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Baumann AN, Trager RJ, Gong DC, Anaspure O, Strony JT, Aleem I. Osteoporosis is Not Associated with Reoperation or Pseudarthrosis after Anterior Cervical Discectomy and Fusion Through Four-Years' Follow-Up: A Retrospective Cohort Study of US Academic Health Centers. Spine J 2024:S1529-9430(24)01049-0. [PMID: 39369795 DOI: 10.1016/j.spinee.2024.09.031] [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: 04/26/2024] [Revised: 09/07/2024] [Accepted: 09/24/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND CONTEXT Osteoporosis has been proposed as a risk factor for reoperation after anterior cervical discectomy and fusion (ACDF), yet this potential association has been understudied, with conflicting results to date. PURPOSE This study examines the hypothesis that adults with osteoporosis would have an increased risk of reoperation after ACDF compared to matched adults without osteoporosis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Two matched cohorts (mean age: 62 years; 75% female), each with 1,019 patients, who underwent primary ACDF. Cohorts were determined by the presence or absence of a diagnosis of osteoporosis. OUTCOME MEASURES Incidence of reoperation occurring over four years postoperatively, with our primary outcome being the risk ratio (RR) of reoperation with 95% confidence intervals (CI). Secondary outcomes included risk and mean count of oral opioid prescriptions and risk of pseudoarthrosis. METHODS We utilized the TriNetX network to identify adults undergoing their first ACDF from 2004-2020, excluding those with serious pathology, and divided patients into two cohorts: osteoporosis and non-osteoporosis. Patients were propensity matched according to key risk factors for reoperation. RESULTS Patients with osteoporosis had no statistically significant or meaningful difference in risk of reoperation compared to non-osteoporotic patients over four-years' follow-up [95% CI] (17.3% versus 16.5%; RR: 1.05 [0.86, 1.27]; p=0.6361). Similarly, there were no significant differences in the risk of pseudoarthrosis (26.5% versus 29.1%; RR: 0.91 [0.79, 1.05]; p=0.1820), oral opioid prescription (75.0% versus 76.0%; RR: 0.99 [0.94, 1.04]; p=0.6067), or mean oral opioid prescription count (11.5 vs. 11.8; p=0.7040). CONCLUSION Compared to matched non-osteoporosis controls, osteoporosis was not associated with a statistically significant or clinically meaningful increase in risk of reoperation in adults over four years after ACDF. Furthermore, osteoporosis was not associated with a significant or meaningful risk of pseudoarthrosis or oral opioid prescription after ACDF, although more research is needed for corroboration. Additional research is needed to clarify whether those with osteoporosis have meaningful differences in pain and function compared to those without osteoporosis following ACDF.
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Affiliation(s)
- Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA; Department of Rehabilitation Services, University Hospitals, Cleveland, OH, USA
| | - Robert J Trager
- Connor Whole Health, University Hospitals, Cleveland, OH, USA; Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Davin C Gong
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Omkar Anaspure
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - John T Strony
- Department of Orthopedic Surgery, University Hospitals, Cleveland, OH, USA
| | - Ilyas Aleem
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA
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Vincent R, Gert R, Eric P, Salah-Eddine A, Sacha M, Maarten W, Sven B, Steven V, De Ridder D, Tomas M, Mark P. Prolonged opioid use after single-level lumbar spinal fusion surgery in a Belgian population: a multicentric observational 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 2024; 33:3559-3566. [PMID: 39168891 DOI: 10.1007/s00586-024-08448-7] [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: 06/03/2024] [Revised: 07/14/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE Lumbar spinal fusion surgeries are increasingly being performed in spinal degenerative disease, often accompanied by perioperative opioid prescriptions. The aim of this study is to analyze prolonged postoperative opioid use following a standardized opioid prescription after single-level lumbar spinal fusion surgery in a Belgian population. METHODS This prospective, multicentric observational study included patients undergoing single-level lumbar fusion surgery for degenerative disease. A standardized postoperative opioid protocol (Targinact 2 × 10 mg/5 mg, Paracetamol 4 × 1 g and Ibuprofen 3 × 600 mg) was applied uniformly. Prolonged opioid use was defined as continued opioid use six months after surgery. Patient data were collected using the Back-App®. RESULTS Among 198 participants, 32.8% continued opioid use six months post-surgery, with 8% utilizing strong opioids. Prolonged opioid use correlated with lower pre-operative back pain. Patients with prolonged opioid use and strong opioid use at six months show less improvement in disability compared to patients without prolonged opioid use. Moreover, patients with prolonged strong opioid use tend to have lesser improvement of the low back pain. The odds for prolonged opioid use decrease with the increase of the improvement in ODI. CONCLUSION 1 in 3 patients undergoing single-level lumbar spinal fusion surgery is at risk for prolonged opioid use. The study underscores the importance of tailored pain management strategies, particularly given the rising prevalence of spinal fusion surgeries. The association between pre-operative low back pain, post-operative improvement in functionality (ODI), and prolonged opioid use emphasizes the need for judicious opioid prescribing practices and highlights the role of functional outcomes in treatment goals.
