1
|
Koltsov JCB, Sambare TD, Kleimeyer JP, Alamin TF, Wood KB, Carragee EJ, Hu SS. Patient-level patterns in daily prescribed opioid dosage in single level lumbar fusion are associated with postoperative opioid dosage and adverse events: a retrospective analysis of claims data. Spine J 2024; 24:1232-1243. [PMID: 38521464 DOI: 10.1016/j.spinee.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/09/2024] [Accepted: 03/12/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Patients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively. PURPOSE Determine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events. STUDY DESIGN/SETTING Retrospective analysis of an administrative claims database (MeritiveTM Marketscan® Research Databases 2007-2015). PATIENT SAMPLE The 9,768 patients undergoing primary single level lumbar fusion. OUTCOME MEASURES Primary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition. METHODS Distinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors. RESULTS Among primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively: (1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day; (2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day; (3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day; (4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery; (5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery. These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High-dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain. Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0-5 MME/day, 29.1%), medium (10-15 MME/day, 12.0%), or high (70-75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids. CONCLUSIONS Identification of a patient's preoperative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Jayme C B Koltsov
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Tanmaya D Sambare
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - John P Kleimeyer
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Todd F Alamin
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Kirkham B Wood
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Eugene J Carragee
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Serena S Hu
- Stanford University School of Medicine, 450 Broadway Street, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| |
Collapse
|
2
|
McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:20-32. [PMID: 37643639 PMCID: PMC10765157 DOI: 10.1093/pm/pnad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined. METHODS LBPr-HU data were pooled from 3 prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both 1- and 5-years using McNemar's test for proportions and paired t-tests for means. RESULTS Two hundred forty-seven patients received BVNA and had 1-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (P < .001; 95% CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (P < .001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (P < .001; 95% CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at 1-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at 1-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA. CONCLUSIONS In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through 5 years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at 5 years in similar populations.
Collapse
Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Timothy Curtis
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Amanda Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Margo Wheatley
- Health Economist, Technomics Research, LLC, Medina, MN 55356, United States
| | - Matthew Smuck
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA 94063, United States
| |
Collapse
|
3
|
Koltsov JCB, Sambare TD, Alamin TF, Wood KB, Cheng I, Hu SS. Patient-level payment patterns prior to single level lumbar decompression are associated with resource utilization, postoperative payments, and adverse events. Spine J 2023; 23:227-237. [PMID: 36241040 DOI: 10.1016/j.spinee.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/11/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions. PURPOSE 1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events. STUDY DESIGN/SETTING Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015). PATIENT SAMPLE Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394). OUTCOME MEASURES Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression. RESULTS We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile. CONCLUSIONS There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Jayme C B Koltsov
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Tanmaya D Sambare
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Todd F Alamin
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Kirkham B Wood
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Ivan Cheng
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Serena S Hu
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| |
Collapse
|
4
|
Shaygan M, Zamani M, Jaberi A, Eghbal K, Dehghani A. The impact of physical and psychological pain management training on pain intensity, anxiety and disability in patients undergoing lumbar surgeries. Spine J 2023; 23:656-664. [PMID: 36736739 DOI: 10.1016/j.spinee.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND/CONTEXT Lumbar surgery is one of the interventions performed for patients with degenerative conditions. PURPOSE This study aimed to investigate the effect of pain management education on pain intensity, anxiety, and disability after the lumbar surgery. STUDY DESIGN/SETTING This randomized controlled trial was performed on seventy 30 to 65-year-old patients with lumbar canal stenosis and lumbar disc herniation from 2018 to 2019. PATIENT SAMPLE Seventy participants were randomly divided into a control and an intervention group by a randomized block design. Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions. OUTCOME MEASURES All participants in the two groups completed the study instruments (numeric rating scale [NRS], Oswestery disability index [ODI], and pain anxiety symptoms scale [PASS]) before, immediately after, and 3 months after the study. METHODS Participants in the intervention group received in-person pain management training twice a week for seven 60 to 90-minute sessions. To analyze the treatment effects, repeated-measures multivariate analysis of variance (MANOVA) and effect sizes were used where appropriate and calculated by Partial ɳ2. Clinical outcome (MDC) for pain intensity and PASS was also reported. For participants lost to follow-up, we also used an "intention-to-treat" (ITT) approach. RESULTS The results of MANOVA indicated that there were significant differences between the two groups on ratings of pain intensity, anxiety, and disability. According to the MDC, the mean differences of pain intensity for the intervention group was also clinically improved. Meanwhile, the mean differences in pain anxiety between three different times in the two groups were not above the MDC (20.14), suggesting that the clinical improvements were not significant. The results were confirmed for all outcome measures; a statistically significant difference was found between the groups in ITT analyses (p<.001). CONCLUSIONS Physical and psychological pain management education was shown to be effective in decreasing pain intensity, anxiety, and disability. This strategy may be beneficial for such patients. Variables such as smoking behavior, past history of psychological disorders, and previous surgeries should be considered in future studies.
