Impact of age within younger populations on outcomes following cervical surgery in the ambulatory setting

Objective

To determine the effect of age within the younger population seen at ambulatory surgical centers on patient-reported outcome measures (PROMs) after cervical spine surgery.

Methods

Patients of age <65 years undergoing single-level anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) were included. Patients were divided by mean age of initial population (46 years). PROMs included Patient-reported Outcome Measurement Information System Physical Function (PROMIS-PF), 12-Item Short-Form Physical Component Survey (SF-12 PCS), Visual Analog Scale (VAS) neck, VAS arm, Neck Disability Index (NDI) collected preoperatively and at postoperative time points up to 2 years.

Results

138 patients were included, with 66 patients <46 years. Both cohorts demonstrated improvement from preoperative baseline with regard to all studied PROMs at multiple time points postoperatively (p ≤ 0.042, all). Between groups, the older cohort demonstrated greater mean PROMIS-PF scores preoperatively and at 6 weeks (p ≤ 0.011, both), while VAS arm scores were lower in the older group at 1 year (p = 0.002), and NDI scores were lower in the older group at 6 weeks and 1 year (p < 0.027, both). Minimal Clinically Important Difference (MCID) achievement rates were greater in the younger group in PROMIS PF at 2 years (p = 0.002), and in the older group in VAS arm score at 1 year (p = 0.007).

Conclusion

Both cohorts showed significant improvement at multiple postoperative time points for all PROMs. Between groups, the older group reported more favorable physical function, VAS arm, and NDI scores at several time points. However, MCID achievement rates only significantly differed in two PROMs at singular time points. Difference in age in patients <65 years likely does not significantly affect long-term outcomes after cervical spine surgery.

Four-level anterior versus posterior cervical fusions: Perioperative outcomes and five-year reoperation rates: Outcomes after four-level anterior versus posterior cervical procedures

Background

Multilevel cervical pathology can often be addressed via anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes. The purpose was to compare perioperative adverse events and long-term cervical reoperation rates of four-level ACDF and PCF.

Methods

The 2010 to Q1 2020 PearlDiver MSpine database was queried. Patients undergoing isolated elective four-level ACDF or PCF were identified (excluding cases performed for trauma, neoplasm, and/or infections) and 1:1 matched based on age, sex, and comorbidities. Ninety-day adverse events were compared with univariate and multivariate analyses. Five-year incidences of subsequent cervical reoperations were also compared.

Results

A total of 3,714 patients 1:1 matched for four-level ACDF and PCF performed for degenerative pathologies were identified (1,857 for each of the study groups). On multivariate analysis controlling for age, sex, and comorbidities, PCF was found to have significantly greater odds ratios (OR) for any (OR 2.12), serious (OR 2.31), and minor (OR 1.95) adverse events, as well as for length of stay ≥3 days (OR 1.76), p<0.001 for each. However, PCF had nearly three times lower odds of dysphagia compared to ACDF (OR 0.36, p<0.001). At five years, four-level ACDF cases were found to have significantly higher reoperation rates compared to four-level PCF cases (26.3% vs 18.3%, p<0.001).

Conclusion

In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.

The Impact of State Level Public Policy, Prescriber Education, and Patient Factors on Opioid Prescribing in Elective Orthopedic Surgery: Findings From a Tertiary, Academic Setting

Background

The United States is in the midst of an opioid misuse epidemic. There have been recent changes to North Carolina’s public policy leading to institutional education attempting to reduce high-risk opioid prescribing. This study investigated whether state-level and institutional efforts were associated with provider-level changes in opioid prescriptions after common orthopedic surgeries.

Patients and Methods

Six-week post-operative opioid prescribing in patients 18 years or older undergoing high-volume elective surgeries were reviewed retrospectively. Three patient cohorts from equivalent calendar year periods were included in this analysis; preceding policy implementation (January 1, 2017, to March 31, 2017), immediately after policy implementation (January 1, 2018, to March 31, 2018), and 1 year after policy implementation (January 1, 2019, to March 31, 2019). Multivariable models were constructed to evaluate the effects of public policy and institutional education on postoperative opioid prescribing.

Results

The mean (standard deviation) amount of oxycodone 5-mg equivalents prescribed at discharge decreased from 75.6 (53.2) in 2017 to 55.7 (36.2) in 2018 and then 45.6 (32.6) in 2019 (P < .05). Similarly, 6-week postoperative cumulative oxycodone 5-mg equivalents prescribed also significantly decreased from 123.3 (145.8) in 2017 to 84.1 (90.3) in 2018 and to 80.2 (150.1) in 2019. Other outcomes including prescription duration and rates of outlier prescribing showed similar trends.

Conclusion

In a North Carolina tertiary academic hospital, opioid prescribing decreased after public policy implementation and an institutional response of education for prescribers within a national context of changing practices in opioid prescribing. State-level public policy and prescriber education could be important avenues for decreasing postoperative opioid prescription in orthopedic settings.