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Cronkhite SE, Daher M, Balmaceno-Criss M, Knebel A, Nassar JE, Singh M, Mcdonald CL, Basques BA, Diebo BG, Daniels AH. Impact of Gender on Peri-Operative Characteristics and Outcomes of Lumbar Spine Surgery: A Current Concepts Review. World Neurosurg 2024; 190:46-52. [PMID: 38977128 DOI: 10.1016/j.wneu.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
The success of spine surgery is variable among patients. Finding reliable predictors of successful outcomes will not only maximize patient benefit, but also increase the cost effectiveness of surgery. Recent research has demonstrated the importance of patient specific factors in predicting patient outcomes, including gender. While many studies show that female patients present with worse pain and function preoperatively, there is conflicting data on whether male and female patients reap the same benefits from lumbar spine surgery. In this manuscript we review the current research on gender and sex differences in preoperative characteristics and post-operative outcomes and comment on the need for more studies to better elucidate the mechanism driving the conflicting evidence.
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Affiliation(s)
- Shelby E Cronkhite
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mohammad Daher
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ashley Knebel
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Joseph E Nassar
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Manjot Singh
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher L Mcdonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Bryce A Basques
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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2
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Spears CA, Hodges SE, Liu B, Venkatraman V, Edwards RM, Than KD, Abd-El-Barr MM, Parente B, Lee HJ, Lad SP. Nationwide Analysis of Risk Factors Related to Opioid Weaning Following Lumbar Decompression Surgery - A Retrospective Database Study. World Neurosurg 2024; 186:e20-e34. [PMID: 38519019 DOI: 10.1016/j.wneu.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Opioids are often prescribed for patients who eventually undergo lumbar decompression. Given the potential for opioid-related morbidity and mortality, postoperative weaning is often a goal of surgery. The purpose of this study was to examine the relationship between preoperative opioid use and postoperative complete opioid weaning among lumbar decompression patients. METHODS We surveyed the IBM Marketscan Databases for patients who underwent lumbar decompression during 2008-2017, had >30 days of opioid use in the year preceding surgery, and consumed a daily average of >0 morphine milligram equivalents in the 3 months preceding surgery. We used multivariable logistic regression and marginal standardization to examine the association between preoperative opioid use duration, average daily dose, and their interactions with complete opioid weaning in the 10-12 months after surgery. RESULTS Of the 11,114 patients who met inclusion criteria, most (54.7%, n = 6083) had a preoperative average daily dose of 1-20 morphine milligram equivalents. Postoperatively, 6144 patients (55.3%) remained on opioids. For patients with >180 days of preoperative use, the adjusted probability of weaning increased as the preoperative dose decreased. Obesity increased the likelihood of weaning, whereas older age, several comorbidities, female sex, and Medicaid decreased the odds of weaning. CONCLUSIONS Patients who used opioids for longer preoperatively were less likely to completely wean following surgery. Among patients with >180 days of preoperative use, those with lower preoperative doses were more likely to wean. Weaning was also associated with several clinical and demographic factors. These findings may help shape expectations regarding opioid use following lumbar decompression.
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Affiliation(s)
- Charis A Spears
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah E Hodges
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vishal Venkatraman
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ryan M Edwards
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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Fortier L, Sinkler MA, De Witt AJ, Wenger DM, Imani F, Morsali SF, Urits I, Viswanath O, Kaye AD. The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature. Anesth Pain Med 2023; 13:e136563. [PMID: 38024004 PMCID: PMC10676665 DOI: 10.5812/aapm-136563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/26/2023] [Accepted: 06/11/2023] [Indexed: 12/01/2023] Open
Abstract
There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.
