SPINE Volume 40, Number 16, pp 1284-1288 ©2015, Wolters Kluwer Health, Inc. All rights reserved.
CLINICAL CASE SERIES
Postoperative Narcotic Consumption in Workman’s Compensation Patients Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion Junyoung Ahn, BS,* Daniel D. Bohl, MPH,† Islam Elboghdady, BA,* Khaled Aboushaala, MD,* Benjamin C. Mayo, BA,* Hamid Hassanzadeh, MD,‡ and Kern Singh, MD*
Study Design. Retrospective cohort analysis of a prospective registry. Objective. To assess the differences in perioperative narcotic consumption between Workman’s compensation (WC) and nonWorkman’s compensation (non-WC) patients after a single-level minimally invasive transforaminal lumbar interbody fusion. Summary of Background Data. There is concern regarding the potential overutilization of opioid pain medication in WC patients. However, the impact of WC status on perioperative narcotic consumption after lumbar spine procedures has not been previously reported. Methods. A cohort of patients who underwent primary 1-level minimally invasive transforaminal lumbar interbody fusion procedures for degenerative spinal pathology between 2007 and 2013 was retrospectively analyzed using a prospectively collected registry. First, preoperative and perioperative characteristics were compared between WC and non-WC patients. Second, mean oral morphine equivalent was compared between WC and nonWC patients with adjustment for any preoperative or perioperative differences between cohorts. Results. A total of 136 single-level, primary minimally invasivetransforaminal lumbar interbody fusion procedures were included in the analysis, of which 46 (33.8%) were WC patients. WC patients
From the *Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; †Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT; and ‡Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA. Acknowledgment date: August 18, 2014. Revision date: March 16, 2015. Acceptance date: April 1, 2015. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, royalties. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Ste #300, Chicago, IL 60612; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000994
1284
were younger (47.8 ± 11.2 vs. 57.9 ± 10.4 yr; P < 0.001) and had a lower comorbidity burden (Charlson Comorbidity Index: 1.85 ± 1.30 vs. 3.42 ± 2.07; P < 0.001) than non-WC patients. The distribution of ethnicity differed between WC and non-WC patients (P = 0.002). WC patients incurred longer procedural times (135.2 ± 52.2 vs. 118.9 ± 33.7 min; P < 0.05). However, the estimated blood loss, length of hospital stay, and day of discharge were no different between WC and non-WC patients. Mean oral morphine equivalent consumption did not differ between WC and non-WC patients after adjustment for differences in age, ethnicity, Charlson Comorbidity Index, and procedural time between cohorts. Conclusion. Despite concerns for greater opioid use in the WC population, this analysis demonstrated similar total narcotic consumption between WC and non-WC patients during the immediate postoperative period. Long-term studies are warranted to assess whether this similarity in regard to perioperative narcotic consumption persists beyond the immediate postoperative period. Key words: MIS-TLIF, workers’ compensation, narcotics, pain medications, lumbar fusion, spine surgery. Level of Evidence: 3 Spine 2015;40:1284–1288
P
roper postoperative pain management is critical to swift patient recovery and the prevention of chronic pain.1,2 However, the availability and use of more potent narcotics in the postoperative setting increases the risk for abuse and subsequent dependence. Overuse of narcotics can result in the development of opioid-related adverse drug events that include gastrointestinal and central nervous system dysfunction, urinary retention, respiratory depression, and death.1 In addition, patients undergoing orthopedic procedures are at increased risk for the development of opioid-related adverse drug events.3 Workers’ compensation (WC) patients tend to be younger, more active, and, therefore, bear less of a disease burden. However, recent studies have demonstrated a significant increase in the use of prescription narcotics in this population.4 Increased
www.spinejournal.com
August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. SPINE141079_LR 1284
28/07/15 7:51 AM
CLINICAL CASE SERIES
WC MIS-TLIF Narcotics • Ahn et al
narcotics use is associated with prolonged disability, delayed return to work, increased costs, and increased duration of WC claims.4–7 Minimally invasive (MIS) spine surgery potentially offers a more rapid recovery and shorter time to narcotic independence.8,9 Despite these touted benefits, the effects of MIS spine surgery on postoperative narcotic consumption in WC patients have yet to be examined. As such, the purpose of this study is to analyze the differences in postoperative narcotics consumption between WC and non-WC patients after an MIS transforaminal lumbar interbody fusion (MIS-TLIF).