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Affiliation(s)
- Raymaekers Vincent
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Roosen Gert
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Put Eric
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Achahbar Salah-Eddine
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Meeuws Sacha
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Wissels Maarten
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Bamps Sven
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Vanvolsem Steven
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Menovsky Tomas
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Plazier Mark
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
- Department of Neurosurgery Jessa Hospital, Hasselt, Belgium
- Department of Neurosurgery St. Trudo Hospital, Sint-Truiden, Belgium
- Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium
- Studie- & opleidingcentrum Neurochirurgie Virga Jesse, Hasselt, Belgium
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Sharma NK, Li H, Aoyagi K, Ritchey S, Mohr E, Burton DC, Arnold PM, Colgrove Y. Tailored Yoga Intervention for Postlumbar Spine Surgical Pain Management: A Feasibility Study. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:753-761. [PMID: 38513063 DOI: 10.1089/jicm.2023.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Introduction: Severe pain, anxiety, and high opioid use are common following lumbar spine surgery (LSS). Yoga helps to reduce pain and anxiety, but it has not been considered for postsurgical care. The authors developed and tested the feasibility of a tailored yoga program designed for individuals undergoing LSS and explored clinical feasibility of yoga intervention on measures of pain, function, psychological status, and opioid use. Methods: Individuals scheduled for LSS were randomized into yoga versus control groups presurgery. Participants in the yoga group received tailored yoga sessions plus usual care, whereas participants in the control group received usual care only during the hospital stay post-LSS. In-person daily yoga sessions were individually presented and performed in the participant's hospital room. Feasibility was assessed by recruitment and retention rates, rate of yoga session completion, tolerance to yoga intervention, and ability to carry out planned assessment. Exploratory clinical outcomes included pain, psychological measures, Timed-Up-and-Go test, gait distance, and opioid use, during the hospital stay post-LSS. Results: Forty-one participants were enrolled, of which 30 completed. There were no dropouts. Planned assessments were completed within 45 min, suggesting no excessive burden on participants. Baseline variables were similar across both groups. The majority of participants participated in yoga intervention on the day of surgery or one day after surgery with acceptance rate of 100%. Participants showed good tolerance to yoga intervention on 0-4 tolerance scale and by their reports of exploratory clinical outcomes. Conclusion: This study indicates feasibility for a modified yoga program for postoperative care following LSS due to participant tolerance and retention. The results provide preliminary framework for future confirmatory studies that can assess the potential benefits of yoga in reducing pain, catastrophizing behavior, and opioid use and improving function. A modified yoga program focusing on diaphragmatic breathing, relaxation, and core isometric contraction exercises can be an important adjunct intervention for patients undergoing LSS. CTR Number: This trial was registered in UMIN CTR (https://rctportal.niph.go.jp/en/) with registration number: UMIN000032595.
