMIS pain intensity and PROMIS pain interference measures. Multivariate linear regression was used to assess the relationship between preoperative PROMIS scores and postoperative pain numeric rating scale (NRS) and oral morphine milligram equivalents (OMME) by day after controlling for age, sex, and body mass index (BMI). Results In comparison to patients with the lowest preoperative pain intensity scores, those with the highest scores required significantly more OMME on postoperative day (POD) zero and one (both p<0.05) and had higher pain NRS on POD one (p=0.02). Patients with the highest pain interference scores reported higher pain NRS on POD zero (p=0.02) but required similar OMME at all time points. After controlling for age, sex, and BMI, each one-point increase in preoperative PROMIS pain interference scores was associated with increased OMME on POD zero (β=0.29, p=0.04) and POD one (β=0.64, p=0.03). Conclusions Patients with high pain intensity reported higher levels of pain and required more opioids during the first 24 hours postoperatively, while those with high pain interference reported higher levels of pain on the day of surgery but utilized similar amounts of opioids. After risk adjustment, increased baseline PROMIS pain interference scores - but not pain intensity - were associated with increased opioid use. These results suggest that both measures should be considered when identifying patients at risk for increased pain and opioid consumption after PLF.

Recovery Kinetics After Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively maintained multisurgeon registry.

OBJECTIVE

To study recovery kinetics and associated factors after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Few studies have described return to activities cervical spine surgery. This is a big gap in the literature, as preoperative counseling and expectations before surgery are important.

MATERIALS AND METHODS

Patients who underwent either anterior cervical discectomy and fusion (ACDF) or cervical disk replacement (CDR) were included. Data collected included preoperative patient-reported outcome measures, return to driving, return to working, and discontinuation of opioids data. A multivariable regression was conducted to identify the factors associated with return to driving by 15 days, return to working by 15 days, and discontinuing opioids by 30 days.

RESULTS

Seventy ACDF patients and 70 CDR patients were included. Overall, 98.2% of ACDF patients and 98% of CDR patients returned to driving in 16 and 12 days, respectively; 85.7% of ACDF patients and 90.9% of CDR patients returned to work in 16 and 14 days; and 98.3% of ACDF patients and 98.3% of CDR patients discontinued opioids in a median of seven and six days. Though not significant, minimal (odds ratio (OR)=1.65) and moderate (OR=1.79) disability was associated with greater odds of returning to driving by 15 days. Sedentary work (OR=0.8) and preoperative narcotics (OR=0.86) were associated with decreased odds of returning to driving by 15 days. Medium (OR=0.81) and heavy (OR=0.78) intensity occupations were associated with decreased odds of returning to work by 15 days. High school education (OR=0.75), sedentary work (OR=0.79), and retired/not working (OR=0.69) were all associated with decreased odds of discontinuing opioids by 30 days.

CONCLUSIONS

Recovery kinetics for ACDF and CDR are comparable. Most patients return to all activities after ACDF and CDR within 16 days. These findings serve as an important compass for preoperative counseling.

The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF).

BACKGROUND

Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery.

PATIENTS AND METHODS

Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index.

RESULTS

Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58).

CONCLUSIONS

While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption.

LEVEL OF EVIDENCE

Level III.

Preoperative Opioid Use Predicts Poorer Outcomes of Total Ankle Arthroplasty and Hindfoot Fusions

BACKGROUND

This study aimed to determine the impact of preoperative opioid use on outcomes of patients undergoing ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA).

METHODS

We conducted a retrospective review of 190 patients undergoing an ankle or hindfoot arthrodesis (n=122) or TAA (n=68) between December 2015 and September 2020 with a single fellowship-trained orthopaedic foot and ankle surgeon at an academic medical center. Data collected included demographics, medical comorbidities, treatment history, complications and reoperation rates, patient-reported outcome measures (PROMs) (eg, Foot and Ankle Outcome Score [FAOS]), and opioid use.

RESULTS

Patients with preoperative opioid use were more likely to continue usage at 90 (r = 0.931, P < .001) and 180 (r = 0.940, P < .001) days postoperatively. For the entire cohort, complication and reoperation rates were 48.9% and 13.2%, respectively. While preoperative opioid use groups did not differ in the overall complication rate, users had significantly more infections (user = 12.5%, nonuser = 3.3%; P = .036) and reoperations (user = 22.5%, nonuser = 10.7%; P = .049). When analyzing postoperative opioid prescriptions, there were many significant correlations with preoperative PROMs, mainly FAOS, such that increased postoperative opioid use was associated with worse subjective outcomes.

CONCLUSION

Preoperative opioid users are more likely to continue postoperative opioid use, experience infections, and undergo reoperations.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Preoperative Opioid Prescribers and Lumbar Fusion: Their Effect on Clinical Outcomes and Postoperative Opioid Usage

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the impact of multiple preoperative opioid prescribers on postoperative patient opioid usage and patient-reported outcome measures after single-level lumbar fusion.

SUMMARY OF BACKGROUND DATA

Prior literature has identified opioid prescriptions from multiple postoperative providers increase opioid usage rates. However, there is limited evidence on how multiple preoperative opioid prescribers affect postoperative opioid usage or clinical outcomes after a single-level lumbar fusion.

PATIENTS AND METHODS

A retrospective review of single-level transforaminal lumbar interbody fusion or posterolateral lumbar fusions between September 2017 and February 2020 at a single academic institution was performed. Patients were excluded if they were not identifiable in our state's prescription drug-monitoring program. Univariate comparisons and regression analyses identified factors associated with postoperative clinical outcomes and opioid usage.