These modifications included the following: (1) a history of myocardial infarction was omitted and (2) liver disease was given an adjusted weight of 2 points rather than 1 point for mild disease and 3 points for moderate to severe liver disease. Previous studies have demonstrated that slight modifications to the CCI have minimal impact on the overall score.10,11 Patients’ smoking status and preoperative visual analogue scale (VAS) scores were also included in the analysis. Perioperative parameters such as procedural time, estimated blood loss, length of hospital stay, and postoperative complications were assessed.
MATERIALS AND METHODS
Postoperative Opioid Consumption
Patient Population A prospectively maintained database was retrospectively reviewed for patients who underwent a primary 1-level MISTLIF. Patients with signs and symptoms consistent with radiculopathy and radiographical evidence of degenerative lumbar spine disease were identified. Nonoperative treatment options (physical therapy, nonsteroidal anti-inflammatory medications, epidural injections) were exhausted in all patients prior to surgery. Patients who underwent multilevel or revision surgery were excluded from this analysis.
Data Collection A total of 136 patients who underwent a primary, single-level MIS-TLIF between 2007 and 2013 were identified. Patients were stratified on the basis of primary payer status (WC vs. non-WC) and analyzed with regard to age, sex, ethnicity, and comorbidity burden. Patient comorbidity burden was calculated via a modified Charlson Comorbidity Index (CCI).10
Postoperative opioid consumption data were collected and narcotics were converted to oral morphine equivalents (OMEs) using a standardized calculation in order to account for differences in dosage, potency, and route of administration.12 The study on opioid equianalgesic calculations by Gordon et al12 was referenced to determine narcotic to oral morphine conversion ratios. Each narcotic was converted via its respective ratio to calculate daily and total OME doses. OMEs (total and daily) were assessed between groups with regard to the postoperative day (POD) of discharge.
Surgical Techniques: MIS-TLIF The MIS-TLIF was accomplished via a 21- to 24-mm nonexpandable tubular dilator. A complete facetectomy was performed along with a bilateral lumbar decompression through a single unilateral approach. Either a straight or banana-shaped intervertebral cage was inserted along with bone graft and posterior percutaneous pedicle screw instrumentation.
TABLE 1. Patient and preoperative Characteristics P*
WC
Non-WC
100% (46)
100% (90)
Age (mean ± SD), yr
47.8 ± 11.2
57.9 ± 10.4
CLINICAL CASE SERIES
Postoperative Narcotic Consumption in Workman’s Compensation Patients Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion Junyoung Ahn, BS,* Daniel D. Bohl, MPH,† Islam Elboghdady, BA,* Khaled Aboushaala, MD,* Benjamin C. Mayo, BA,* Hamid Hassanzadeh, MD,‡ and Kern Singh, MD*
Study Design. Retrospective cohort analysis of a prospective registry. Objective. To assess the differences in perioperative narcotic consumption between Workman’s compensation (WC) and nonWorkman’s compensation (non-WC) patients after a single-level minimally invasive transforaminal lumbar interbody fusion. Summary of Background Data. There is concern regarding the potential overutilization of opioid pain medication in WC patients. However, the impact of WC status on perioperative narcotic consumption after lumbar spine procedures has not been previously reported. Methods. A cohort of patients who underwent primary 1-level minimally invasive transforaminal lumbar interbody fusion procedures for degenerative spinal pathology between 2007 and 2013 was retrospectively analyzed using a prospectively collected registry. First, preoperative and perioperative characteristics were compared between WC and non-WC patients. Second, mean oral morphine equivalent was compared between WC and nonWC patients with adjustment for any preoperative or perioperative differences between cohorts. Results. A total of 136 single-level, primary minimally invasivetransforaminal lumbar interbody fusion procedures were included in the analysis, of which 46 (33.8%) were WC patients. WC patients
From the *Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; †Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT; and ‡Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA. Acknowledgment date: August 18, 2014. Revision date: March 16, 2015. Acceptance date: April 1, 2015. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, royalties. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Ste #300, Chicago, IL 60612; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000994
1284
