Is There a Preoperative Morphine Equianalgesic Dose that Predicts Ability to Achieve a Clinically Meaningful Improvement Following Spine Surgery?

Neurosurgery ◽  
2017 ◽  
Vol 83 (2) ◽  
pp. 245-251 ◽  
Author(s):  
Joseph B Wick ◽  
Ahilan Sivaganesan ◽  
Silky Chotai ◽  
Kristin R Archer ◽  
Samuel L Posey ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Spine Surgery ◽  
Elective Surgery ◽  
Neck Disability Index ◽  
Credible Interval ◽  
Minimum Clinically Important Difference ◽  
Opioid Use ◽  
Meaningful Improvement ◽  
Opioid Dose ◽  
Patient Reported

Abstract BACKGROUND Preoperative opioid use is widespread and associated with worse patient-reported outcomes following spine surgery. OBJECTIVE To calculate a threshold preoperative morphine equianalgesic (MEA) dose beyond which patients are less likely to achieve the minimum clinically important difference (MCID) following elective surgery for degenerative spine disease. METHODS The study included 543 cervical and 1293 lumbar patients. Neck Disability Index and Oswestry Disability Index scores were collected at baseline and 12 mo postoperatively. Preoperative MEA doses were calculated retrospectively. Multivariate logistic regression was then performed to determine the relationship between MEA dose and the odds of achieving MCID. As a part of this regression, Bayesian inference and Markov Chain Monte Carlo methods were used to estimate the values of inflection points (or “thresholds”) in MEA. RESULTS Overall, 1020 (55.5%) patients used preoperative opioids. A total of 50.3% of cervical and 61.9% of lumbar patients achieved MCID. The final logistic regression model demonstrated that MCID achievement decreased significantly when mean preoperative MEA dose exceeded 47.8 mg/d, with a 95% credible interval of 29.0 to 60.0 mg/d. CONCLUSION Minimum and maximum MEA doses exist, between which increasing opioid dose is associated with decreased ability to achieve clinically meaningful improvement following spine surgery. Patients with preoperative MEA dose exceeding 29 mg/d, the lower limit of the 95% credible interval for the mean MEA dose above which patients exhibit significantly decreased achievement of MCID, may be considered for preoperative opioid weaning.

The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study

2021 ◽  
pp. 1-9
Author(s):  
Travis Hamilton ◽  
Mohamed Macki ◽  
Seok Yoon Oh ◽  
Michael Bazydlo ◽  
Lonni Schultz ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Patient Reported Outcomes ◽  
Minimum Clinically Important Difference ◽  
Estimating Equation ◽  
Generalized Estimating Equation ◽  
Measurement Information ◽  
Patient Reported ◽  
Physical Function Score ◽  
Measurement Information System ◽  
College Educated

OBJECTIVE Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)–level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

scholarly journals Patient-reported outcomes 3 months after spine surgery: is it an accurate predictor of 12-month outcome in real-world registry platforms?

2015 ◽  
Vol 39 (6) ◽  
pp. E17 ◽  
Author(s):  
Scott L. Parker ◽  
Anthony L. Asher ◽  
Saniya S. Godil ◽  
Clinton J. Devin ◽  
Matthew J. McGirt
Keyword(s):  
Health Care ◽  
Spine Surgery ◽  
Real World ◽  
Patient Reported Outcomes ◽  
Lumbar Spine Surgery ◽  
Meaningful Improvement ◽  
Patient Level ◽  
Life Years ◽  
Patient Reported ◽  
Prospective Longitudinal

