An institutional intervention to modify opioid prescribing practices after lumbar spine surgery

OBJECTIVEPatients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the “minimum necessary quantity” of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery.METHODSQualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016–November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017–October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded.RESULTSFor all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07).CONCLUSIONSQualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

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Do Orthopedic Surgeons or Neurosurgeons Detect More Hip Disorders in Patients with Hip-Spine Syndrome? A Nationwide Database Study

Brain Sciences ◽

10.3390/brainsci11040485 ◽

2021 ◽

Vol 11 (4) ◽

pp. 485

Author(s):

Tsung-Cheng Yin ◽

Adam M. Wegner ◽

Meng-Ling Lu ◽

Yao-Hsu Yang ◽

Yao-Chin Wang ◽

...

Keyword(s):

Lumbar Spine ◽

Spine Surgery ◽

Hip Surgery ◽

Lumbar Spine Surgery ◽

Research Database ◽

X Rays ◽

Replacement Surgery ◽

Orthopedic Surgeons ◽

Spine Pathology ◽

Sh Group

Background: Disorders of the hip and lumbar spine can create similar patterns of pain and dysfunction. It is unknown whether all surgeons, regardless of orthopedic or neurosurgery training, investigate and diagnose concurrent hip and spine pathology at the same rate. Methods: Data were retrieved from Taiwan’s National Health Insurance Research Database (NHIRD). Enrolled patients were stratified into hip and spine surgery at the same admission (Both), hip surgery before spine surgery (HS), or spine surgery before hip surgery (SH). The SH group was further subdivided based on whether spine surgery was performed by an orthopedic surgeon (OS) or neurosurgeon (NS), and differences in preoperative radiographic examinations and diagnoses were collected and analyzed. Results: In total, 1824 patients received lumbar spine surgery within 1 year before or after hip replacement surgery. Of these, 103 patients had spine and hip surgery in the same admission (Both), 1290 patients had spine surgery before hip surgery (SH), and 431 patients had hip surgery before spine surgery (HS). In the SH group, patients were categorized into spine surgery by orthopedic surgeons (OS) (n = 679) or neurosurgeons (NS) (n = 522). In the SH group, orthopedic surgeons investigated hip pathology with X-rays more often (52.6% vs. 38.1%, p < 0.001) and diagnosed more cases of hip disease (43.6% vs. 28.9%, p < 0.001) than neurosurgeons. Conclusions: Of patients in Taiwan’s NHIRD who had concurrent surgical degenerative hip and lumbar spine disorders who had spine surgery before hip surgery, orthopedic surgeons obtained hip images and made hip-related diagnoses more frequently than did neurosurgeons.

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Variations in 30-day readmissions and length of stay among spine surgeons: a national study of elective spine surgery among US Medicare beneficiaries

Journal of Neurosurgery Spine ◽

10.3171/2018.1.spine171064 ◽

2018 ◽

Vol 29 (3) ◽

pp. 286-291 ◽

Cited By ~ 8

Author(s):

Siddhartha Singh ◽

Rodney Sparapani ◽

Marjorie C. Wang

Keyword(s):

Lumbar Spine ◽

Length Of Stay ◽

Spine Surgery ◽

Practice Patterns ◽

Lumbar Spine Surgery ◽

Medicare Beneficiaries ◽

Readmission Rates ◽

Underlying Assumption ◽

The Mean ◽

Hospital Characteristics

OBJECTIVEPay-for-performance programs are targeting hospital readmissions. These programs have an underlying assumption that readmissions are due to provider practice patterns that can be modified by a reduction in reimbursement. However, there are limited data to support the role of providers in influencing readmissions. To study this, the authors examined variations in readmission rates by spine surgeon within 30 days among Medicare beneficiaries undergoing elective lumbar spine surgery for degenerative conditions.METHODSThe authors applied validated ICD-9-CM algorithms to 2003–2007 Medicare data to select beneficiaries undergoing elective inpatient lumbar spine surgery for degenerative conditions. Mixed models, adjusting for patient demographics, comorbidities, and surgery type, were used to estimate risk of 30-day readmission by the surgeon. Length of stay (LOS) was also studied using these same models.RESULTSA total of 39,884 beneficiaries were operated on by 3987 spine surgeons. The mean readmission rate was 7.2%. The mean LOS was 3.1 days. After adjusting for patient characteristics and surgery type, 1 surgeon had readmission rates significantly below the mean, and only 5 surgeons had readmission rates significantly above the mean. In contrast, for LOS, the patients of 288 surgeons (7.2%) had LOS significantly lower than the mean, and the patients of 397 surgeons (10.0%) had LOS significantly above the mean. These findings were robust to adjustments for surgeon characteristics and clustering by hospital. Similarly, hospital characteristics were not significantly associated with readmission rates, but LOS was associated with hospital for-profit status and size.CONCLUSIONSThe authors found almost no variations in readmission rates by surgeon. These findings suggest that surgeon practice patterns do not affect the risk of readmission. Likewise, no significant variation in readmission rates by hospital characteristics were found. Strategies to reduce readmissions would be better targeted at factors other than providers.