Collapse
Affiliation(s)
- Maryam Shaygan
- Maryam Shaygan, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mahsa Zamani
- Mahsa Zamani, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azita Jaberi
- Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Keyvan Eghbal
- Keyvan Eghbal, Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Azime Dehghani
- Azime Dehghani, Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
5
|
Koltsov JCB, Sambare TD, Alamin TF, Wood KB, Cheng I, Hu SS. Healthcare resource utilization and costs 2 years pre- and post-lumbar spine surgery for stenosis: a national claims cohort study of 22,182 cases. Spine J 2022; 22:965-974. [PMID: 35123048 DOI: 10.1016/j.spinee.2022.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Improved understanding of the pre- and postoperative trends in costs and healthcare resource utilization (HCRU) is needed to better inform patient expectations and aid in the development of strategies to minimize the significant healthcare burden associated with lumbar spine surgery. PURPOSE Examine the time course of costs and HCRU in the 2 years preceding and following elective lumbar spine surgery for stenosis in a large national claims cohort. STUDY DESIGN/SETTING Retrospective analysis of an administrative claims database (IBM® Marketscan® Research Databases 2007-2015). PATIENT SAMPLE Adult patients undergoing elective primary single-level lumbar surgery for stenosis with at least 2 years of continuous health plan enrollment pre- and postoperatively. OUTCOME MEASURES Functional measures, including monthly rates of HCRU (15 categories), monthly gross covered payments (including payments made by the health plan and deductibles and coinsurance paid by the patient) overall, by HCRU category, and by spine versus non-spine-related. METHODS All available patients were utilized for analysis of HCRU. For analysis of payments, only patients on noncapitated health plans providing accurate financial information were analyzed. Payments were converted to 2015 United States dollars using the medical care component of the consumer price index. Trends in payments and HCRU were plotted on a monthly basis pre- and post-surgery and assessed with regression models. Relationships with demographics, surgical factors, and comorbidities were assessed with multivariable repeated measures generalized estimating equations. RESULTS Median monthly healthcare payments 2 years prior to surgery were $275 ($22, $868). Baseline HCRU at 2 years preoperatively was stable or only gradually rising (office visits, prescription drug use), but began an increasingly steep rise in many categories 6 to 12 months prior to surgery. Monthly payments began an increasingly steep rise 6 months prior to surgery, reaching a peak of $1,402 ($634, $2,827) in the month prior to surgery. This was driven by an increase in radiology, office visits, PT, injections, prescription medications, ER encounters, and inpatient admissions. Payments dropped dramatically immediately following surgery. Over the remainder of the 2 years, the median total payments declined only slightly, as a continued decline in spine-related payments was offset by gradually increased non-spine related payments as patients aged. By 2 years postoperatively, the percentage of patients using PT and injections returned to within 1% of the baseline levels observed 2 years preoperatively; however, spine-related prescription medication use remained elevated, as did other categories of HCRU (radiology, office visits, lab/diagnostic services, and also rare events such as inpatient admissions, ER encounters, and SNF/IRF). Patients with a fusion component to their surgeries had higher payments and HCRU preoperatively, and this did not resolve postoperatively. Variations in payments and HCRU were also evident among plan types, with patients on comprehensive medical plans-predominantly employer-sponsored supplemental Medicare coverage-utilizing more inpatient, ER, and inpatient rehabilitation & skilled nursing facilities. Patients on high-deductible plans had fewer payments and HCRU across all categories; however, we are unable to distinguish whether this is because they used fewer of these services or if they were paying for these services out of pocket without submitting to the payer. By 2 years postoperatively, 51% of patients had no spine-related monthly payments, while 33% had higher and 16% had lower monthly payments relative to 2 years preoperatively. CONCLUSIONS This is the first study to characterize time trends in direct healthcare payments and HCRU over an extended period preceding and following spine surgery. Differences among plan types potentially highlight disparities in access to care and plan-related financial mediators of patients' healthcare resource utilization.
