Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial (RCT).

OBJECTIVE

Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures.

SUMMARY OF BACKGROUND DATA

Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures.

METHODS

This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC).

RESULTS

Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively.

CONCLUSIONS

A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.

Clinical presentation, imaging findings, and arthroscopic features in skeletally immature and mature adolescent hip patients: a comparative double-cohort retrospective study

The purpose of this study was to evaluate differences in clinical presentation and extent of surgery required based on skeletal maturity between two cohorts of adolescent hip arthroscopy patients. We hypothesized that skeletal immaturity would be associated with a lower frequency of pincer impingement and a decreased need for surgical acetabuloplasty. A database of 1481 hip arthroscopies performed by a single orthopaedic surgeon between 2008 and 2016 was queried. Patients ≤18 years of age with femoroacetabular impingement were divided into two groups based on Risser score: Risser 1-4 (skeletally immature) or Risser 5 (skeletally mature). Groups were compared with respect to presentation, diagnosis, and arthroscopic procedures performed. Eighty-eight skeletally immature and 49 skeletally mature patients were included. Mixed impingement was more common in skeletally mature patients than immature (67.3% vs. 48.9%, P = 0.037). Skeletal maturity was associated with a significantly increased probability of undergoing acetabuloplasty (odds ratio = 4.6, 95% confidence interval 1.4-15.5; P = 0.014). Extent of chondral degeneration was similar between groups. Our findings support the hypothesis that skeletally immature hips undergo acetabuloplasty less frequently and demonstrate similar chondromalacia compared with a skeletally mature cohort. These results suggest that arthroscopic treatment for impingement-associated hip pain may be a reasonable option to consider for symptomatic skeletally immature patients who have completed a structured course of nonoperative treatment. Additional longitudinal outcomes data are needed to clarify the natural history of impingement-associated hip pain in younger populations and whether hip arthroscopy delays progression of osteoarthritis in these patients.

Dermatomyositis and polymyositis in total hip arthroplasty

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are systemic autoimmune disorders such as dermatomyositis (DM), polymyositis (PM), inclusion body myopathy, and autoimmune necrotizing myopathy that, similar to osteoarthritis, affect quality of life and activities of daily living. Moreover, these patients are often burdened with chronic pain and disability; however, the outcomes and risk of total hip arthroplasty (THA) in this patient population remain unclear.

AIM

To evaluate 90-d complications and costs in patients with these conditions.

METHODS

A retrospective case control study was designed by accessing data from the Medicare dataset available on the PearlDiver server. Patients with IIM, here, those with DM and PM were matched based on possible confounding variables to a cohort without these diseases and with the same 10-year risk of mortality as defined by the Charlson Comorbidity Index Score (CCI). Univariate and multivariate analysis were performed to evaluate complications and t-tests to evaluate 90-d Medicare reimbursements as markers of costs after THA.

RESULTS

The total sample was 1090 patients with each cohort comprised of 545. Females were 74.9% of the population. The mean CCI was 5.89 (SD 2.11). Those with IIM had increased rates of pneumonia [odds ratio (OR) 1.45, P < 0.001] and pulmonary embolism (OR 1.46, P = 0.035) and decreased hematoma risks (OR 0.58, P = 0.00). 90-d costs were on average $1411 greater for those with IIM yet not significantly different (P = 0.034).

CONCLUSION

Patients with IIM have an increased 90-d rate of pneumonia and pulmonary embolism concomitant with a decreased hematoma rate consistent with their pro-coagulatory state. Further attention to increased resource utilization in these patients is also warranted.