OBJECT The health care landscape is rapidly shifting to incentivize quality of care rather than quantity of care. Quality and outcomes registry platforms lie at the center of all emerging evidence-driven reform models and will be used to inform decision makers in health care delivery. Obtaining real-world registry outcomes data from patients 12 months after spine surgery remains a challenge. The authors set out to determine whether 3-month patient-reported outcomes accurately predict 12-month outcomes and, hence, whether 3-month measurement systems suffice to identify effective versus noneffective spine care. METHODS All patients undergoing lumbar spine surgery for degenerative disease at a single medical institution over a 2-year period were enrolled in a prospective longitudinal registry. Patient-reported outcome instruments (numeric rating scale [NRS], Oswestry Disability Index [ODI], 12-Item Short Form Health Survey [SF-12], EQ-5D, and the Zung Self-Rating Depression Scale) were recorded prospectively at baseline and at 3 months and 12 months after surgery. Linear regression was performed to determine the independent association of 3- and 12-month outcome. Receiver operating characteristic (ROC) curve analysis was performed to determine whether improvement in general health state (EQ-5D) and disability (ODI) at 3 months accurately predicted improvement and achievement of minimum clinical important difference (MCID) at 12 months. RESULTS A total of 593 patients undergoing elective lumbar surgery were included in the study. There was a significant correlation between 3-month and 12-month EQ-5D (r = 0.71; p < 0.0001) and ODI (r = 0.70; p < 0.0001); however, the authors observed a sizable discrepancy in achievement of a clinically significant improvement (MCID) threshold at 3 versus 12 months on an individual patient level. For postoperative disability (ODI), 11.5% of patients who achieved an MCID threshold at 3 months dropped below this threshold at 12 months; 10.5% of patients who did not meet the MCID threshold at 3 months continued to improve and ultimately surpassed the MCID threshold at 12 months. For ODI, achieving MCID at 3 months accurately predicted 12-month MCID with only 62.6% specificity and 86.8% sensitivity. For postoperative health utility (EQ-5D), 8.5% of patients lost an MCID threshold improvement from 3 months to 12 months, while 4.0% gained the MCID threshold between 3 and 12 months postoperatively. For EQ-5D (quality-adjusted life years), achieving MCID at 3 months accurately predicted 12-month MCID with only 87.7% specificity and 87.2% sensitivity. CONCLUSIONS In a prospective registry, patient-reported measures of treatment effectiveness obtained at 3 months correlated with 12-month measures overall in aggregate, but did not reliably predict 12-month outcome at the patient level. Many patients who do not benefit from surgery by 3 months do so by 12 months, and, conversely, many patients reporting meaningful improvement by 3 months report loss of benefit at 12 months. Prospective longitudinal spine outcomes registries need to span at least 12 months to identify effective versus noneffective patient care.

scholarly journals Outcomes of Revision Surgery for Pseudarthrosis After Anterior Cervical Fusion: Case Series and Systematic Review

2019 ◽  
Vol 10 (5) ◽  
pp. 559-570
Author(s):  
Michael E. Steinhaus ◽  
Philip J. York ◽  
Rachel S. Bronheim ◽  
Jingyan Yang ◽  
Francis Lovecchio ◽  
...  
Keyword(s):  
Systematic Review ◽  
Statistical Significance ◽  
Neck Disability Index ◽  
Case Series ◽  
Difficult Problem ◽  
Cervical Fusion ◽  
Meaningful Improvement ◽  
Time Points ◽  
Patient Reported ◽  
Optimal Approach

Study Design: Case series/systematic review. Objectives: To report on patients undergoing posterior cervical fusion for symptomatic pseudarthrosis following anterior cervical discectomy and fusion (ACDF), and to assess outcomes reporting in the literature. Methods: Patients undergoing posterior instrumented fusion for pseudarthrosis after primary ACDF from 2013 to 2018 by a single surgeon were reviewed consecutively. Neck Disability Index (NDI) and visual analogue scale (VAS) arm/neck were recorded at preoperative, 6-month, and 1-year time points. A systematic review of the literature was performed, and outcomes reporting was recorded. Results: NDI scores were 54.4 (SD 19.1), 36.6 (SD 18.1), and 41.2 (SD 19.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .004). VAS neck scores were 8.1 (SD 1.3), 5.0 (SD 2.9), and 5.8 (SD 2.2) at preoperative, 6-month, and 1-year time points, respectively, with improvement from preoperatively to 6 months ( P = .038). VAS arm scores were 5.1 (SD 4.1), 3.5 (SD 3.2), and 3.6 (SD 2.7) at preoperative, 6-month, and 1-year time points, respectively, with improvement although these did not reach statistical significance ( P = .145). The most common subjective outcomes reported in the literature were general symptoms assessments (43%), ordinal scales (43%), and VAS neck (19%) scales, with the majority of studies (67%) documenting one measure. Conclusions: Patient-reported outcomes demonstrate clinically meaningful improvement within the first 6 months after posterior fusion for pseudarthrosis. Studies demonstrate substantial variability and no standardization in outcomes reporting, limiting the ability to compare results across interventions and pathologies. Standardized reporting will enable comparisons to inform patients and physicians on the optimal approach to treat this difficult problem.