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Affiliation(s)
- Luc Fortier
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Margaret A. Sinkler
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Audrey J. De Witt
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | | | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Fatemeh Morsali
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
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4
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Stonner MM, Skladman R, Bettlach CLR, Kennedy C, Mackinnon SE. Recruiting hand therapists improves disposal of unused opioid medication. J Hand Ther 2023; 36:507-513. [PMID: 35909068 DOI: 10.1016/j.jht.2022.06.005] [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: 07/27/2021] [Revised: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Opioids often remain unused after upper extremity surgery, and leftover prescriptions are frequently diverted. When administered in a hand surgery clinic, an educational brochure outlining a simple method of opioid disposal has been shown to improve disposal rates after surgery. PURPOSE To understand whether administration of an opioid disposal educational brochure in a hand therapy clinic would increase opioid disposal rates, compared to a hand surgery clinic. STUDY DESIGN Prospective cohort study. METHODS Patients who presented to a hand therapy clinic postoperatively were recruited to participate in this prospective cohort study. An educational brochure outlining a simple method of opioid disposal was made available at the hand therapy and surgery clinics. A questionnaire was later issued to obtain: location of brochure receipt, demographic information, pre- and post-operative opioid use history, and opioid disposal patterns. Chi-square tests and multivariable binary logistic regression assessed associations between medication disposal and explanatory variables. RESULTS Patients who received the brochure were significantly more likely to dispose of excess opioid medication, compared to those who did not receive the brochure (57.1% vs 10.8%, p < .001). Patients who received the brochure at the hand therapy clinic were significantly more likely to dispose of excess opioids (86.4%) compared to those who received the brochure at the surgery clinic (25.0%). Older age was predictive of increased disposal (p =.028*). There were no significant associations between gender, length of follow-up, or surgery type with the incidence of opioid disposal. CONCLUSION Recruiting both hand therapists and surgeons in the distribution of a simple, educational brochure on opioid disposal can increase disposal rates. Patients who received the brochure from the hand therapist were more likely to dispose of excess opioids. The longstanding patient-therapist relationship creates an opportunity for educational initiatives and discussion of stigmatized topics, such as opioid use.
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Affiliation(s)
- Macyn M Stonner
- Program in Occupational Therapy, Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie L Roth Bettlach
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Lim S, Yeh HH, Macki M, Haider S, Hamilton T, Mansour TR, Telemi E, Schultz L, Nerenz DR, Schwalb JM, Abdulhak M, Park P, Aleem I, Easton R, Khalil JG, Perez-Cruet M, Chang V. Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study. J Neurosurg Spine 2023; 38:242-248. [PMID: 36208431 DOI: 10.3171/2022.8.spine22571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.
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Affiliation(s)
| | | | | | | | | | | | | | - Lonni Schultz
- Departments of1Neurological Surgery
- 2Public Health Services, and
| | - David R Nerenz
- Departments of1Neurological Surgery
- 3Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | | | | | - Ilyas Aleem
- 5Orthopedics, University of Michigan, Ann Arbor, Michigan
| | - Richard Easton
- 6Department of Orthopedics, William Beaumont Hospital, Troy, Michigan; and
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Abstract
PURPOSE OF REVIEW Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity. RECENT FINDINGS Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.
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Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers. Health Care Manag Sci 2022; 25:649-665. [PMID: 35895214 DOI: 10.1007/s10729-022-09605-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).
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8
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A machine learning algorithm for predicting prolonged postoperative opioid prescription after lumbar disc herniation surgery. An external validation study using 1,316 patients from a Taiwanese cohort. Spine J 2022; 22:1119-1130. [PMID: 35202784 DOI: 10.1016/j.spinee.2022.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/31/2022] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative prediction of prolonged postoperative opioid prescription helps identify patients for increased surveillance after surgery. The SORG machine learning model has been developed and successfully tested using 5,413 patients from the United States (US) to predict the risk of prolonged opioid prescription after surgery for lumbar disc herniation. However, external validation is an often-overlooked element in the process of incorporating prediction models in current clinical practice. This cannot be stressed enough in prediction models where medicolegal and cultural differences may play a major role. PURPOSE The authors aimed to investigate the generalizability of the US citizens prediction model SORG to a Taiwanese patient cohort. STUDY DESIGN Retrospective study at a large academic medical center in Taiwan. PATIENT SAMPLE Of 1,316 patients who were 20 years or older undergoing initial operative management for lumbar disc herniation between 2010 and 2018. OUTCOME MEASURES The primary outcome of interest was prolonged opioid prescription defined as continuing opioid prescription to at least 90 to 180 days after the first surgery for lumbar disc herniation at our institution. METHODS Baseline characteristics were compared between the external validation cohort and the original developmental cohorts. Discrimination (area under the receiver operating characteristic curve and the area under the precision-recall curve), calibration, overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithm in the validation cohort. This study had no funding source or conflict of interests. RESULTS Overall, 1,316 patients were identified with sustained postoperative opioid prescription in 41 (3.1%) patients. The validation cohort differed from the development cohort on several variables including 93% of Taiwanese patients receiving NSAIDS preoperatively compared with 22% of US citizens patients, while 30% of Taiwanese patients received opioids versus 25% in the US. Despite these differences, the SORG prediction model retained good discrimination (area under the receiver operating characteristic curve of 0.76 and the area under the precision-recall curve of 0.33) and good overall performance (Brier score of 0.028 compared with null model Brier score of 0.030) while somewhat overestimating the chance of prolonged opioid use (calibration slope of 1.07 and calibration intercept of -0.87). Decision-curve analysis showed the SORG model was suitable for clinical use. CONCLUSIONS Despite differences at baseline and a very strict opioid policy, the SORG algorithm for prolonged opioid use after surgery for lumbar disc herniation has good discriminative abilities and good overall performance in a Han Chinese patient group in Taiwan. This freely available digital application can be used to identify high-risk patients and tailor prevention policies for these patients that may mitigate the long-term adverse consequence of opioid dependence: https://sorg-apps.shinyapps.io/lumbardiscopioid/.