were younger (47.8 ± 11.2 vs. 57.9 ± 10.4 yr; P < 0.001) and had a lower comorbidity burden (Charlson Comorbidity Index: 1.85 ± 1.30 vs. 3.42 ± 2.07; P < 0.001) than non-WC patients. The distribution of ethnicity differed between WC and non-WC patients (P = 0.002). WC patients incurred longer procedural times (135.2 ± 52.2 vs. 118.9 ± 33.7 min; P < 0.05). However, the estimated blood loss, length of hospital stay, and day of discharge were no different between WC and non-WC patients. Mean oral morphine equivalent consumption did not differ between WC and non-WC patients after adjustment for differences in age, ethnicity, Charlson Comorbidity Index, and procedural time between cohorts. Conclusion. Despite concerns for greater opioid use in the WC population, this analysis demonstrated similar total narcotic consumption between WC and non-WC patients during the immediate postoperative period. Long-term studies are warranted to assess whether this similarity in regard to perioperative narcotic consumption persists beyond the immediate postoperative period. Key words: MIS-TLIF, workers’ compensation, narcotics, pain medications, lumbar fusion, spine surgery. Level of Evidence: 3 Spine 2015;40:1284–1288
P
roper postoperative pain management is critical to swift patient recovery and the prevention of chronic pain.1,2 However, the availability and use of more potent narcotics in the postoperative setting increases the risk for abuse and subsequent dependence. Overuse of narcotics can result in the development of opioid-related adverse drug events that include gastrointestinal and central nervous system dysfunction, urinary retention, respiratory depression, and death.1 In addition, patients undergoing orthopedic procedures are at increased risk for the development of opioid-related adverse drug events.3 Workers’ compensation (WC) patients tend to be younger, more active, and, therefore, bear less of a disease burden. However, recent studies have demonstrated a significant increase in the use of prescription narcotics in this population.4 Increased
www.spinejournal.com
August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. SPINE141079_LR 1284
28/07/15 7:51 AM
CLINICAL CASE SERIES
WC MIS-TLIF Narcotics • Ahn et al
narcotics use is associated with prolonged disability, delayed return to work, increased costs, and increased duration of WC claims.4–7 Minimally invasive (MIS) spine surgery potentially offers a more rapid recovery and shorter time to narcotic independence.8,9 Despite these touted benefits, the effects of MIS spine surgery on postoperative narcotic consumption in WC patients have yet to be examined. As such, the purpose of this study is to analyze the differences in postoperative narcotics consumption between WC and non-WC patients after an MIS transforaminal lumbar interbody fusion (MIS-TLIF).
These modifications included the following: (1) a history of myocardial infarction was omitted and (2) liver disease was given an adjusted weight of 2 points rather than 1 point for mild disease and 3 points for moderate to severe liver disease. Previous studies have demonstrated that slight modifications to the CCI have minimal impact on the overall score.10,11 Patients’ smoking status and preoperative visual analogue scale (VAS) scores were also included in the analysis. Perioperative parameters such as procedural time, estimated blood loss, length of hospital stay, and postoperative complications were assessed.
MATERIALS AND METHODS
Postoperative Opioid Consumption
Patient Population A prospectively maintained database was retrospectively reviewed for patients who underwent a primary 1-level MISTLIF. Patients with signs and symptoms consistent with radiculopathy and radiographical evidence of degenerative lumbar spine disease were identified. Nonoperative treatment options (physical therapy, nonsteroidal anti-inflammatory medications, epidural injections) were exhausted in all patients prior to surgery. Patients who underwent multilevel or revision surgery were excluded from this analysis.
Data Collection A total of 136 patients who underwent a primary, single-level MIS-TLIF between 2007 and 2013 were identified. Patients were stratified on the basis of primary payer status (WC vs. non-WC) and analyzed with regard to age, sex, ethnicity, and comorbidity burden. Patient comorbidity burden was calculated via a modified Charlson Comorbidity Index (CCI).10
Postoperative opioid consumption data were collected and narcotics were converted to oral morphine equivalents (OMEs) using a standardized calculation in order to account for differences in dosage, potency, and route of administration.12 The study on opioid equianalgesic calculations by Gordon et al12 was referenced to determine narcotic to oral morphine conversion ratios. Each narcotic was converted via its respective ratio to calculate daily and total OME doses. OMEs (total and daily) were assessed between groups with regard to the postoperative day (POD) of discharge.
Surgical Techniques: MIS-TLIF The MIS-TLIF was accomplished via a 21- to 24-mm nonexpandable tubular dilator. A complete facetectomy was performed along with a bilateral lumbar decompression through a single unilateral approach. Either a straight or banana-shaped intervertebral cage was inserted along with bone graft and posterior percutaneous pedicle screw instrumentation.
TABLE 1. Patient and preoperative Characteristics P*
WC
Non-WC
100% (46)
100% (90)
Age (mean ± SD), yr
47.8 ± 11.2
57.9 ± 10.4