scholarly journals Towards Opioid-Free Elective Spine Surgery: A Prospective Cohort Study

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ahilan Sivaganesan ◽  
Amanda Wright ◽  
Regis W Haid ◽  
Praveen V Mummaneni ◽  
Richard Berkman
Keyword(s):  
Cohort Study ◽  
Prospective Cohort Study ◽  
Spine Surgery ◽  
Prospective Cohort ◽  
Multivariate Regression ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
Average Pain ◽  
Student’S T

Abstract INTRODUCTION The opioid crisis is a national emergency. We conducted a prospective cohort study to determine whether elective spine surgery can be performed without any opioids whatsoever. METHODS Every consecutive elective spine surgery performed by author R.A.B. between January 1st and December 31st of 2018 was included. For cohort A, between January and April 15th, opioids were minimized but PRN doses were given. For cohort B, between April 15th and December, the goal was to eliminate opioids altogether. Pain scores were collected at discharge, 1 wk, and 1-mo follow-up. Patient-reported outcomes (PRO) were collected at baseline and at 3 mo for lumbar procedures. Emergency room visits and readmissions were tracked. Student's t-tests were used to compare pain scores and PROs, and multivariate regression analyses were performed to understand drivers of opioid use. RESULTS A total of 158 patients were included. In cohort A, 37.9% of patients took no opioids between PACU and 1 mo. Average pain scores were 5.2 in PACU and 2.5 at 1 mo. In cohort B, 86.7% took no opioids after PACU. Average pain scores were 4.2 in PACU and 2.5 at 1 mo. Both cohorts had equivalent improvements in PROs. Multivariate regression revealed that, adjusting for case mix differences, cohort B had lower odds of opioid use after PACU (P < .0001). Moreover, preoperative opioid use is a driver of postoperative opioid use (P = .02), whereas procedure type/invasiveness is not. CONCLUSION We have shown that opioid-free spine surgery, including lumbar fusions, is feasible and effective. In all 87% of patients in our opioid-elimination cohort took no opioids from PACU until 1 mo after surgery, and 94% were taking none at the 1-mo visit. Pain scores and PROs were favorable. We have also shown that preoperative opioids are a driver of postoperative opioid use, however procedural invasiveness is not.

A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series

2016 ◽  
Vol 13 (1) ◽  
pp. 27-31 ◽  
Author(s):  
Sameer Hassamal ◽  
Margaret Haglund ◽  
Karl Wittnebel ◽  
Itai Danovitch
Keyword(s):  
Spine Surgery ◽  
Physical Functioning ◽  
Preliminary Data ◽  
Case Series ◽  
Pain Interference ◽  
Opioid Analgesia ◽  
Opioid Dose ◽  
Patient Reported ◽  
Reduction Program ◽  
The Mean

AbstractBackgroundSpine surgery candidates are commonly treated with long-term opioid analgesia. However, chronic opioid analgesia is associated with poor pain control, psychological distress, decreased functional status and operative complications. Therefore, our medical centre piloted an outpatient biopsychosocial interdisciplinary opioid reduction program for spine surgery candidates on chronic opioid analgesia.MethodsOur case series reviews the outcomes of the first 5 interdisciplinary program completers. Data was collected on admission to the program, preoperatively at completion of the program, and 1 month postoperatively. We recorded changes in pain interference scores, physical functioning, and symptoms of depression and anxiety as captured by the Patient-Reported Outcome Measurement Information System (PROMIS-29) Profile.ResultsThe mean duration of the preoperative opioid reduction program was 6–7 weeks. The mean morphine equivalent daily dose (SD) decreased from 238.2 (226.9) mg on admission to 157.1 (161.0) mg preoperatively and 139.1 (84.0) mg one month postoperatively. Similarly, the mean pain interference score (SD) decreased from 72.4 (5.1) on admission to 66.5 (6.9) preoperatively and 67.7 (5.4) one month postoperatively. The preoperative opioid dose and pain interference scores decreased in all 5 patients, but one month postoperatively increased in one patient related to a surgical complication. Pre- and postoperative depression, anxiety and fatigue improved in all patients. Satisfaction with participation in social roles, sleep disturbances, and physical functioning improved in most patients.ConclusionsPre- and post-operative pain improved despite the opioid dose being tapered. These preliminary data suggest that a short-term outpatient preoperative interdisciplinary biopsychosocial opioid reduction program is safe, feasible, and improves patient-centred outcomes.ImplicationsOur preliminary data support the rationale for expansion of the opioid reduction program; opioid use and pain should be evaluated in all surgical candidates. These findings need to be replicated in larger studies.