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The Effect of Obesity on the Improvement in Health State Outcomes following Minimally Invasive Transforaminal Interbody Fusion

Global Spine Journal ◽

10.1055/s-0036-1579747 ◽

2016 ◽

Vol 6 (8) ◽

pp. 744-748 ◽

Cited By ~ 8

Author(s):

Steven J. McAnany ◽

Diana C. Patterson ◽

Samuel Overley ◽

Daniel Alicea ◽

Javier Guzman ◽

...

Keyword(s):

Lumbar Spine ◽

Minimally Invasive ◽

Spine Surgery ◽

Interbody Fusion ◽

Normal Weight ◽

Lumbar Spine Surgery ◽

Obese Patients ◽

Obesity Status ◽

Spine Pathology ◽

Composite Scores

Study Design Observational study. Objective Studies have shown a correlation between obesity and lumbar spine pathology, but also that obese patients have higher rates of complication following lumbar spine surgery. It is unknown if obese patients have clinical gains following lumbar spine surgery comparable to the gain of normal-weight patients. This study investigated the correlation of obesity and the delta change in outcomes in a single surgeon's cohort of normal-weight and obese patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). Methods A retrospective review was performed of a single surgeon's patients at an academic medical center who underwent MIS TLIF between July 2011 and December 2013. Statistical analyses included independent sample t test for continuous variables, Fisher exact test for categorical data, and repeated measures two-way analysis of variance to assess the interaction between obesity status and the change in Short-Form Health Survey 12 (SF-12) results. Results Thirty-eight patients from a single institution were reviewed, and 19 had a body mass index greater than 30. The nonobese and obese postoperative SF-12 mental composite scores (MCS; 52.70 ± 2.50 versus 52.16 ± 1.91; p = 0.87) and physical composite scores (PCS; 45.56 ± 2.72 versus 41.03 ± 2.65; p = 0.24) did not show any significant differences. There was no significant interaction between obesity and change in SF-12 MCS ( F [1, 36] = 0.96, p = 0.33) or SF-12 PCS ( F [1, 36] = 0.74, p = 0.40) between the pre- and postoperative scores. There was a significant effect of obesity on SF-12 PCS scores ( F [1, 36] = 7.15, p = 0.01). Conclusions Patients undergoing MIS TLIF sustain meaningful and significant gains in SF-12 MCS and PCS that is not impacted by their obesity status.

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Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery

Global Spine Journal ◽

10.1177/2192568220983291 ◽

2021 ◽

pp. 219256822098329

Author(s):

Ram Haddas ◽

William Pipkin ◽

Dan Hellman ◽

Leonard Voronov ◽

Young-Hoo Kwon ◽

...

Keyword(s):

Lumbar Spine ◽

Spine Surgery ◽

Treatment Options ◽

High Impact ◽

Return To Play ◽

Lumbar Spine Surgery ◽

Contact Sport ◽

Contact Sports ◽

Spine Pathology ◽

Modern Era

Study Design: Narrative review. Objective: To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. Methods: This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature. Results: Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field. Conclusions: With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

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Use of intrathecal morphine for postoperative pain relief following lumbar spine surgery

Journal of Neurosurgery ◽

10.3171/jns.1985.63.3.0413 ◽

1985 ◽

Vol 63 (3) ◽

pp. 413-416 ◽

Cited By ~ 33

Author(s):

Padraic O'Neill ◽

Christine Knickenberg ◽

Senarath Bogahalanda ◽

Anthony E. Booth

Keyword(s):

Lumbar Spine ◽

Postoperative Pain ◽

Pain Relief ◽

Spine Surgery ◽

Intrathecal Morphine ◽

Postoperative Pain Relief ◽

Lumbar Spine Surgery ◽

Double Blind ◽

Content Type ◽

The Mean

✓ A randomized prospective double-blind trial of intrathecal morphine for postoperative pain relief following lumbar spine surgery is described. Intrathecal morphine significantly reduced the mean pain score in the postoperative period (p < 0.01) and there was a corresponding significant reduction in the need for additional postoperative analgesia (p < 0.05). The possible mechanism of action of intrathecal morphine and the potential advantages of this technique are discussed. Possible side effects are also considered, and caution is urged until wider experience has been obtained.