Collapse
Affiliation(s)
- Jayme C B Koltsov
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Tanmaya D Sambare
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Todd F Alamin
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Kirkham B Wood
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| | - Serena S Hu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA
| |
Collapse
|
6
|
The association between opioid misuse or abuse and hospital-based, acute care after spinal surgery. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
7
|
Claus CF, Lytle E, Lawless M, Tong D, Sigler D, Garmo L, Slavnic D, Jasinski J, McCabe RW, Kaufmann A, Anton G, Yoon E, Alsalahi A, Kado K, Bono P, Carr DA, Kelkar P, Houseman C, Richards B, Soo TM. The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial. Spine J 2022; 22:8-18. [PMID: 34506986 DOI: 10.1016/j.spinee.2021.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses. PURPOSE We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period. STUDY DESIGN/SETTING This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis. PATIENT SAMPLE Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index. METHODS A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis. RESULTS Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications. CONCLUSIONS Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.
Collapse
Affiliation(s)
- Chad F Claus
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA.
| | - Evan Lytle
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Michael Lawless
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Doris Tong
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Diana Sigler
- Department of Pharmacy, Ascension Providence Hospital, Southfield, MI, USA
| | - Lucas Garmo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Dejan Slavnic
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Jacob Jasinski
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Robert W McCabe
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Ascher Kaufmann
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Gustavo Anton
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Elise Yoon
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Ammar Alsalahi
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Karl Kado
- Division of Neuroradiology, Department of Radiology, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Peter Bono
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Daniel A Carr
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Prashant Kelkar
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Clifford Houseman
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Boyd Richards
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| | - Teck M Soo
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, MI, USA
| |
Collapse
|
8
|
Radcliff K, Zigler J, Braxton E, Buttermann G, Coric D, Derman P, Garcia R, Jorgensen A, Ferko NC, Situ A, Yue J. Final Long-Term Reporting from a Randomized Controlled IDE Trial for Lumbar Artificial Discs in Single-Level Degenerative Disc Disease: 7-Year Results. Int J Spine Surg 2021; 15:612-632. [PMID: 34266934 PMCID: PMC8375685 DOI: 10.14444/8083] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study compared 7-year safety and efficacy outcomes of activL and ProDisc-L lumbar total disc replacements in patients with symptomatic, single-level lumbar degenerative disc disease (DDD). The objectives are to report 7-year outcomes of the trial, evaluate the outcomes for patients lost to follow-up, and determine whether early outcomes predict long-term outcomes. METHODS This was a prospective, multicenter, randomized, controlled investigational device exemption study. Eligible patients with symptomatic, single-level lumbar DDD had failed ≥6 months of nonsurgical management. Patients (N = 283) were randomized to receive activL (n = 218) or ProDisc-L (n = 65). At 7 years, data were available from 206 patients (activL, 160; ProDisc-L, 46). Logistic regression models were fit to predict 7-year outcomes for patients lost to follow-up after 2 years. RESULTS At 7 years, the activL group was noninferior to the ProDisc-L group on the primary composite endpoint (P = .0369). Both groups showed significant reductions in back/leg pain severity and improvements in disability index and quality-of-life relative to baseline (P < .0001). In both groups, opioid use was significantly reduced at 7 years (0%) relative to baseline (P < .01), and the overall reoperation rates were low (4.6%). activL patients showed a significantly better range of motion (ROM) for flexion-extension rotation than ProDisc-L patients (P = .0334). A significantly higher proportion of activL patients did not report serious adverse events (activL, 62%; ProDisc-L, 43%; P = .011). Predictive modeling indicated that >70% of patients (depending on outcome) lost to follow-up after 2 years would show clinically significant improvement at 7 years if improvements were achieved at 2 years. CONCLUSIONS The benefits of activL and ProDisc-L are maintained after 7 years, with significant improvements from baseline observed in pain, function, and opioid use. activL is more effective at preserving ROM than ProDisc-L and has a more favorable safety profile. Improvements in other primary and secondary outcomes were similar between both disc designs. LEVEL OF EVIDENCE 1.