Impact of Preoperative Opioid Use on Postoperative Patient-reported Outcomes in Lumbar Spine Surgery Patients

2020 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Joseph A. Weiner ◽  
Joseph E. Snavely ◽  
Daniel J. Johnson ◽  
Wellington K. Hsu ◽  
Alpesh A. Patel
Keyword(s):  
Lumbar Spine ◽  
Spine Surgery ◽  
Patient Reported Outcomes ◽  
Lumbar Spine Surgery ◽  
Opioid Use ◽  
Postoperative Patient ◽  
Patient Reported

A randomized trial of medical cannabis (MC) in patients with advanced cancer (AC) to assess impact on opioid use and cancer-related symptoms.

2019 ◽  
Vol 37 (31_suppl) ◽  
pp. 109-109
Author(s):  
Dylan M. Zylla ◽  
Justin Eklund ◽  
Grace Gilmore ◽  
Alissa Gavenda ◽  
Gabriela Vazquez-Benitez ◽  
...  
Keyword(s):  
Pain Control ◽  
Negative Impact ◽  
Stage Iv ◽  
Scientific Data ◽  
Medical Cannabis ◽  
Opioid Use ◽  
Negative Effects ◽  
Opioid Dose ◽  
Patient Reported ◽  
Oncology Care

109 Background: Higher pain and greater long-term opioid requirements have been associated with shorter survival and decreased quality of life (QOL) in patients with AC. Routine use of MC is limited by a lack of rigorous scientific data and concerns about side effects, legal ramifications, and cost. Methods: 30 patients with stage IV cancer requiring opioids were randomized 1:1 to early cannabis (EC, n=15) vs. delayed cannabis (DC, n=15). The EC group was provided with 3 months (3M) of MC at no charge, while the DC group received standard oncology care without MC for the first 3M. Patients met with licensed pharmacists at one of two MC manufacturers to determine optimal MC dosing, formulation, and route. Patients completed monthly pain logs, opioid/MC logs, and validated Patient-Reported Symptom Monitoring surveys. Results: A higher proportion of EC patients achieved a reduction in opioid use and improved pain control. On average over a 3M window, EC patients did not require opioid dose escalation, had lower mean pain, and had similar QOL compared to DC patients. Estimated mean daily THC and CBD dose at 3M was 76 mg (range 5-186 mg) and 36 mg (range <1-516 mg), respectively. Mean perceived benefit of MC was 5.1 and mean perceived negative impact was 2.7 (1 = no benefit/negative effects, 7 = a great deal of benefit/negative effects). 33% of patients died during the anticipated 6-month study period and patient compliance with study logs limited analysis. Conclusions: Randomized studies of MC in the oncology setting are feasible, but rigorous data collection is challenging. The addition of MC to standard oncology care in patients with AC was well-tolerated and may lead to improved pain control and lower opioid requirements. [Table: see text]

scholarly journals The Impact of NSAID Use After Lumbar Fusion Surgery on Fusion Rate and Complications: A Meta-Analysis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Yahya Othman ◽  
Avani Vaishnav ◽  
Steven Mcanany ◽  
Sravisht Iyer ◽  
Todd Albert ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Spine Surgery ◽  
Spinal Surgery ◽  
Meta Analysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
The Impact