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Affiliation(s)
- Neena K Sharma
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Haiyin Li
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopedics, University of Rochester Medical Center, Rochester, New York, USA
| | - Kosaku Aoyagi
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Physical Therapy and Movement Science, College of Health Sciences, University of Texas at El Paso, El Paso, Texas, USA
| | - Shannon Ritchey
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Elisa Mohr
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Paul M Arnold
- Department of Neurosurgery, School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Yvonne Colgrove
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas, USA
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Kaye AD, Plaisance TR, Smith SA, Ragland AR, Alfred MJ, Nguyen CG, Chami AA, Kataria S, Dufrene K, Shekoohi S, Robinson CL. Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review. Curr Pain Headache Rep 2024; 28:691-698. [PMID: 38642233 DOI: 10.1007/s11916-024-01257-z] [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] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE OF REVIEW Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. RECENT FINDINGS Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Taylor R Plaisance
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Summer A Smith
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Amanda R Ragland
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Michael J Alfred
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Catherine G Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Azem A Chami
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Saurabh Kataria
- Department of Neurology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Kylie Dufrene
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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Tretiakov PS, Onafowokan OO, Lorentz N, Galetta M, Mir JM, Das A, Dave P, Yee T, Buell TJ, Jankowski PP, Eastlack R, Hockley A, Schoenfeld AJ, Passias PG. Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains? Clin Spine Surg 2024; 37:164-169. [PMID: 38637936 DOI: 10.1097/bsd.0000000000001625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery. STUDY DESIGN Retrospective review of prospective CD database. BACKGROUND Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. METHODS Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy. RESULTS In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048]. CONCLUSIONS Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.
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Affiliation(s)
- Peter S Tretiakov
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Oluwatobi O Onafowokan
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Nathan Lorentz
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Matthew Galetta
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Jamshaid M Mir
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Ankita Das
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Timothy Yee
- Department of Neurosurgery, University of California San Francisco, CA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburg, PA
| | - Pawel P Jankowski
- Department of Neurosurgery, Hoag Neurosciences Institute, Irvine, CA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Health, San Diego, CA
| | - Aaron Hockley
- Department of Neurological Surgery, University of Alberta, Edmonton, AB, Canada
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Peter G Passias
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
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Passias PG, Tretiakov PS, Onafowokan OO, Galetta M, Lorentz N, Mir JM, Das A, Dave P, Lafage R, Yee T, Diebo B, Vira S, Jankowski PP, Hockley A, Daniels A, Schoenfeld AJ, Mummaneni P, Paulino CB, Lafage V. The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery. Clin Spine Surg 2024; 37:182-187. [PMID: 38637915 DOI: 10.1097/bsd.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/28/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery. BACKGROUND ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery. METHODS Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis. RESULTS A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034). CONCLUSIONS The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Peter S Tretiakov
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Oluwatobi O Onafowokan
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Matthew Galetta
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Nathan Lorentz
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Jamshaid M Mir
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Ankita Das
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Pooja Dave
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Timothy Yee
- Department of Neurosurgery, University of California San Francisco, CA
| | - Bassel Diebo
- Department of Orthopedic Surgery, The Warren Alpert School of Medicine, Brown University, RI
| | - Shaleen Vira
- Departments of Orthopedic and Neurosurgery, Banner Health, Phoenix, AZ
| | - Pawel P Jankowski
- Department of Neurosurgery, Hoag Neurosciences Institute, Irvine, CA
| | - Aaron Hockley
- Department of Neurological Surgery, University of Alberta, Edmonton, AB, Canada
| | - Alan Daniels
- Department of Orthopedic Surgery, The Warren Alpert School of Medicine, Brown University, RI
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Praveen Mummaneni
- Department of Neurosurgery, University of California San Francisco, CA
| | - Carl B Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