Collapse
Affiliation(s)
- Kris Radcliff
- Rothman Orthopedic Institute, Philadelphia, Pennsylvania
| | | | - Ernest Braxton
- Vail Health Vail Summit Orthopaedics and Neurosurgery, Vail, Colorado
| | | | - Dom Coric
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | | | | | | | - Aaron Situ
- CRG-EVERSANA Canada, Inc, Burlington, Ontario, Canada
| | - James Yue
- Frank H. Netter School of Medicine, Quinnipiac University, Hamden, Connecticut
| |
Collapse
|
9
|
Reisener MJ, Hughes AP, Okano I, Zhu J, Lu S, Salzmann SN, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. The association of transversus abdominis plane block with length of stay, pain and opioid consumption after anterior or lateral lumbar fusion: a retrospective study. 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 2021; 30:3738-3745. [PMID: 33934219 DOI: 10.1007/s00586-021-06855-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Anterior (ALIF) and lateral (LLIF) lumbar interbody fusion is associated with significant postoperative pain, opioid consumption and length of stay. Transversus abdominis plane (TAP) blocks improve these outcomes in other surgical subtypes but have not been applied to spine surgery. A retrospective study of 250 patients was performed to describe associations between TAP block and outcomes after ALIF/LLIF. METHODS The electronic medical records of 129 patients who underwent ALIF or LLIF with TAP block were compared to 121 patients who did not. All patients were cared for under a standardized perioperative care pathway with comprehensive multimodal analgesia. Differences in patent demographics, surgical factors, length of stay (LOS), opioid consumption, opioid-related side effects and pain scores were compared in bivariable and multivariable regression analyses. RESULTS In bivariable analyses, TAP block was associated with a significantly shorter LOS, less postoperative nausea/vomiting and lower opioid consumption in the post-anesthesia care unit (PACU). In multivariable analyses, TAP block was associated with significantly shorter LOS (β - 12 h, 95% CI (- 22, - 2 h); p = 0.021). Preoperative opioid use was a strong predictive factor for higher opioid consumption in the PACU, opioid use in the first 24 h after surgery and longer LOS. We did not find significant differences in pain scores at any times between the groups. CONCLUSION TAP block may represent an effective addition to pain management and opioid-reducing strategies and improve outcomes after ALIF/LLIF. Prospective trials are warranted to further explore these associations.
Collapse
Affiliation(s)
- Marie-Jacqueline Reisener
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ichiro Okano
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Shuting Lu
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| |
Collapse
|
10
|
Intraoperative epidural analgesia for pain relief after lumbar decompressive spine surgery: A systematic review and meta-analysis. BRAIN AND SPINE 2021; 1:100306. [PMID: 36247401 PMCID: PMC9562248 DOI: 10.1016/j.bas.2021.100306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/02/2021] [Indexed: 11/23/2022]
Abstract
Introduction Research question Material and method Results Discussion and conclusion Literature on intraoperative nonsteroidal epidural analgesia as a bolus in decompressive lumbar surgery was reviewed. Primary outcome measures were reduction in postoperative pain, analgesics consumption and duration of hospital stay. The extracted data was heterogenic and challenging to compare. Intraoperative nonsteroidal epidural analgesia is effective in reducing postoperative pain and analgesics consumption. More data from well-powered randomized placebo-controlled trials is required to draw indisputable conclusions.
