Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting

Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion

STUDY DESIGN

Retrospective, single-center, cohort study.

OBJECTIVE

Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration.

SUMMARY OF BACKGROUND DATA

Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting.

METHODS

Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics.

RESULTS

The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ).

CONCLUSION

Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.

Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients

STUDY DESIGN/SETTING

A retrospective observational study.

OBJECTIVE

The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient.

SUMMARY OF BACKGROUND DATA

Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion.

MATERIALS AND METHODS

Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h).

RESULTS

In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management.

CONCLUSIONS

Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.

Multimodal analgesic protocol for cervical disc replacement in the ambulatory setting: Clinical case series

Background

Effective pain management is paramount for outpatient surgical success. This study aims to report a case series of patients undergoing cervical disc replacement (CDR) in an ambulatory surgery center (ASC) with the use of an enhanced multimodal analgesic (MMA) protocol.

Methods

Primary, single-/2-level CDR procedures at an ASC with an enhanced MMA protocol were included. ASC patients were discharged day of surgery. Patient-reported outcome measures (PROMs) were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included Visual Analogue Scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), and 12-Item Short-Form Physical and Mental Composite Score (SF-12 PCS/SF-12 MCS). A t-test assessed postoperative PROM improvement from baseline. MCID achievement was determined by comparing ΔPROM scores to previously established thresholds.

Results

106 patients were included, 76 single-level and 30 2-level. Most single-levels occurred at C5-C6, most 2-levels at C5-C7. One 2-level patient developed a hematoma 5 days postoperatively and underwent revision for evacuation. Five patients reported postoperative dysphagia; all were quickly resolved. One patient had an episode of seizure secondary to serotonin syndrome from concealed drug use. Patient was reintubated, transferred, and treated for serotonin syndrome. Two patients experienced postoperative nausea/vomiting. Cohort significantly improved from baseline for all PROMS at all timepoints except SF-12 MCS at 1-year/2-years and SF-12 PCS at 2 years (p < 0.047, all). Overall MCID achievement rates were: VAS arm (48.7%), VAS neck (69.1%), NDI (98.9%), SF-12 MCS (50.0%), SF-12 PCS (54.6%), and PROMIS-PF (73.4%).

Conclusion

Outpatient CDR, incorporating an enhanced MMA protocol, can be safely and effectively performed with proper patient selection and surgical technique. Patients saw timely discharge, well-controlled postoperative pain, and favorable long-term outcomes.

Is Patient Geography a Risk Factor for Chronic Opioid Use After ACDF?

The social and medical implications intrinsic to patient zip codes with high opioid fatality may reveal residence in these locations to be a risk factor predicting chronic opioid use after anterior cervical discectomy and fusion (ACDF). The purpose of this study is to determine if residence in Pennsylvania zip codes with high incidence of opioid overdose deaths is a risk factor for chronic postoperative opioid use after ACDF. Preoperative opioid usage did not vary meaningfully between high- and low-risk zip code groups. Patients in high-risk opioid overdose zip codes were significantly more likely to exhibit chronic postoperative opioid use. The Kaplan-Meier curve demonstrated that opioid discontinuation was less probable at any postoperative time for patients residing in high opioid fatality zip codes. Logistic regression found opioid tolerance, smoking, and depression to predict extended opioid use.