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Baumann AN, Fiorentino A, Sidloski K, Fiechter J, Uhler MA, Calton TJ, Hoffmann C, Hoffmann JC. The Impact of Ketorolac Utilization on Outcomes for Lumbar Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2024; 184:87-102. [PMID: 38224904 DOI: 10.1016/j.wneu.2024.01.042] [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: 01/02/2024] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVE Ketorolac is one of the most potent nonsteroidal anti-inflammatory drugs commonly used in spine surgery. The purpose of this study is to examine the impact of ketorolac utilization with or without other medications on a patient's postoperative course after lumbar surgery. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed using PubMed, CINAHL, MEDLINE, and Web of Science in July 2023. Inclusion criteria were RCTs that used ketorolac for lumbar surgery. RESULTS Thirteen RCTs were included (N = 997; mean age, 54.6 ± 7.8 years; n = 535 in the ketorolac group) in this systematic review. There was no significant difference in the 24-hour and total postoperative morphine utilization (P = 0.185 and P = 0.109, respectively), 24-hour and final postoperative pain scores (0-10 scale) (P = 0.065 and P = 0.582, respectively), and length of stay at the hospital (P = 0.990) between patients in the ketorolac group and patients in the non-ketorolac group who underwent lumbar surgery. Overall, patients had similar rates of major complications (3.7% vs. 5.4%) and minor complications (42.1% vs. 51.7%) between groups after lumbar surgery. However, patients in the ketorolac group had a significantly lower rate of nausea and/or vomiting compared with the non-ketorolac group after lumbar surgery (21.6% vs. 37.1%, respectively; P = 0.018). CONCLUSIONS There is no significant difference in 24-hour and total postoperative morphine utilization, pain scores, or length of stay, with similar complication rates after lumbar surgery between patients receiving ketorolac and patients not receiving ketorolac via meta-analysis of RCTs.
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Affiliation(s)
- Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA.
| | - Andrew Fiorentino
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Katelyn Sidloski
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Jay Fiechter
- College of Medicine, Indiana University School of Medicine, Fort Wayne, Indiana, USA
| | - Mathias A Uhler
- College of Biological Sciences, University of Akron, Akron, Ohio, USA
| | - Tyler J Calton
- Department of Orthopedic Surgery, Cleveland Clinic Akron General, Akron, Ohio, USA
| | | | - Jacob C Hoffmann
- Department of Orthopedic Surgery, Cleveland Clinic Akron General, Akron, Ohio, USA
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Patel TD, McNicholas MN, Paschell PA, Arnold PM, Lee CT. Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review. BMC Anesthesiol 2024; 24:122. [PMID: 38539065 PMCID: PMC10976846 DOI: 10.1186/s12871-024-02500-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/15/2024] [Indexed: 07/23/2024] Open
Abstract
Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.
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Affiliation(s)
| | | | | | - Paul M Arnold
- Carle Neuroscience Institute, Carle Foundation Hospital, Urbana, IL, USA
| | - Cheng-Ting Lee
- Department of Anesthesiology, Carle Foundation Hospital Urbana, Illinois, USA
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Rana P, Brennan JC, Johnson AH, Turcotte JJ, Patton C. The Relationship Between Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity Scores and Early Postoperative Pain and Opioid Consumption After Lumbar Fusion. Cureus 2024; 16:e55335. [PMID: 38559542 PMCID: PMC10981900 DOI: 10.7759/cureus.55335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background The Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and pain intensity measures quantify separate dimensions of pain from the patient's perspective. This study aimed to assess differences in these outcomes and to evaluate whether baseline PROMIS pain scores could be used as a leading indicator of increased pain and opioid consumption during early recovery after lumbar fusion. Methods A retrospective review of 199 consecutive patients undergoing posterolateral fusion (PLF) at a single institution was performed. All patients underwent one to three level lumbar PLF and preoperatively completed the PROMIS pain intensity and PROMIS pain interference measures. Multivariate linear regression was used to assess the relationship between preoperative PROMIS scores and postoperative pain numeric rating scale (NRS) and oral morphine milligram equivalents (OMME) by day after controlling for age, sex, and body mass index (BMI). Results In comparison to patients with the lowest preoperative pain intensity scores, those with the highest scores required significantly more OMME on postoperative day (POD) zero and one (both p<0.05) and had higher pain NRS on POD one (p=0.02). Patients with the highest pain interference scores reported higher pain NRS on POD zero (p=0.02) but required similar OMME at all time points. After controlling for age, sex, and BMI, each one-point increase in preoperative PROMIS pain interference scores was associated with increased OMME on POD zero (β=0.29, p=0.04) and POD one (β=0.64, p=0.03). Conclusions Patients with high pain intensity reported higher levels of pain and required more opioids during the first 24 hours postoperatively, while those with high pain interference reported higher levels of pain on the day of surgery but utilized similar amounts of opioids. After risk adjustment, increased baseline PROMIS pain interference scores - but not pain intensity - were associated with increased opioid use. These results suggest that both measures should be considered when identifying patients at risk for increased pain and opioid consumption after PLF.