Collapse
|
11
|
Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, Miller TE, Shaw AD, Gan TJ, Thacker JKM, McEvoy MD. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg 2020; 129:543-552. [PMID: 30897590 DOI: 10.1213/ane.0000000000003941] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
Collapse
Affiliation(s)
- Michael L Kent
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Robert W Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Gary M Oderda
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Debra B Gordon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Monty Mythen
- University College London National Institute of Health Research (NIHR) Biomedical Research Centre, London, United Kingdom
| | - Timothy E Miller
- From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, New York
| | - Julie K M Thacker
- Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | |
Collapse
|
12
|
Zakaria HM, Mansour TR, Telemi E, Asmaro K, Bazydlo M, Schultz L, Nerenz DR, Abdulhak M, Khalil JG, Easton R, Schwalb JM, Park P, Chang V. The Association of Preoperative Opioid Usage With Patient-Reported Outcomes, Adverse Events, and Return to Work After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC). Neurosurgery 2019; 87:142-149. [DOI: 10.1093/neuros/nyz423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/31/2019] [Indexed: 11/14/2022] Open
Abstract
AbstractBACKGROUNDIt is important to delineate the relationship between opioid use and spine surgery outcomes.OBJECTIVETo determine the association between preoperative opioid usage and postoperative adverse events, patient satisfaction, return to work, and improvement in Oswestry Disability Index (ODI) in patients undergoing lumbar fusion procedures by using 2-yr data from a prospective spine registry.METHODSPreoperative opioid chronicity from 8693 lumbar fusion patients was defined as opioid-naïve (no usage), new users (<6 wk), short-term users (6 wk-3 mo), intermediate-term users (3-6 mo), and chronic users (>6 mo). Multivariate generalized estimating equation models were constructed.RESULTSAll comparisons were to opioid-naïve patients. Chronic opioid users showed less satisfaction with their procedure at 90 d (Relative Risk (RR) 0.95, P = .001), 1 yr (RR 0.89, P = .001), and 2 yr (RR 0.89, P = .005). New opioid users were more likely to show improvement in ODI at 90 d (RR 1.25, P < .001), 1 yr (RR 1.17, P < .001), and 2 yr (RR 1.19, P = .002). Short-term opioid users were more likely to show ODI improvement at 90 d (RR 1.25, P < .001). Chronic opioid users were less likely to show ODI improvement at 90 d (RR 0.90, P = .004), 1 yr (RR 0.85, P < .001), and 2 yr (RR 0.80, P = .003). Chronic opioid users were less likely to return to work at 90 d (RR 0.80, P < .001).CONCLUSIONIn lumbar fusion patients and when compared to opioid-naïve patients, new opioid users were more likely and chronic opioid users less likely to have improved ODI scores 2 yr after surgery. Chronic opioid users are less likely to be satisfied with their procedure 2 yr after surgery and less likely to return to work at 90 d. Preoperative opioid counseling is advised.
Collapse
Affiliation(s)
| | - Tarek R Mansour
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Edvin Telemi
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Karam Asmaro
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Michael Bazydlo
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Lonni Schultz
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - David R Nerenz
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Jad G Khalil
- Department of Orthopedic Surgery, Beaumont Health, Royal Oak, Michigan
- Beaumont Hospital, Royal Oak, William Beaumont School of Medicine, Oakland University, Royal Oak, Michigan
| | - Richard Easton
- Orthopedic Surgery Beaumont Health, Troy, Michigan
- Beaumont Hospital, Troy, William Beaumont School of Medicine, Oakland University, Troy, Michigan
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
13
|
Fischgrund JS, Rhyne A, Franke J, Sasso R, Kitchel S, Bae H, Yeung C, Truumees E, Schaufele M, Yuan P, Vajkoczy P, Depalma M, Anderson DG, Thibodeau L, Meyer B. Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain: 2-Year Results From a Prospective Randomized Double-Blind Sham-Controlled Multicenter Study. Int J Spine Surg 2019; 13:110-119. [PMID: 31131209 DOI: 10.14444/6015] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of the present study is to report the 2-year clinical outcomes for chronic low back pain (CLBP) patients treated with radiofrequency (RF) ablation of the basivertebral nerve (BVN) in a randomized controlled trial that previously reported 1-year follow up. Methods A total of 147 patients were treated with RF ablation of the BVN in a randomized controlled trial designed to demonstrate safety and efficacy as part of a Food and Drug Administration-Investigational Device Exemption trial. Evaluations, including patient self-assessments, physical and neurological examinations, and safety assessments, were performed at 2 and 6 weeks, and 3, 6, 12, 18, and 24 months postoperatively. Participants randomized to the sham control arm were allowed to cross to RF ablation at 12 months. Due to a high rate of crossover, RF ablation treated participants acted as their own control in a comparison to baseline for the 24-month outcomes. Results Clinical improvements in the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and the Medical Outcomes Trust Short-Form Health Survey Physical Component Summary were statistically significant compared to baseline at all follow-up time points through 2 years. The mean percent improvements in ODI and VAS compared to baseline at 2 years were 53.7 and 52.9%, respectively. Responder rates for ODI and VAS were also maintained through 2 years with patients showing clinically meaningful improvements in both: ODI ≥ 10-point improvement in 76.4% of patients and ODI ≥ 20-point improvement in 57.5%; VAS ≥ 1.5 cm improvement in 70.2% of patients. Conclusions Patients treated with RF ablation of the BVN for CLBP exhibited sustained clinical benefits in ODI and VAS and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP.