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9
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André A, Peyrou B, Carpentier A, Vignaux JJ. Feasibility and Assessment of a Machine Learning-Based Predictive Model of Outcome After Lumbar Decompression Surgery. Global Spine J 2022; 12:894-908. [PMID: 33207969 PMCID: PMC9344503 DOI: 10.1177/2192568220969373] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective study at a unique center. OBJECTIVE The aim of this study is twofold, to develop a virtual patients model for lumbar decompression surgery and to evaluate the precision of an artificial neural network (ANN) model designed to accurately predict the clinical outcomes of lumbar decompression surgery. METHODS We performed a retrospective study of complete Electronic Health Records (EHR) to identify potential unfavorable criteria for spine surgery (predictors). A cohort of synthetics EHR was created to classify patients by surgical success (green zone) or partial failure (orange zone) using an Artificial Neural Network which screens all the available predictors. RESULTS In the actual cohort, we included 60 patients, with complete EHR allowing efficient analysis, 26 patients were in the orange zone (43.4%) and 34 were in the green zone (56.6%). The average positive criteria amount for actual patients was 8.62 for the green zone (SD+/- 3.09) and 10.92 for the orange zone (SD 3.38). The classifier (a neural network) was trained using 10,000 virtual patients and 2000 virtual patients were used for test purposes. The 12,000 virtual patients were generated from the 60 EHR, of which half were in the green zone and half in the orange zone. The model showed an accuracy of 72% and a ROC score of 0.78. The sensitivity was 0.885 and the specificity 0.59. CONCLUSION Our method can be used to predict a favorable patient to have lumbar decompression surgery. However, there is still a need to further develop its ability to analyze patients in the "failure of treatment" zone to offer precise management of patient health before spinal surgery.
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Affiliation(s)
- Arthur André
- Ramsay santé, Clinique Geoffroy
Saint-Hilaire, Paris, France,Neurosurgery Department,
Pitié-Salpêtrière University Hospital, Paris, France,Cortexx Medical Intelligence, Paris,
France,Arthur André, Cortexx Medical Intelligence,
156 Boulevard, Haussmann 75008, Paris.
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10
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Persistent Use of Prescription Opioids Following Lumbar Spine Surgery: Observational Study with Prospectively Collected Data From Two Norwegian Nationwide Registries. Spine (Phila Pa 1976) 2022; 47:607-614. [PMID: 34798646 DOI: 10.1097/brs.0000000000004275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective pharmacoepidemiological study. OBJECTIVE To investigate the use of prescription opioids 2 years following degenerative lumbar spine surgery. SUMMARY OF BACKGROUND DATA There are limited data providing details to evaluate patterns of opioid use. The number of patients is often limited and data on opioid use following some of the most common surgical procedures are lacking. METHODS Data from the Norwegian Registry for Spine Surgery and the Norwegian Prescription Database were linked on an individual level. The primary outcome measure was persistent opioid use the second year after surgery. Functional disabilitywas measured with the Oswestry disability index (ODI). Study participants were operated between 2007 and 2017. RESULTS Among 32,886 study participants, 2754 (8.4%) met criteria for persistent opioid use the second year after surgery. Among persistent opioid users in the second year after surgery, 64% met the criteria for persistent opioid use the year preceding surgery. Persistent opioid use the year preceding surgery (odds ratio [OR] 31.10, 95% confidence interval [CI] 26.9-36.0, P = 0.001), use of high doses of benzodiazepines (OR 1.62, 95% CI 1.30-2.04, P = 0.001), and use of high doses of z-hypnotics (OR 1.90, 95% CI 1.58-2.22, P = 0.001) the year before surgery were associated with increased risk of persistent opioid use the second year after surgery. A higher ODI score at 1 year was observed in persistent opioid users compared with non-persistent users (41.5 vs. 18.8 points) and there was a significant difference in ODI change (-13.7 points). Patients with persistent opioid use in the year preceding surgery were less likely to achieve a minimal clinically important ODI change at 1 year compared with non-persistent users (37.7% vs. 52.6%, P = 0.001). CONCLUSION Patients with or at risk of developing persistent opioid should be identified and provided counseling and support to taper off opioid treatment.Level of Evidence: 2.