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Affiliation(s)
- Parimal Rana
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | - Jane C Brennan
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | | | | | - Chad Patton
- Orthopedic Surgery, Anne Arundel Medical Center, Annapolis, USA
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Khoshrang H, Damavand RS, Nasseh H, Tavakoli AA, Esmaeili S, Ghaffari M, Shakiba M. Comparing spinal anesthesia approaches for transurethral lithotripsy in patients with proximal ureteral stones: A randomized clinical trial of bupivacaine alone versus bupivacaine with fentanyl. J Med Life 2023; 16:1508-1513. [PMID: 38313179 PMCID: PMC10835565 DOI: 10.25122/jml-2023-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/14/2023] [Indexed: 02/06/2024] Open
Abstract
Despite the benefits of spinal anesthesia and the preference of anesthesiologists for this technique, it is less accepted by urologists due to the proximity of the stone place in the ureter and the possibility of pain, restlessness, and occasional movements of the patient during surgery. The current study investigated the success of bupivacaine plus intrathecal fentanyl in patients undergoing transurethral lithotripsy (TUL). In this randomized clinical trial, from April 2021 to September 2021, 54 patients with proximal urolithiasis candidates for TUL were enrolled. Patients were randomly categorized into two groups: group A received bupivacaine 10 mg and 0.5 ml of normal saline, while group B received bupivacaine 10 mg with 0.5 ml (25µg) of intrathecal fentanyl. According to our findings, about 74% of the patients were men, and the mean age of the patients was 66.14±22.46 years. The onset time of the sensory block, sensory block level, pain score, degree of relaxation, depth of the motor block, occurrence of anesthesia complications, oxygen saturation, and mean arterial blood pressure were not significantly different between the two groups. However, the duration of the motor block in group B was longer than in group A (p<0.001). Also, retropulsion was observed only in five patients (18.5%) in group A, significantly higher than in group B (p=0.019). Bupivacaine with fentanyl 25µg provided adequate spinal anesthesia with lower retropulsion in patients with urolithiasis who are candidates for TUL.
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Affiliation(s)
- Hossein Khoshrang
- Anesthesiology Research Center, Alzahra Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Reza Shahrokhi Damavand
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Hamidreza Nasseh
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Ardalan Akhavan Tavakoli
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Samaneh Esmaeili
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mehdi Ghaffari
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Maryam Shakiba
- Urology Research Center, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
- Cardiovascular Diseases Research Center, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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Schultz E, Zhuang T, Shapiro LM, Hu SS, Kamal RN. Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis. Spine J 2023; 23:1451-1460. [PMID: 37355048 PMCID: PMC10538426 DOI: 10.1016/j.spinee.2023.06.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND CONTEXT Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting. PURPOSE To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures. STUDY DESIGN Retrospective analysis using national administrative claims database. PATIENT SAMPLE A total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery. OUTCOME MEASURES Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users. METHODS We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors. RESULTS A total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient. CONCLUSION Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification. LEVEL OF EVIDENCE Level III Prognostic Study. MINI ABSTRACT We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.
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Affiliation(s)
- Emily Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California San Francisco
| | - Serena S Hu
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University.