Collapse
Affiliation(s)
- Jeffrey S Fischgrund
- Department of Orthopedic Surgery, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan
| | - Alfred Rhyne
- OrthoCarolina Spine Center, Charlotte, North Carolina
| | - Jörg Franke
- Department of Orthopedics-Spine and Pediatric Orthopedics, Klinikum Magdeburg gGmbH, Magdeburg, Germany
| | - Rick Sasso
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Hyun Bae
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Eeric Truumees
- Seton Brain & Spine Institute, Department of Surgery, Dell Medical School, Seton Spine & Scoliosis Center, Austin, Texas
| | | | - Philip Yuan
- Department of Surgery, Long Beach Memorial Medical Center, Long Beach, California
| | - Peter Vajkoczy
- Department of Neurosugery, Charité Universitätsmedizin, Berlin Campus, Virchow Medical Center, Berlin, Germany
| | | | - David G Anderson
- Department of Orthopaedic and Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Bernhard Meyer
- Direktor der Neurochirurgische Klinik und Poliklinik, Technischen Universität München, Klinikum rechts der Isar, Munich, Germany
| |
Collapse
|
14
|
Abstract
Lumbar fusion surgery is usually prompted by chronic back pain, and many patients receive long-term preoperative opioid analgesics. Many expect surgery to eliminate the need for opioids. We sought to determine what fraction of long-term preoperative opioid users discontinue or reduce dosage postoperatively; what fraction of patients with little preoperative use initiate long-term use; and what predicts long-term postoperative use. This retrospective cohort study included 2491 adults undergoing lumbar fusion surgery for degenerative conditions, using Oregon's prescription drug monitoring program to quantify opioid use before and after hospitalization. We defined long-term postoperative use as ≥4 prescriptions filled in the 7 months after hospitalization, with at least 3 occurring >30 days after hospitalization. Overall, 1045 patients received long-term opioids preoperatively, and 1094 postoperatively. Among long-term preoperative users, 77.1% continued long-term postoperative use, and 13.8% had episodic use. Only 9.1% discontinued or had short-term postoperative use. Among preoperative users, 34.4% received a lower dose postoperatively, but 44.8% received a higher long-term dose. Among patients with no preoperative opioids, 12.8% became long-term users. In multivariable models, the strongest predictor of long-term postoperative use was cumulative preoperative opioid dose (odds ratio of 15.47 [95% confidence interval 8.53-28.06] in the highest quartile). Cumulative dose and number of opioid prescribers in the 30-day postoperative period were also associated with long-term use. Thus, lumbar fusion surgery infrequently eliminated long-term opioid use. Opioid-naive patients had a substantial risk of initiating long-term use. Patients should have realistic expectations regarding opioid use after lumbar fusion surgery.
Collapse
|
15
|
Opioid Dependence and Health Care Utilization After Decompression and Fusion in Patients With Adult Degenerative Scoliosis. Spine (Phila Pa 1976) 2019; 44:280-290. [PMID: 30015717 DOI: 10.1097/brs.0000000000002794] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To identify factors associated with opioid dependence after surgery for adult degenerative scoliosis (ADSc). SUMMARY OF BACKGROUND DATA Opioid epidemic is of prodigious concern throughout the United States. METHODS Data was extracted using national MarketScan database (2000-2016). Opioid dependence was defined as continued opioid use or >10 opioid prescriptions for 1 year either before or 3 to 15 months after the procedure. Patients were segregated into four groups based on opioid dependence before and postsurgery: NDND (before nondependent who remain non-dependent), NDD (before nondependent who become dependent), DND (before dependent who become non-dependent) and DD (before dependent who remain dependent). Outcomes were discharge disposition, length of stay, complications, and healthcare resource utilization. RESULTS Approximately, 35.82% (n = 268) of patients were identified to have opioid dependence before surgery and 28.34% (n = 212) were identified to have opioid dependence after surgery for ADSc. After surgical fusion for ADSc, patients were twice likely to become opioid independent than they were to become dependent (13.77% vs. 6.28%, OR: 2.191, 95% CI: 21.552-3.094; P < 0.0001). Before opioid dependence (RR: 14.841; 95% CI: 9.867, 22.323; P < 0.0001) was identified as a significant predictor of opioid dependence after surgery for ADSc. In our study, 57.9%, 6.28%, 13.77%, and 22.06% of patients were in groups NDND, NDD, DND, and DD respectively. DD and NDD were likely to incur 3.03 and 2.28 times respectively the overall costs compared with patients' ingroup NDND (P < 0.0001), at 3 to 15 months postsurgery (median $21648 for NDD; $40,975 for DD; and $ 13571 for NDND groups). CONCLUSION Surgery for ADSc was not associated with increased likelihood of opioid dependence, especially in opioid naïve patients. Patients on regular opiate treatment before surgery were likely to remain on opiates after surgery. Patients who continued to be opioid dependent or become dependent after surgery incur significantly higher healthcare utilization at 3 and 3 to 15 months. LEVEL OF EVIDENCE 4.