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Osteoporosis in spine surgery patients: what is the best way to diagnose osteoporosis in this population?

Neurosurgical FOCUS ◽

10.3171/2020.5.focus20277 ◽

2020 ◽

Vol 49 (2) ◽

pp. E4 ◽

Cited By ~ 1

Author(s):

Jeffery D. St. Jeor ◽

Taylor J. Jackson ◽

Ashley E. Xiong ◽

Aamir Kadri ◽

Brett A. Freedman ◽

...

Keyword(s):

Lumbar Spine ◽

Fracture Risk ◽

Spine Surgery ◽

Bone Health ◽

Assessment Tools ◽

Lumbar Spine Surgery ◽

Total Hip ◽

T Score ◽

Preoperative Optimization ◽

The Mean

OBJECTIVEThe goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization.METHODSA retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ −2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) “expanded spine” criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or “degraded” TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit.RESULTSTwo hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors’ proposed “expanded spine” criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools.CONCLUSIONSLimitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.

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Reoperation, Readmission, and Discharge Disposition for Patients With Degenerative Lumbar Pathology Treated With Either Open or Minimally Invasive Techniques: A Single-Center Retrospective Review of 1435 Cases

Neurosurgery ◽

10.1093/neuros/nyaa246 ◽

2020 ◽

Author(s):

Marcelle Altshuler ◽

Kyle B Mueller ◽

Ashley MacConnell ◽

Peter Wirth ◽

Faheem A Sandhu ◽

...

Keyword(s):

Lumbar Spine ◽

Minimally Invasive ◽

Spine Surgery ◽

Open Surgery ◽

Lumbar Spine Surgery ◽

Minimally Invasive Techniques ◽

Readmission Rates ◽

Discharge Disposition ◽

Spine Pathology ◽

Invasive Techniques

Abstract BACKGROUND Spine surgery has been transformed by the growth of minimally invasive surgery (MIS) procedures. Previous studies agree that MIS has shorter hospitalization and faster recovery time when compared to conventional open surgery. However, the reoperation and readmission rates between the 2 techniques have yet to be well characterized. OBJECTIVE To evaluate the rate of subsequent revision between MIS and open techniques for degenerative lumbar pathology. METHODS A total of 1435 adult patients who underwent lumbar spine surgery between 2013 and 2016 were included in this retrospective analysis. The rates of need for subsequent reoperation, 30- and 90-d readmission, and discharge to rehabilitation were recorded for both MIS and traditional open techniques. Groups were divided into decompression alone and decompression with fusion. RESULTS The rates of subsequent reoperation following MIS and open surgery were 10.4% and 12.2%, respectively (P = .32), which were maintained when subdivided into decompression and decompression with fusion. MIS and open 30-d readmission rates were 7.9% and 7.2% (P = .67), while 90-d readmission rates were 4.3% and 3.6% (P = .57), respectively. Discharge to rehabilitation was significantly lower for patients under 60 yr of age undergoing MIS (1.64% vs 5.63%, P = .04). CONCLUSION The use of minimally invasive techniques for the treatment of lumbar spine pathology does not result in increased reoperation or 30- and 90-d readmission rates when compared to open approaches. Patients under the age of 60 yr undergoing MIS procedures were less likely to be discharged to rehab.

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Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single-institution experience

Journal of Neurosurgery Spine ◽

10.3171/2017.5.spine17199 ◽

2017 ◽

Vol 27 (6) ◽

pp. 670-675 ◽

Cited By ~ 10

Author(s):

Owoicho Adogwa ◽

Aladine A. Elsamadicy ◽

Victoria D. Vuong ◽

Jessica Moreno ◽

Joseph Cheng ◽

...

Keyword(s):

Lumbar Spine ◽

Elderly Patients ◽

Hospital Stay ◽

Spine Surgery ◽

Lumbar Fusion ◽

Perioperative Complications ◽

Academic Medical Center ◽

Nursing Home Admission ◽

Lumbar Spine Surgery ◽

The Mean

OBJECTIVEGeriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown.METHODSA unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes.RESULTSOne hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01).CONCLUSIONSGeriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

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