The use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).
Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.
In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”
However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Nitin Jain, MD, MSPH, a co-author of the November 16, 2016 Specialty Update on Orthopaedic Rehabilitation, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.
–A prospective cohort study1 evaluating the benefit of early imaging (within 6 weeks of index visit) for patients ≥65 years old with new-onset back pain found that those with early imaging had significantly higher resource utilization and expenditures compared with matched controls who did not undergo early imaging. One year after the index visit, authors found no significant between-group differences in patient-reported pain or disability. They concluded that “early imaging should not be performed routinely for older adults with acute back pain.”
–A randomized clinical trial2 comparing 10 days of NSAID monotherapy with 10 days of NSAIDs + muscle relaxants or opioids for acute nonradicular low back pain found no significant differences across the groups for pain, functional impairment, or use of health care resources. The authors said these findings suggest that combination therapy is not better than monotherapy in this situation, and that the use of opioids in such patients is not indicated.
Rotator Cuff Tears
–A two year follow-up of a randomized trial comparing three treatments for supraspinatus tears (physiotherapy, physiotherapy + acromioplasty, and rotator cuff repair + acromioplasty +physiotherapy) found no significant pain or function differences among the three groups. However, mean tear size was significantly smaller in the cuff-repair group than in the other two.
–A meta-analysis3 investigating the use of cannabinoids for managing chronic pain and spasticity concluded that those substances reduced pain and spasticity more than placebo, but the benefits came with an increased risk of side effects such as dizziness, nausea, confusion, and loss of balance.
–A randomized controlled trial4 comparing a phone-based cognitive-behavioral/physical therapy (CBPT) program to standard education following lumbar spine surgery found that patients in the CBPT group had greater decreases in pain and disability and increases in general health and physical performance.
- Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW,Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar17;313(11):1143-53.
- Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
- Whiting PF, Wolff RF, Deshpande S, DiNisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73.
- Skolasky RL, Maggard AM, Li D, Riley LH 3rd., Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil. 2015 Jul;96(7):1200-7. Epub 2015 Mar 28.
Improvements in surgical procedures continue to evolve at a brisk pace. It seems that, every year, incisions become smaller and operations, more streamlined. Certain operations that in the past would only have been performed as inpatient procedures are now being considered for outpatient surgery with same-day discharge.
In the May 2015 issue of JBJS Reviews, Kurd et al. review the ability to perform spine surgery in an ambulatory setting. The authors note that anterior surgical discectomy and fusion is now commonly performed in an ambulatory surgery center and, if patients are carefully selected, lumbar microdiscectomies and laminectomies can be performed in an ambulatory surgery center as well. The authors stress the importance of an established transfer plan to a hospital when needed and the ability to treat neurologic complications if they occur. Most importantly, the ability to treat potentially serious complications in a timely manner is critical.
The rationale for performing spine surgery in an ambulatory surgery center is primarily for the convenience of the patient. The authors note that friendly staff, minimal wait times, efficiency, and perhaps ease of parking allow for ambulatory surgery centers to have overall patient satisfaction rates of up to 92%. In addition, by moving procedures out of a hospital and into ambulatory surgery centers, the cost savings to Medicare alone have been substantial.
Practice guidelines for some of the important decisions regarding patients undergoing anesthesia have been established by the Society for Ambulatory Anesthesia (SAMBA), whose goal is to provide guidance on the use of anesthesia in an ambulatory setting. Recommendations such as avoiding general anesthesia when possible, using propofol for induction and maintenance, avoiding nitrous oxide and other volatile anesthetics, minimizing the use of opioids, and maintaining adequate hydration are among the most important. In addition, SAMBA recommends that all diabetic patients undergoing surgery at an ambulatory surgery center should have a hemoglobin A1C of <7%.
While several reports have established the safety of performing cervical surgical spine surgery in an ambulatory surgery center, concerns still exist regarding the treatment of life-threatening events such as an epidural hematoma. Other rare complications such as vertebral artery injury or esophageal injury require intraoperative consultation with another surgery subspecialty such as vascular surgery or otolaryngology, and such consultations may not be available in an ambulatory surgery center.
The spinal procedure that is most commonly performed on an outpatient basis is a single-level lumbar decompression. Microdiscectomy is also frequently performed. This article reviews the largest prospective series of outpatient lumbar discectomies to date and indicates that the role of proper patient selection is paramount and that comorbidities such as obesity, chronic obstructive pulmonary disease, and a history of stroke increase the risk of needing hospitalization. As the use of the ambulatory setting for spinal surgery continues to evolve, further delineation of the ideal conditions and requirements will become evident. In the meantime, elderly patients and patients with multiple comorbidities may be better managed at a hospital as they are at an increased risk of requiring hospitalization.
Thomas A. Einhorn, MD
Editor, JBJS Reviews