Collapse
|
16
|
Machado ES, Leite R, dos Santos CC, Artuso GL, Gluszczak F, de Jesus LG, Caldas JMP, Bredemeier M. Turn down - turn up: a simple and low-cost protocol for preparing platelet-rich plasma. Clinics (Sao Paulo) 2019; 74:e1132. [PMID: 31433042 PMCID: PMC6691835 DOI: 10.6061/clinics/2019/e1132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/10/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To describe and analyze a new protocol for the extraction of platelet-rich plasma (PRP) for use in clinical practice and compare this technique with methods that have been previously described in the medical literature. METHODS We extracted PRP from 20 volunteers using four different protocols (single spin at 1600 ×g, single spin at 600 ×g, double spin at 300 and 700 ×g, and double spin at 600 and 900 ×g). In another group of 12 individuals, we extracted PRP with our new technique (named 'turn down-turn up') consisting of a double spin (200 ×g and 1600 ×g) closed system using standard laboratory equipment (including an ordinary benchtop centrifuge), where the blood remained in the same tube during all processes, reducing the risk of contamination. Platelet counts adjusted to baseline values were compared using analysis of covariance (ANCOVA). RESULTS Using the four previously described protocols (mentioned above), we obtained concentrations of platelets that were 1.15-, 2.07-, 2.18-, and 3.19-fold greater than the baseline concentration, respectively. With the turn down-turn up technique, we obtained a platelet count that was 4.17-fold (95% confidence interval (CI): 3.09 to 5.25) greater than the baseline platelet count (p=0.063 compared with the double spin at 600 and 900 ×g method). The total cost of the disposable materials used in the extraction process was less than US$10.00 per individual. CONCLUSION In the present study, we described a simple and safe method for obtaining PRP using low-cost devices.
Collapse
Affiliation(s)
- Edilson Silva Machado
- Servico de Dor e Cuidados Paliativos, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
- Centro de Pesquisa e Gerenciamento da Dor, Clinica Univida, Canoas, RS, BR
- *Corresponding author. E-mail:
| | - Renata Leite
- Laboratorio de Analises Clinicas, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
| | - Cintia Cichowski dos Santos
- Laboratorio de Analises Clinicas, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
| | - Georgia Lazzari Artuso
- Laboratorio de Analises Clinicas, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
| | - Fernando Gluszczak
- Centro de Pesquisa e Gerenciamento da Dor, Clinica Univida, Canoas, RS, BR
| | - Leonardo Giovani de Jesus
- Servico de Dor e Cuidados Paliativos, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
| | | | - Markus Bredemeier
- Servico de Reumatologia, Grupo Hospitalar Conceicao, Hospital Nossa Senhora da Conceicao, Porto Alegre, RS, BR
| |
Collapse
|
17
|
Sharma M, Ugiliweneza B, Aljuboori Z, Nuño MA, Drazin D, Boakye M. Factors predicting opioid dependence in patients undergoing surgery for degenerative spondylolisthesis: analysis from the MarketScan databases. J Neurosurg Spine 2018; 29:271-278. [DOI: 10.3171/2018.1.spine171258] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVEThe opioid crisis is identified as a national emergency and epidemic in the United States. The aim of this study was to identify risk factors associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS).METHODSThe authors queried MarketScan databases to investigate the factors affecting postsurgery opioid use in patients with DS between 2000 and 2012. The outcome of interest was opioid dependence, which was defined as continued opioid use, > 10 opioid prescriptions, or diagnosis of or prescription for opioid dependence disorder in the period of 1 year before or 3–15 months after the procedure. Comparisons of outcomes were performed using nonparametric 2-group tests and generalized regression models.RESULTSA cohort of 10,708 patients was identified from the database. The median patient age was 61 years (interquartile range 54–69 years), and 65.1% were female (n = 6975). A majority of patients had decompression with fusion (n = 10,068; 94%) and underwent