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11
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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.
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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
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Dietz N, Sharma M, Kelly M, Ugiliweneza B, Wang D, Osorio J, Karikari I, Drazin D, Boakye M. Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up. Global Spine J 2022; 12:92-101. [PMID: 32844671 PMCID: PMC8965293 DOI: 10.1177/2192568220947377] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. METHODS We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. RESULTS Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. CONCLUSIONS In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.
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Affiliation(s)
| | | | | | | | | | - Joseph Osorio
- University of California, San Diego, San Diego, CA, USA
| | | | - Doniel Drazin
- Pacific Northwest University of Health Sciences College of Medicine, Yakima, WA, USA
| | - Maxwell Boakye
- University of Louisville, Louisville, KY, USA,Maxwell Boakye, Department of Neurosurgery, School of Medicine, University of Louisville, 220 Abraham Flexner Way, Louisville, KY 40202, USA.
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Berardino K, Carroll AH, Kaneb A, Civilette MD, Sherman WF, Kaye AD. An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery. Orthop Rev (Pavia) 2021; 13:24978. [PMID: 34745473 DOI: 10.52965/001c.24978] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 06/19/2021] [Indexed: 11/06/2022] Open
Abstract
Opioids are commonly prescribed postoperatively for pain control, especially in spine surgery. Not only does this pose concerns for potential abuse, but it also has been shown to worsen certain outcomes. Risk factors for increased use include preoperative opioid use, female sex, psychiatric diagnoses, and drug and alcohol use. Over the past few decades, there have been increasing efforts mostly spearheaded by governmental agencies to decrease postoperative opioid use via opioid prescription limitation laws regulating the number of days and amounts of analgesics prescribed and promotion of the use of enhanced recovery after surgery (ERAS) protocols, multimodal pain regimens, epidural catheters, and ultrasound-guided peripheral nerve blocks. These strategies collectively have been efficacious in decreasing overall opioid use and better controlling patients' postoperative pain while simultaneously improving other outcomes such as postoperative nausea, vomiting, and length of stay. With an aging population undergoing an increasing number of spinal surgeries each year, it is now more important than ever to continue these efforts to improve the quality and safety of pain control methods after spinal surgery and limit the transition of acute management to the development of opioid dependence and addiction long-term.
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Affiliation(s)
| | | | - Alicia Kaneb
- Georgetown University School of Medicine, Washington D.C
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Impact of preoperative treatment of osteoporosis on re-operations, complications and health care utilization in patients undergoing thoraco-lumbar spine fusions. A 5-year national database analysis. J Clin Neurosci 2021; 93:122-129. [PMID: 34656235 DOI: 10.1016/j.jocn.2021.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/27/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify the impact of preoperative treatment of Osteoporosis (OP) on reoperation rates, complications and healthcare utilization following thoraco-lumbar (TL) spine fusions. MATERIALS AND METHODS We used ICD9/10 and CPT codes to extract data from MarketScan (2000-2018). Patients were divided into two groups based on preoperative treatment of OP within one year prior to the index spinal fusion: medication (m-OP) cohort and non-medication (nm-OP) cohort. Outcomes (re-operation rates, re-admission, complications, healthcare utilization) were analyzed at 1-, 12-, 24- and 60-months. RESULTS Of 3606 patients, 65% (n = 2330) of patients did not receive OP medications (nm-OP). At index hospitalization, there were no difference in LOS (median nm-OP: 3 days vs. m-OP:4 days), discharge to home (nm-OP 80% vs. m-OP 75%) and complications (nm-OP 13% vs. m-OP 12%). Reoperation rates were not different among the cohorts at 1- (nm-OP 5.7% vs. m-OP 4.2%), 2- (nm-OP 9.4% vs. m-OP 7.8) and 5 years (nm-OP 16.9% vs. m-OP 14.8%). Patients in m-OP cohort incurred higher overall median payments at 1 year ($17,866 vs. $ 16,010), 2 years ($38,634 vs. $34,454) and 5 years ($94,797 vs. $91,072) compared to nm-OP cohort. CONCLUSION Preoperative treatment of OP had no impact on complications, LOS, discharge disposition following TL fusions at index hospitalization. Similarly, no impact of preoperative treatment was noted in terms of reoperation rates at 12-, 24- and 60 months following the index spine fusion. Patients who received preoperative treatment for OP incurred higher health care utilization at 12-, 24- and 60 months following surgery.