Abstract INTRODUCTION The purpose of this study is to compile data presented in literature regarding the efficacy of incorporating NSAIDs in the postoperative course for patients undergoing spine surgery, in particular its impact on pain levels, opioid use, complications, and hospital length of stay METHODS This is a meta-analysis and systematic review. A literature search was conducted using the backbone search [spinal surgery] [Nsaid] [complications]. Criteria for inclusion are as follows: use of NSAIDs for postoperative pain management of spinal surgery, comparison between NSAID and NSAID-free cohort, and reporting on any of pain scores, hospital opioid use, hospital length of stay, complications rate, and operative outcomes. RESULTS Out of 799 studies, 19 studies met the inclusion criteria. A total of 1522 patient were included in this analysis. The studies included randomized controlled trials, Prospective and retrospective cohorts. Operations included discectomies, laminectomies, and fusions. Most commonly regimens included the NSAID Ketorelac, as in injection given immediately postoperatively. Patients that received NSAID analgesia postoperatively had significantly lower VAS pain scores at 1 and 12 h postoperatively. This group also had a significantly lower opioid consumption and shorter hospital length of stay. A total of 7 fusion studies reported on arthrodesis, showing a significantly lower odds of fusion after NSAIDs use, however after subgrouping according to smoking, this difference proves to be no longer significant. CONCLUSION Incorporation of NSAIDs into the postoperative regimen for analgesia in patients undergoing spine surgery is an effective approach in reducing hospital length of stay, patient reported pain scores, hospital opioid use, and has no increased risk of complications. Furthermore, use of NSAIDs in the nonsmoking population does not seem to affect arthrodesis rates in patients undergoing spine surgery.

scholarly journals The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Patient-Reported Pain, Disability, Quality of Life, and Prescription Opioid Use in Lumbar Spine Degenerative Disease: Three- and Twelve-Month Results

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Juneyoung L Chavez ◽  
Christina A Porucznik ◽  
Lisa H Gren ◽  
Jian Guan ◽  
Evan Joyce ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Treatment Group ◽  
Spine Surgery ◽  
Stress Reduction ◽  
Postoperative Outcomes ◽  
Prescription Opioid ◽  
Lumbar Spine Surgery ◽  
Opioid Use ◽  
Patient Reported ◽  
Change In Mean

Abstract INTRODUCTION Prescription opioids negatively affect postoperative outcomes after lumbar spine surgery, and according to the CDC, the drug overdose epidemic has been exacerbated by the involvement of prescription medications. Thus, alternatives for pain control are imperative. Mindfulness-based stress reduction (MBSR) has been associated with improved activity, mood, walking, and work in opioid-using chronic pain patients. Prospective studies utilizing preoperative MBSR to impact postoperative outcomes in degenerative lumbar spine surgery are lacking. METHODS The intervention group underwent a preoperative online MBSR course. The comparison group was matched retrospectively in a 1:1 ratio by age, sex, type of surgery, and preoperative opioid use. A total of 3- and 12-mo postoperative patient-reported outcomes for pain, disability, quality of life, and prescription opioid use were compared. Univariate linear regression was used to assess if MBSR use was a significant predictor of outcomes. RESULTS At 3 mo, follow-up was 87.5% and 95.8% in the comparison and treatment groups, respectively. Mean ODI was significantly lower (P = .032), mean PROMIS-PF was significantly higher (P = .002), and mean PROMIS-PI was significantly lower (P = .025) in the treatment group. Also, change in mean PROMIS-PF and change in mean PROMIS-PI were significantly greater (P = .002, P = .038). MBSR use was a significant predictor of change in PROMIS-PF (P = .003). At 12 mo, follow-up was 58.3% and 83.3% in the comparison and treatment groups, respectively. Mean PROMIS-PI was significantly lower (P = .011) and change in mean PROMIS-PI was significantly greater (P = .003) in the treatment group. MBSR use was a significant predictor of change in PROMIS-PI (P = .004). CONCLUSION At 3 mo, the treatment group experienced significantly lower disability, higher physical function, and lower pain interference. At 12 mo, only lower pain interference persisted. Further clinical trials are needed to assess the effectiveness of preoperative MBSR on postoperative outcomes in lumbar spine surgery for degenerative disease.

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