multilevel procedures (n = 8123; 75.9%). Of 10,708 patients, 14.85% (n = 1591) were identified as having opioid dependence within 12 months prior to the index surgical procedure and 9.90% (n = 1060) were identified as having opioid dependence within 3–15 months after the procedure. Of all the variables, prior opioid dependence (OR 16.29, 95% CI 14.10–18.81, p < 0.001) and younger age (1-year increase in age: OR 0.972, 95% CI 0.963–0.980, p < 0.001) were independent predictors of opioid dependence following surgery for DS. The use of fusion was not associated with opioid dependence following the procedure (p = 0.8396). Following surgery for DS, patients were more likely to become opioid independent than they were to become opioid dependent (8.54% vs 3.58%, p < 0.001).CONCLUSIONSThe majority of patients underwent fusion for DS. Surgical decompression with fusion was not associated with increased risk of postsurgery opioid dependence in patients with DS. Overall, opioid dependence was reduced by 4.96% after surgery for DS. Prior opioid dependence is associated with increased risk and increasing age is associated with decreased risk of opioid dependence following surgery for DS.
Collapse
Affiliation(s)
- Mayur Sharma
- 1Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | | | - Zaid Aljuboori
- 1Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Miriam A. Nuño
- 2Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Davis, California; and
| | - Doniel Drazin
- 3Department of Neurosurgery, Swedish Medical Center, Seattle, Washington
| | - Maxwell Boakye
- 1Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| |
Collapse
|
18
|
Sharma M, Ugiliweneza B, Aljuboori Z, Boakye M. Health care utilization and overall costs based on opioid dependence in patients undergoing surgery for degenerative spondylolisthesis. Neurosurg Focus 2018; 44:E14. [DOI: 10.3171/2018.2.focus17764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEOpioid abuse is highly prevalent in patients with back pain. The aim of this study was to identify health care utilization and overall costs associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS).METHODSThe authors queried the MarketScan database using ICD-9 and CPT-4 codes from 2000 to 2012. Opioid dependency was defined as having a diagnosis of opioid use disorder, having a prescription for opioid use disorder, or having 10 or more opioid prescriptions. Opioid dependency was evaluated in 12-month period leading to surgery and in the period 3–15 months following the procedure. Patients were segregated into 4 groups based on opioid dependence before and after surgery: group NDND (prior nondependent who remain nondependent), group NDD (prior nondependent who become dependent), group DND (prior dependent who become nondependent), and group DD (prior dependent who remain dependent). The outcomes of interest were discharge disposition, hospital length of stay (LOS), complications, and health care resource costs. The 4 groups were compared using the Kruskal-Wallis test and linear contrasts built from generalized regression models.RESULTSA total of 10,708 patients were identified, with 81.57%, 3.58%, 8.54%, and 6.32% of patients in groups NDND, NDD, DND, and DD, respectively. In group DD, 96.31% of patients had decompression with fusion, compared with 93.59% in group NDND. Patients in group NDD, DND, and DD had longer hospital LOS compared with those in group NDND. Patients in group DD were less likely to be discharged home compared with those in group NDND (odds ratio 0.639, 95% confidence interval 0.52–0.785). At 3–15 months postdischarge, patients in group DD incurred 21% higher hospital readmission costs compared with those in group NDND. However, patients in groups NDD and DD were likely to incur 2.8 times the overall costs compared with patients in group NDND (p < 0.001) at 3–15 months after surgery (median overall payments: group NDD $20,033 and group DD $19,654, vs group NDND $7994).CONCLUSIONSPatients who continued to be opioid dependent or became opioid dependent following surgery for DS incurred significantly higher health care utilization and costs within 3 months and in the period 3–15 months after discharge from surgery.
Collapse
|