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Fritz JM, Rhon DI, Garland EL, Hanley AW, Greenlee T, Fino N, Martin B, Highland KB, Greene T. The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S115-S125. [PMID: 36069630 PMCID: PMC10403309 DOI: 10.1093/pm/pnac138] [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: 05/07/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP. DESIGN Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome. SUMMARY This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Eric L Garland
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Adam W Hanley
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Tina Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Nora Fino
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
| | - Brook Martin
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Krista B Highland
- Department of Orthopedics, School of Medicine, The University of Utah, Salt Lake City, Utah
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Rockville, Maryland, USA
| | - Tom Greene
- Department of Population Health Sciences, The University of Utah, Salt Lake City, Utah
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Cleary DR, Tan H, Ciacci J. Intradermal and Intramuscular Bupivacaine Reduces Opioid Use Following Noninstrumented Spine Surgery. World Neurosurg 2023; 170:e716-e723. [PMID: 36442775 DOI: 10.1016/j.wneu.2022.11.099] [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: 10/06/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy of intraoperative bupivacaine hydrochloride wound infiltration as an adjunct means of pain relief following noninstrumented posterior spine surgery. METHODS A retrospective cohort analysis was performed of all patients who underwent posterior spinal decompression surgery at the University of California, San Diego, and at the San Diego VA Medical Center between June 2020 and July 2021, following a change in practice to including bupivacaine infiltration at the end of the surgery. Patients were stratified into groups based on whether they received intrawound bupivacaine during surgery. Demographic and clinical data were extracted from the electronic health record. Postoperative opioid use, visual analog pain scores, heart rate, and blood pressure were compared. RESULTS The analysis included 43 patients; 21 received bupivacaine infiltration, and 22 did not. No complications were encountered in the perioperative period. Patients who received bupivacaine consumed significantly less opioids over the 72 hours following surgery, had slightly lower pain scores, and experienced slightly lower heart rates. No significant difference was found between groups with respect to systolic blood pressure, operative time, or length of hospital stay. CONCLUSIONS Intraoperative infiltration of the exposed paraspinous musculature and peri-incisional subdermal layer with bupivacaine significantly reduced postoperative opioid consumption for 72 hours after surgery and slightly reduced pain ratings and conferred superior heart rate control. This low-cost intervention produced significant patient benefit with minimal risk and no significant increase in surgical time or hospital stay.
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Affiliation(s)
- Daniel R Cleary
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA.
| | - Hao Tan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph Ciacci
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
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Neurocognitive monitoring in patients undergoing opioid pain medication after spinal surgery: a feasibility study of a new monitoring method. Acta Neurochir (Wien) 2023; 165:335-340. [PMID: 36625907 PMCID: PMC9922216 DOI: 10.1007/s00701-023-05486-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023]
Abstract
PURPOSE Patients undergoing spinal surgery require postoperative pain management to alleviate wound pain. Pain medication includes WHO grade 1 analgesic as well as potent opioids, potentially leading to cognitive decline. Up until now, the cognitive impairment is only poorly studied and difficult to monitor. We hereby investigate the feasibility of a digital monitoring method for neurocognitive function under opioid medication after spinal instrumentation. METHODS Prospective monocenter feasibility study enrolling patients before undergoing spinal surgery. We performed cognitive testing using a tablet-based application before (baseline), as well as on day 2 after surgery (intravenous opioids), before discharge (oral opioids), and at follow-up. We recorded the exact pain medication and its other side effects. Potential risk factors for the postoperative decline in cognition included age, high-dose opioid application, and length of surgery. RESULTS We included 20 patients in our study. The baseline assessment revealed no cognitive impairment before surgery. All patients underwent dorsal instrumentation for degenerative (60%), osteoporotic fracture (15%), or spinal tumor (25%) indications. Cognitive testing after surgery showed a significant decline under intravenous opioid therapy including short time and delayed verbal recall (p < 0.001) as well as arithmetic fluency. Cognitive performance significantly improved with partial recovery until follow-up and opioid discontinuation. CONCLUSION Cognition testing and monitoring of neurocognitive decline under high-dose opioid medication were feasible using the digital tablet-based application. The cognition app helps to identify difficulties in cognitive function as a side effect of overdosage in opioid medication, and care givers should evaluate the risk of non-comprehension and impaired informed consent appropriately.
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