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D'Antonio ND, Lambrechts MJ, Heard JC, Siegel N, Karamian BA, Huang A, Canseco JA, Woods B, Kaye ID, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Preoperative Marijuana Use on Surgical Outcomes, Patient-Reported Outcomes, and Opioid Consumption Following Lumbar Fusion. Global Spine J 2024; 14:568-576. [PMID: 35849499 PMCID: PMC10802534 DOI: 10.1177/21925682221116819] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed. METHODS Patients > 18 years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively. RESULTS Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P > .05). CONCLUSIONS Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jeremy C Heard
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Angela Huang
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Nielsen LM, Getz EN, Young JL, Rhon DI. Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:264-273. [PMID: 37803158 DOI: 10.1007/s00586-023-07926-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE To identify how pre-surgical conservative care is characterized and reported in randomized controlled trials of adults undergoing elective lumbar fusion, including duration and type of treatment. METHODS The study design is a scoping review. Data sources include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials published in English between January 1, 2005, and February 15, 2022, assessing lumbar fusion as the intervention were included in this review. RESULTS Of 166 studies, 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative care received. None of the trials provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, recency/timing, or dosage of conservative interventions. CONCLUSION Although roughly two-thirds of trials reported that patients failed conservative care prior to receiving a lumbar fusion, few studies named the conservative intervention provided and no studies provided any details regarding dosing or recency of care. This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.
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Affiliation(s)
- Lauren M Nielsen
- Doctor of Science in Physical Therapy Program, Bellin College, Eaton Road, Green Bay, WI, 54311, USA.
| | - Emily N Getz
- Doctor of Science in Physical Therapy Program, Bellin College, Eaton Road, Green Bay, WI, 54311, USA
| | - Jodi L Young
- Doctor of Science in Physical Therapy Program, Bellin College, Eaton Road, Green Bay, WI, 54311, USA
| | - Daniel I Rhon
- Doctor of Science in Physical Therapy Program, Bellin College, Eaton Road, Green Bay, WI, 54311, USA
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Eubanks JE, Carlesso C, Sundaram M, Bejarano G, Smeets RJEM, Skolasky R, Vanushkina M, Turner R, Schneider MJ. Prehabilitation for spine surgery: A scoping review. PM R 2023; 15:1335-1350. [PMID: 36730164 DOI: 10.1002/pmrj.12956] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 12/27/2022] [Accepted: 01/15/2023] [Indexed: 02/03/2023]
Abstract
We aimed to identify and describe the current interventions used in preoperative programs ("prehabilitation") for spine surgery. Knowledge gaps in approaches, feasibility, timing, patient experience, clinical outcomes, and health care costs were explored while describing their potential benefits on physical and psychological outcomes. An electronic search was conducted from January 2004 to February 2022 in Ovid Medline, Embase, EBSCO CINAHL, the Cochrane Database of Systematic Reviews, and PEDro to identify studies in English evaluating adults enrolled in prehabilitation before undergoing elective spine surgeries. Studies were uploaded into DistillerSR for systematic screening after removing duplicates. Four reviewers screened nested references for inclusion based on titles and abstracts, followed by their full-text review. Two reviewers subsequently extracted data and summarized the results. The results were reported using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. Studies were rated for quality using National Health and Medical Research Council criteria. Out of 18,879 potential studies, a total of 23 studies (0.12%) met the eligibility criteria and were included in this scoping review. The prehabilitation programs included general education (n = 6, 26%), exercise (n = 6, 26%), cognitive behavioral therapy (n = 3, 13%), pain neuroscience education (n = 3, 13%), health behavior counseling (n = 3, 13%), and mindfulness (n = 2, 9%). Additional studies are needed to identify optimal patient characteristics, intervention dosage, and whether multimodal approaches using a combination of physical and psychological strategies lead to more favorable outcomes. Although studies on prehabilitation for spine surgery are limited, they seem to demonstrate that prehabilitation programs are feasible, reduce medical expenditures, and improve patients' postoperative pain, disability, self-efficacy, psychological behaviors, and satisfaction with surgical outcomes. The available literature suggests there is an opportunity to improve patient experience, clinical outcomes and reduce medical costs with the use of prehabilitation in spine surgery.