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Burden of preoperative opioid use and its impact on healthcare utilization after primary single level lumbar discectomy. Spine J 2021; 21:1700-1710. [PMID: 33872806 DOI: 10.1016/j.spinee.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/28/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The complication profile and higher cost of care associated with preoperative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models. PURPOSE To study the burden of pre-operative opioid use and its effect on postoperative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A 29,745 patients undergoing primary single level lumbar discectomy from the IBM MarketScan (2000-2018) database. OUTCOME MEASURES Ninety-day and 1-year utilization of lumbar epidural steroid injections, emergency department (ED) services, lumbar magnetic resonance imaging, hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months postoperatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups. METHODS Patients were categorized in opioid use groups based on the duration and number of oral prescriptions before discectomy (opioid naïve, < 3-months opioid use, chronic preoperative use, chronic preoperative opioid use with 3-month gap before surgery, and other). The risk of association of preoperative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables. RESULTS A total of 29,745 patients with mean age of 45.3±9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar epidural steroid injections, magnetic resonance imaging , ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared with patients with < 3-months use and opioid naïve patients (p<.001). Chronic post-operative opioid use was present in 62.6% of the preoperative chronic opioid users as compared with 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described. CONCLUSION Chronic preoperative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year postoperatively. Two-third of chronic preoperative opioid users had continued long-term postoperative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term postoperative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.
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Boakye M, Sharma M, Adams S, Chandler T, Wang D, Ugiliweneza B, Drazin D. Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery. Neurosurgery 2021; 89:E19-E32. [PMID: 33862621 DOI: 10.1093/neuros/nyab096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Preoperative depression is a risk factor for poor outcomes after spine surgery. OBJECTIVE To understand effects of depression on spine surgery outcomes and healthcare resource utilization. METHODS Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use. RESULTS Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery. CONCLUSION EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.
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Affiliation(s)
- Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Shawn Adams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Thomas Chandler
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Doniel Drazin
- Pacific Northwest University of Health Sciences, Yakima, Washington, USA
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta J, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery. JOURNAL OF SPINE SURGERY 2021; 7:19-25. [PMID: 33834124 DOI: 10.21037/jss-20-626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. Methods This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. Results A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Conclusions Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | | | | | | | - R Kirk Owens
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - Morgan Brown
- Norton Leatherman Spine Center, Louisville, KY, USA
| | | | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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Dietz N, Sharma M, Alhourani A, Ugiliweneza B, Nuno M, Drazin D, Wang D, Boakye M. Preoperative and Postoperative Opioid Dependence in Patients Undergoing Anterior Cervical Diskectomy and Fusion for Degenerative Spinal Disorders. J Neurol Surg A Cent Eur Neurosurg 2021; 82:232-240. [PMID: 33540452 DOI: 10.1055/s-0040-1718759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anterior cervical diskectomy and fusion (ACDF) is a procedure for effectively relieving radiculopathy. Opioids are commonly overprescribed in postsurgical settings and prescriptions vary widely among providers. We identify trends in opioid dependence before and after ACDF. METHODS We used the Truven Health MarketScan data to identify adult patients undergoing ACDF for degenerative cervical spine conditions between 2009 and 2015. Patients were segregated in four cohorts of preoperative and postoperative opioid nondependence (ND) or dependence (D) with 15 months of postoperative follow-up. RESULTS A total of 25,403 patients with median age of 52 years (18-92) who underwent ACDF met the inclusion criteria. Breakdown of the four cohorts was as follows: prior nondependent who remain nondependent (NDND): 62.76% (n = 15,944); prior nondependent who become dependent (NDD): 4.6% (n = 1,168); prior dependent who become nondependent (DND): 14.03% (n = 3,564); and prior dependent who remain dependent (DD): 18.61% (n = 4,727). Opioid dependence decreased 9.43% postoperatively. Overall payments and 30-day readmissions increased 1.96 and 1.79 times for opioid dependent versus nondependent cohorts, respectively. Adjusted payments at 3 to 15 months were significantly increased for dependent cohorts with 3.56-fold increase for the DD cohort when compared with the NDND cohort. Length of stay, complications, medication refills, outpatient measures, and hospital admissions were also higher in those groups with postoperative opioid dependence when compared with those who were not opioid dependent. CONCLUSIONS Opioid dependence after ACDF is associated with increased hospital readmissions, complication rates at 30 days, and payments within 3 months and 3 to 15 months postdischarge. Overall opioid dependence was decreased after ACDF procedure, however, a smaller number of opioid-dependent and opioid-naive patients became dependent postoperatively and should be followed carefully.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Mayur Sharma
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Ahmad Alhourani
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Miriam Nuno