RESULTS

Of 239 patients, 160 (66.9%) had one or fewer preoperative prescribers and 79 (33.1%) had >1 prescribers. On regression analysis, the presence of multiple preoperative prescribers was an independent predictor of increased improvement in Visual Analog Scale (∆VAS) Back (β=-1.61, P =0.012) and the involvement of a nonoperative spine provider was an independent predictor of increased improvement in ∆VAS Leg (β = -1.53, P = 0.034). Multiple preoperative opioid prescribers correlated with an increase in opioid prescriptions postoperatively (β = 0.26, P = 0.014), but it did not significantly affect the amount of morphine milligram equivalents prescribed (β = -48.79, P = 0.146). A greater number of preoperative opioid prescriptions predicted worse improvements in VAS Back, VAS Leg, and Oswestry Disability Index and predicted increased postoperative opioid prescriptions, prescribers, and morphine milligram equivalents.

CONCLUSIONS

Multiple preoperative opioid prescribers predicted increased improvement in postoperative back pain, whereas preoperative involvement of a nonoperative spine provider predicted improvements in leg pain after surgery. The number of preoperative opioid prescriptions was a better metric for predicting poor postoperative outcomes and increased opioid consumption compared with the number of preoperative opioid prescribers.

Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression

PURPOSE

Obesity is associated with increased surgical complexity and postoperative complications in spine surgery. Minimally invasive procedures have been shown to lessen some of the increased risk in obese patients. This study investigated whether utilization of a working channel endoscope can further mitigate obesity-associated challenges in spinal surgery.

METHODS

A retrospective review of a single-surgeon database was conducted for all adult patients undergoing full-endoscopic unilateral laminotomies for bilateral decompression between November 2015 and March 2021. Data collected included body mass index, in operating room preparation time, procedure time, length of hospital stay, use of analgesics, complications, and quality of life measured by Oswestry Disability Index.

RESULTS

Our cohort included 174 patients. Of these, 74 (42.5%) were obese. The average age was 63.6 years. In-operating room preparation time was 70.0 ± 1.7 min for obese patients and 64.4 ± 1.5 min for non-obese patients (p = 0.02). There was no difference in operative time, durotomy rates or other perioperative complications between obese and non-obese patients. Hospital length of stay trended toward longer in the obese group, but did not reach significance. A greater percentage of obese patients were still using both narcotic and non-narcotic pain medications 2 weeks after surgery. There was no significant difference in functional outcomes between groups.

CONCLUSION

Full-endoscopic unilateral laminotomies for bilateral decompression are safe and effective in both non-obese and obese patients. The use of an endoscope can partially mitigate obesity-related morbidity in lumbar decompression. However, obesity is significantly related to increased postoperative analgesic use.

The efficacy of thoracolumbar interfascial plane block for lumbar spinal surgeries: a systematic review and meta-analysis

BACKGROUND

The intent of this meta-analysis was to examine the efficacy of thoracolumbar interfascial plane block (TLIP) for pain control after lumbar spinal surgery.

METHODS

Randomized controlled trials (RCTs) published on PubMed, CENTRAL, Scopus, Embase, and Web of Science databases up to February 10, 2023, comparing TLIP with no or sham block or wound infiltration for lumbar spinal surgeries were included. Pain scores, total analgesic consumption, and postoperative nausea and vomiting (PONV) were analyzed.

RESULTS

Seventeen RCTs were eligible. Comparing TLIP with no block or sham block, the meta-analysis showed a significant decrease of pain scores at rest and movement at 2 h, 8 h, 12 h, and 24 h. Pooled analysis of four studies showed a significant difference in pain scores at rest between TLIP and wound infiltration group at 8 h but not at 2 h, 12 h, and 24 h. Total analgesic consumption was significantly reduced with TLIP block as compared to no block/sham block and wound infiltration. TLIP block also significantly reduced PONV. GRADE assessment of the evidence was moderate.

CONCLUSION

Moderate quality evidence indicates that TLIP blocks are effective in pain control after lumbar spinal surgeries. TLIP reduces pain scores at rest and movement for up to 24 h, reduces total analgesic consumption, and the incidence of PONV. However, evidence of its efficacy as compared to wound infiltration of local anesthetics is scarce. Results should be interpreted with caution owing low to moderate quality of the primary studies and marked heterogeneity.

Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity

INTRODUCTION

Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD.

METHODS

A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost.

RESULTS

Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis.

CONCLUSION

Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.

Emulsion-induced polymersomes taming tetrodotoxin for prolonged duration local anesthesia

Injectable local anesthetics that can provide a continuous nerve block approximating the duration of a pain state would be a life-changing solution for patients experiencing post-operative pain or chronic pain. Tetrodotoxin (TTX) is a site 1 sodium channel blocker that is extremely potent compared to clinically used local anesthetics. Challengingly, TTX doses are limited by its associated systemic toxicity, thus shortening the achievable duration of nerve blocks. Here, we explore emulsion-induced polymersomes (EIP) as a drug delivery system to safely use TTX for local anesthesia. By emulsifying hyperbranched polyglycerol-poly (propylene glycol)-hyperbranched polyglycerol (HPG-PPG-HPG) in TTX aqueous solution, HPG-PPG-HPG self-assembled into micrometer-sized polymersomes within seconds. The formed polymersomes have microscopically visible internal aqueous pockets that encapsulate TTX with an encapsulation efficiency of up to 94%. Moreover, the polymersomes are structurally stable, enabling sustained TTX release. In vivo, the freshly prepared EIP/TTX formulation can be directly injected and increased the tolerated dose of TTX in Sprague-Dawley rats to 11.5 μg without causing any TTX-related systemic toxicity. In the presence of the chemical penetration enhancer (CPE) sodium octyl sulfate (SOS), a single perineural injection of EIP/TTX/SOS formulation produced a reliable sciatic nerve block for 22 days with minimal local toxicity.

Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review

Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.