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Affiliation(s)
- James E Eubanks
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - Cristiane Carlesso
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Meenakshi Sundaram
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Geronimo Bejarano
- Michael & Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston (UTHealth), Austin, Texas, USA
| | - Rob J E M Smeets
- Research School CAPHRI, Department of Rehabilitation Medicine, Maastricht University and CIR Revalidatie, Eindhoven, The Netherlands
- Pain in Motion International Research Group (PiM), Eindhoven, The Netherlands
| | - Richard Skolasky
- Orthopaedic Surgery and Physical Medicine & Rehabilitation, Spine Outcomes Research Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Maria Vanushkina
- Interventional Spine and Musculoskeletal Physiatry, UCHealth Medical Group, Colorado Springs, Colorado, USA
| | - Rose Turner
- Liaison Services and Instruction, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Schneider
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Robertson I, Rhon DI, Fritz JM, Velosky A, Lawson BK, Highland KB. Post-lumbar surgery prescription variation and opioid-related outcomes in a large US healthcare system: an observational study. Spine J 2023; 23:1345-1357. [PMID: 37220814 PMCID: PMC10524933 DOI: 10.1016/j.spinee.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/04/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND CONTEXT Spinal decompression and fusion procedures are one of the most common procedures performed in the United States (US) and remain associated with high postsurgical opioid burden. Despite guidelines emphasizing nonopioid pharmacotherapy strategies for postsurgical pain management, prescribing practices are likely variable and guideline-incongruent. PURPOSE The purpose of this study was to characterize patient-, care-, and system-level factors associated with opioid, nonopioid pain medication, and benzodiazepine prescribing variation in the US Military Health System (MHS). STUDY DESIGN/SETTING Retrospective study analyzing medical records from the US MHS Data Repository. PATIENT SAMPLE Adult patients (N=6,625) undergoing lumbar decompression and spinal fusion procedures from 2016 to 2021 in the MHS enrolled in TRICARE at least a year prior to their procedure and had at least one encounter beyond the 90-day postprocedure period, without recent trauma, malignancy, cauda equina syndrome, and co-occurring procedures. OUTCOME MEASURES Patient-, care-, and system-level factors influencing outcomes of discharge morphine equivalent dose (MED), 30-day opioid refill, and persistent opioid use (POU). POU was defined as dispensing of opioid prescriptions monthly for the first 3 months after surgery and then at least once between 90 and 180 days after surgery. METHODS (Generalized) linear mixed models evaluated multilevel factors associated with discharge MED, opioid refill, and POU. RESULTS The median discharge MED was 375 mg (IQR 225, 580) and days' supply was 7 days (IQR 4, 10); 36% received an opioid refill and 5%, overall, met criteria for POU. Discharge MED was associated with fusion procedures (+151-198 mg), multilevel procedures (+26 mg), policy release (-184 mg), opioid naïvty (-31 mg), race (Black -21 mg, another race and ethnicity -47 mg), benzodiazepine receipt (+100 mg), opioid-only medications (+86 mg), gabapentinoid receipt (-20 mg), and nonopioid pain medications receipt (-60 mg). Longer symptom duration, fusion procedures, beneficiary category, mental healthcare, nicotine dependence, benzodiazepine receipt, and opioid naivety were associated with both opioid refill and POU. Multilevel procedures, elevated comorbidity score, policy period, antidepressant receipt, and gabapentinoid receipt, and presurgical physical therapy were also associated with opioid refill. POU increased with increasing discharge MED. CONCLUSIONS Significant variation in discharge prescribing practices require systems-level, evidence-based intervention.
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Affiliation(s)
- Ian Robertson
- Department of Internal Medicine, Walter Reed National Military Medical Center, 9499 Palmer Rd N, Bethesda, MD, 20814, USA.
| | - Daniel I Rhon
- University of Utah, 201 Presidents' Cir, Salt Lake City, UT 84112, USA
| | - Julie M Fritz
- University of Utah, 201 Presidents' Cir, Salt Lake City, UT 84112, USA
| | - Alexander Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, 11300 Rockville Pike Suite 709, Rockville, MD 20852, USA
| | - Bryan K Lawson
- Department of Orthopedics, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234-6200, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814
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Rhon DI, Tucker CJ. Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes. Arthrosc Sports Med Rehabil 2022; 4:e231-e236. [PMID: 35141556 PMCID: PMC8811522 DOI: 10.1016/j.asmr.2021.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Level of Evidence
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Affiliation(s)
- Daniel I. Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas, U.S.A
- Department of Rehabilitation Medicine, The Uniformed Services University of Health Science, Bethesda, Maryland, U.S.A
- Address correspondence to Daniel Rhon, Primary Care Musculoskeletal Research, Department of Rehabilitation Medicine, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, TX 78234, U.S.A.
| | - Christopher J. Tucker
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
- Department of Surgery, The Uniformed Services University of Health Sciences, Bethesda, Maryland, U.S.A
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Peterson S, Mesa A, Halpert B, Bordenave L. How people with lumbar spinal stenosis make decisions about treatment: A qualitative study using the Health Belief Model. Musculoskelet Sci Pract 2021; 54:102383. [PMID: 33965775 DOI: 10.1016/j.msksp.2021.102383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Surgery rates for lumbar spinal stenosis (LSS) have increased despite inherent risks, high reoperation rates, and a lack of evidence for benefit over conservative treatment. Scant research has investigated how people make decisions about treatment, which may help clinicians better support patients during the course of care. The purpose of the present study was to explore the beliefs of people with LSS and how they make decisions about treatment. DESIGN Cross-sectional qualitative study. METHODS Semi-structured individual interviews were conducted with participants who had LSS (based on diagnostic imaging and recent symptoms). Transcribed interview data was analyzed using directed content analysis informed by the Health Belief Model. RESULTS Twelve patients (mean age 75.3 years, range 63-87 years, 9 female, 6 with previous LSS surgery) participated. The Health Belief Model appeared useful for explaining decisions about treatment. Perceived threat of LSS was higher in those who had surgery. Patients who decided on surgery perceived themselves as more susceptible to surgery, often because of pathoanatomical beliefs. These patients had lower perceived control over symptoms and the treatment decision itself. Although patients saw benefit in conservative treatment because of its lower risk and ability to foster self-management, many had no or poor education and reported previous experiences with ineffective conservative treatment. CONCLUSION Patients with LSS make decisions about treatment by weighing the perceived threat of LSS against the perceived barriers and benefits of conservative treatment. Consistent and nonthreatening educational messages from clinicians may help these patients during their decision-making process.
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Affiliation(s)
- Seth Peterson
- Physical Therapist, The Motive Physical Therapy Specialists, Oro Valley, Arizona, USA; Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA.
| | - Adriana Mesa
- Physical Therapist, APM Physical Therapy, Watsonville, CA, USA
| | - Brett Halpert
- Physical Therapist, Sparks Physical Therapy, Sparks Glencoe, MD, USA
| | - Lori Bordenave
- Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA
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