- Department of Neurosurgery, University of California Davis, Davis, California, United States
| | - Doniel Drazin
- Department of Neurosurgery, Pacific Northwest University of Health Sciences, Yakima, Washington, United States
| | - Dengzhi Wang
- Department of Neurosurgery, University of California Davis, Davis, California, United States
| | - Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States.,Department of Neurosurgery, Robley Rex VA Medical Center, Louisville, Kentucky, United States
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Predictors and Characteristics of Opioid Utilization >15 Days Following Total Knee Arthroplasty. J Arthroplasty 2020; 35:2027-2032. [PMID: 32307293 DOI: 10.1016/j.arth.2020.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/12/2020] [Accepted: 03/16/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND America is amid an opioid epidemic, best characterized by liberal prescribing practices; widespread opioid misuse, abuse, and diversion; and rising rates of prescription-related opioid overdose. While many contributors to opioid overprescribing exist, orthopedic surgery is identified as a key driver. The purpose of this study is to determine predictors of ongoing opioid use >15 days post-total knee arthroplasty (TKA) and those patients prescribed >1350 morphine milligram equivalents (MMEs) in the 15 days following surgery. METHODS A retrospective cohort study was conducted in patients undergoing TKA (January 2016-December 2017) in an integrated healthcare system. Outcomes of interest were patient and clinical characteristics. RESULTS A total of 621 patients were included in the study. The majority were female (57.6%), were non-Hispanic/Latino white (92.3%), and from metropolitan areas (64.3%) with fewer than 110,000 population. Mean age was 66.3. Being female (odds ratio [OR] = 1.547, P = .092), having a higher body mass index (OR = 1.043, P = .036), and receipt of more postdischarge prescriptions in the 60-day follow-up period (OR = 8.815, P < .0001) were associated with a greater likelihood of receipt of opioid prescriptions for more than 15 days. Older patients (OR = 0.954, P = .01) and those discharged to home (OR = 0.478, P = .045) were less likely to receive >1350 MME; longer length of stay (OR = 1.447, P = .013) was more likely in those prescribed >1350 MMEs. CONCLUSION Several predictors were associated with longer duration and higher doses of opioid prescriptions post-TKA. Further research is needed to ascertain the challenges of opioid prescribing from both the metropolitan surgical team and rural healthcare provider perspective.
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Mendoza-Elias N, Dunbar M, Ghogawala Z, Whitmore RG. Opioid Use, Risk Factors, and Outcome in Lumbar Fusion Surgery. World Neurosurg 2020; 135:e580-e587. [DOI: 10.1016/j.wneu.2019.12.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
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Long-Term Comparison of Health Care Utilization and Reoperation Rates in Patients Undergoing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disc Disease. World Neurosurg 2020; 134:e855-e865. [DOI: 10.1016/j.wneu.2019.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022]
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Bhargava S, Sharma M, Dietz N, Dettori J, Ugiliweneza B, Nuno M, Boakye M, Drazin D. Demographics and Outcomes of Spine Surgery in Octogenarians and Nonagenarians: A Comparison of the National Inpatient Sample, MarketScan and National Surgical Quality Improvement Program Databases. Cureus 2019; 11:e6195. [PMID: 31886087 PMCID: PMC6922298 DOI: 10.7759/cureus.6195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Despite the increasing use of national databases to conduct spine research, questions remain regarding their study validity and consistency. This study tested for similarity and inter-database reliability in reported measures between three commonly used national databases. Methods International Classification of Diseases, 9th edition (ICD-9) codes were used to identify elderly (80-100 years) who underwent spine surgery patients in Truven Health Analytics MarketScan® claims database, National (Nationwide) Inpatient Sample (NIS) discharge database and National Surgical Quality Improvement Program (NSQIP) database (2006-2016). Patient baseline characteristics, comorbid status, insurance enrollment, and outcomes were queried and compared. Results We analyzed 15,105 MarketScan, 40,854 NIS, and 7682 NSQIP patients between ages 80 to 100 years (median, 82 years) who underwent spine surgeries during the study period. A majority of patients in both MarketScan and NIS were insured by Medicare (97% vs. 94%). Patients in MarketScan had lower comorbidity scores (comorbidity, 0-2) compared to those in NIS and NSQIP databases. The most common diagnosis was spinal stenosis in MarketScan (54.4%), NIS (54.6%), and NSQIP databases (65.2%). Fusion was the most common procedure performed in MarketScan (48.9%) and NIS databases (46.2%), whereas decompression (laminectomy/laminotomy) was the most common procedure in the NSQIP database (51.84%). In-hospital complications (any) were 6.5% in the MarketScan cohort, 5.3% in the NIS, and 2.02% in the NSQIP cohort. In terms of 30-day complications (any), the MarketScan database reported higher complications rate (12.7%) compared to the NSQIP database (5.08%). In-hospital mortality was slightly higher in the NIS database (0.32%) compared to MarketScan (0.21%) and NSQIP database (0.2%). MarketScan and NIS databases showed an increased risk of complications with increasing age, whereas NIS and NSQIP showed increasing complications with a higher number of comorbidities. Male gender had higher complication at 30-day post-discharge using MarketScan and NSQIP database. Conclusions Patients in the NSQIP and NIS database have more comorbidities; patients in the MarketScan database had the highest number of perioperative and 30-day post-discharge complications with the highest number of fusion procedures performed. Patients in the NSQIP database had the lowest number of fusion procedures and complication rates. As databases gain popularity in spine surgery, clinicians and reviewers should be cautious in generalizing results to whole populations and pay close attention to the population being represented by the data from which the statistical significance was derived.
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Affiliation(s)
| | - Mayur Sharma
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Nicholas Dietz
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Joseph Dettori
- Evidence Practice Center, Spectrum Research, Tacoma, USA
| | | | - Miriam Nuno
- Statistics, University of California, Davis, USA
| | - Maxwell Boakye
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Doniel Drazin
- Medicine, Pacific Northwest University of Health Sciences, Yakima, USA
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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.
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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
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Turcotte J, Sanford Z, Broda A, Patton C. Centers for Medicare & Medicaid Services Hierarchical Condition Category score as a predictor of readmission and reoperation following elective inpatient spine surgery. J Neurosurg Spine 2019; 31:600-606. [PMID: 31226682 DOI: 10.3171/2019.3.spine1999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A universal, objective predictor of postoperative resource utilization following inpatient spine surgery has not been clearly established. The Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment model, based on a formula using patient demographics and coded diagnoses, is currently used to prospectively estimate financial risk in Medicare Advantage patients; however, the value of this score as a clinical tool is currently unknown. The authors present an analysis evaluating the utility of the CMS HCC score as a universal predictive tool for patients undergoing inpatient spine surgery. METHODS A total of 1966 consecutive patients (551 with lumbar laminectomy [LL] alone, 592 with lumbar laminectomy and fusion [LF], and 823 with anterior cervical discectomy and fusion [ACDF]) undergoing inpatient spine surgery at a single institution from January 2014 to May 2018 were included in this retrospective outcomes study. Perioperative outcome measures included procedure time, 30-day readmission, reoperation, hospital length of stay (LOS), opioid utilization measured by morphine milligram equivalents (MMEs), and cost of inpatient hospitalization (in US dollars). Published CMS algorithms were incorporated into the electronic health records and used to calculate HCC scores for all patients. Patients were stratified into HCC score quartiles. Linear regression was performed on LOS, procedure time, inpatient opioid consumption, discharge opioid prescriptions, and cost to identify predictors of HCC quartiles when controlling for procedure type. One-way ANOVA and Pearson's chi-square analysis were used to compare perioperative outcomes stratified by HCC score. RESULTS Across all procedures, the HCC score demonstrated significant association with 30-day readmission (OR 1.45, 95% CI 1.11-1.91, p = 0.007). The average BMI, median American Society of Anesthesiologists score, and 30-day readmission rate were similar across procedures (LL: 30.6 kg/m2, 2, 3.6%; LF: 30.6 kg/m2, 2, 4.6%; ACDF: 30.2 kg/m2, 2, 3.9%; p = 0.265, 0.061, and 0.713, respectively). LOS (p < 0.0001), duration of procedure (p < 0.0001), discharge MME (p = 0.031), total cost (p < 0.001), daily MME (p < 0.001), reoperation (p < 0.001), and 30-day readmission rate (p < 0.001) were significantly different between HCC quartiles. CONCLUSIONS The HCC score may hold value as an objective, automated predictor of postoperative resource utilization and outcomes, including readmission and reoperation. This may have value as a universal, reproducible tool to target clinical interventions for higher-risk patients.
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Affiliation(s)
| | | | | | - Chad Patton
- 2Center for Spine Surgery, and
- 3Orthopedic and Sports Medicine Specialists, Anne Arundel Medical Center, Annapolis, Maryland
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Kursumovic A, Muir JM, Ammerman J, Bostelmann R. The Disability Cascade: A Preventable Consequence of the Loss of Disc Height following Lumbar Microdiscectomy. Cureus 2019; 11:e5169. [PMID: 31528519 PMCID: PMC6743668 DOI: 10.7759/cureus.5169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Lumbar discectomy is a mainstay surgical treatment for herniation of the lumbar discs and is effective at treating radicular symptomology. Despite the overall success of the procedure; the potential for reherniation and reoperation is significant. To avoid this potential recurrence, surgeons often perform discectomy more aggressively, removing a larger volume of nuclear material in the hopes of minimizing the likelihood of reherniation. This approach, while beneficial in minimizing the chance of reherniation, is associated with a volumetric reduction of the nucleus within the disc space, making the disc more prone to collapse and thus inducing a significant post-operative loss of disc height. While potentially minor in isolation, the loss of disc height, in fact, impacts several aspects of overall patient well-being. We hypothesize that the loss of disc height following discectomy causes an increase in pain and subsequent disability, the combination of which ultimately impacts socioeconomic factors affecting both the patient and the healthcare system as a whole. In this report, we outline the evidence in support of this disability cascade and provide recommendations on methods for limiting its impact. Given the current focus on cost-effectiveness in healthcare decision-making, methods for limiting this potentially damaging sequence of events must be investigated.
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Affiliation(s)
- Adisa Kursumovic
- Neurosurgery, Schwarzwald - Baar Klinikum, Villingen-Schwenningen, DEU
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Sharma M, Dietz N, Ugiliweneza B, Wang D, Drazin D, Boakye M. Differences in clinical outcomes and health care utilization between octogenarians and nonagenarians following decompression for lumbar spinal stenosis. A market scan analysis. Clin Neurol Neurosurg 2019; 182:63-69. [PMID: 31082620 DOI: 10.1016/j.clineuro.2019.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/02/2019] [Accepted: 04/30/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80-89 vs.90+) undergoing decompression for LSS. PATIENTS AND METHODS Data was extracted using ICD9/10 and CPT codes from MarketScan (2001-2015) in this retrospective study. We defined the comparative groups based on the age groups (80-89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4. RESULTS A cohort of 5387 was identified from the database, 96.38% were in the 80-89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80-89 (95.7-98.5%) and 90+ age group (1.5-4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80-89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80-89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80-89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80-89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80-89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80-89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14]. CONCLUSION Using MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Doniel Drazin
- Pacific Northwest University of Health Sciences College of Medicine, Yakima, WA, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA.
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Kern M, Setzer M, Weise L, Mroe A, Frey H, Frey K, Seifert V, Duetzmann S. Upright MRI after decompression of spinal stenosis and concurrent spondylolisthesis. Neurosurg Focus 2019; 46:E14. [PMID: 31042654 DOI: 10.3171/2019.3.focus18730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe treatment of patients with spinal stenosis and concurrent degenerative spondylolisthesis is controversial. Two large randomized controlled clinical trials reported contradictory results. The authors hypothesized that a substantial number of patients will show evidence of micro-instability after a sole decompression procedure.METHODSThis study was a retrospective analysis of all cases of lumbar spinal stenosis treated at the Frankfurt University Clinic (Universitätsklinik Frankfurt) from 2010 through 2013. Patients who had associated spondylolisthesis underwent upright MRI studies in flexion and extension for identification of subtle signs of micro-instability. Clinical outcome was assessed by means of SF-36 bodily pain (BP) and physical functioning (PF) scales.RESULTSA total of 21 patients were recruited to undergo upright MRI studies. The mean duration of follow-up was 65 months (SD 16 months). Of these 21 patients, 10 (47%) showed signs of micro-instability as defined by movement of > 4 mm on flexion/extension MRI. Comparison of mean SF-36 BP and PF scores in the group of patients who showed micro-instability versus those who did not showed no statistically significant difference on either scale.CONCLUSIONSThere seems to be a substantial subset of patients who develop morphological micro-instability after sole decompression procedures but do not experience any clinically significant effect of the instability.
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Affiliation(s)
- Michael Kern
- 1Department of Neurosurgery, University of Frankfurt; and
| | | | - Lutz Weise
- 1Department of Neurosurgery, University of Frankfurt; and
| | - Ali Mroe
- 2Center for Upright MRI, Frankfurt, Germany
| | | | | | - Volker Seifert
- 1Department of Neurosurgery, University of Frankfurt; and
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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.
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