Harrison F. Kay

Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery.

Study Design. Prospective cohort. Objective. To assess whether preoperative opioid use is associated with increased perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Summary of Background Data. Previous work has demonstrated increased opioid requirements during the intraoperative and immediate postoperative period in patients with high levels of preoperative opioid use. Despite this, they remain a common agent class used for the management of pain in patients prior to spine surgery. Methods. A total of 583 patients were included. Self-reported daily opioid consumption was obtained preoperatively and converted into morphine equivalent amounts and opioid use was recorded at the 12-month postoperative time. Intraoperative and immediate postoperative opioid demand was calculated. Linear regression analyses for intraoperative and immediate postoperative opioid demand while logistic regression analyses for opioid independence at 12 months including relevant covariates such as depression and anxiety were performed. Results. The median preoperative morphine equivalent amount for the cohort was 8.75 mg, with 55% of patients reporting some degree of opioid use. Younger age, more invasive surgery, anxiety, and primary surgery were significantly associated with increased intraoperative opioid demand (P < 0.05). Younger age, anxiety, and greater preoperative opioid use were significantly associated with increased immediate postoperative opioid demand (P < 0.05). More invasive surgery, anxiety, revision surgery, and greater preoperative opioid use were significantly associated with a decreased incidence of opioid independence at 12 months postoperatively (P < 0.01). Conclusion. Greater preoperative opioid use prior to undergoing spine surgery predicts increased immediate postoperative opioid demand and decreased incidence of postoperative opioid independence. Psychiatric diagnoses in those using preoperative opioids were predictors of continued opioid use at 12 months. Patients may benefit from preoperative counseling that emphasizes minimizing opioid use prior to undergoing spine surgery. Level of Evidence: 2

Preoperative narcotic use and its relation to depression and anxiety in patients undergoing spine surgery.

Study Design. Prospective review of registry data at a single institution from October 2010 to June 2012. Objective. To assess whether the amount of preoperative narcotic use is associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion. Summary of Background Data. Previous work suggests that narcotic use and psychiatric comorbidities are significantly related. Among other psychological considerations, depression and anxiety may be associated with the amount of preoperative narcotic use in patients undergoing spine surgery. Methods. Five hundred eighty-three patients undergoing lumbar (60%), thoracolumbar (11%), or cervical spine (29%) were included. Self-reported preoperative narcotic consumption was obtained at the initial preoperative visit and converted to daily morphine equivalent amounts. Preoperative Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores were also obtained at the initial preoperative visit and recorded as measures of depression and anxiety, respectively. Resistant and robust bootstrapped multivariable linear regression analysis was performed to determine the association between ZDS and MSPQ scores and preoperative narcotics, controlling for clinically important covariates. Mann-Whitney U tests examined preoperative narcotic use in patients who were categorized as depressed (ZDS ≥ 33) or anxious (MSPQ ≥ 12). Results. Multivariable analysis controlling for age, sex, smoking status, preoperative employment status, and prior spinal surgery demonstrated that preoperative ZDS (P = 0.006), prior spine surgery (P = 0.007), and preoperative pain (0.014) were independent risk factors for preoperative narcotic use. Preoperative MSPQ (P = 0.083) was nearly a statistically significant risk factor. Patients who were categorized as depressed or anxious on the basis of ZDS and MSPQ scores also showed higher preoperative narcotic use than those who were not (P < 0.0001). Conclusion. Depression and anxiety as assessed by ZDS and MSPQ scores were significantly associated with increased preoperative narcotic use, underscoring the importance of thorough psychological and substance use evaluation in patients being evaluated for spine surgery. Level of Evidence: 2

The effects of American Society of Anesthesiologists physical status on length of stay and inpatient cost in the surgical treatment of isolated orthopaedic fractures.

Objectives: To identify the impact of the American Society of Anesthesiologists (ASA) physical status on postoperative length of stay (LOS) and to document the cost due to LOS after surgical management of the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic fractures. Design: Retrospective chart review. Setting: All patients who presented and underwent one of the 10 selected isolated orthopaedic surgical procedures at a large tertiary care center between January 1, 2000, and December 31, 2010. Patients/Participants: Charts for patients undergoing the 10 selected isolated orthopaedic surgical fracture procedures more than 10 years were reviewed. Thirteen thousand seven hundred seventy-six distinct operations were identified. One thousand three hundred ninety-eight distinct operations were included in analysis after selection. Intervention: This was an observational study. Patients who received operative management for isolated orthopaedic fractures were identified utilizing a CPT code search for analysis in a retrospective chart review. Main Outcome Measurements: LOS and cost secondary to LOS. Results: ASA physical status proved the strongest predictor of postoperative LOS for the 8 most common lower extremity and 2 most common upper extremity isolated orthopaedic procedures. ASA was also a significant predictor of inpatient cost for all isolated orthopaedic procedures included in the study with the exception of CPT code 27536. Conclusions: ASA classification is an indicator for variance in LOS and total inpatient cost for hospitalized patients. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. In addition, this study provides a foundation for many other studies to be conducted which will include multiple institutions and fracture types, such that ASA can be used as a more generalizable predictor of LOS and inpatient cost in orthopaedic trauma patients. This model may be used to accurately predict a patients postoperative course and the expected cost to the health care system of a given procedure. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery.

Study Design:Prospective cohort analysis. Objective:To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery. Summary of Background Data:Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use. Despite this and recent national attention highlighting the negative effects of narcotics, they remain commonly used for the management of pain in patients undergoing spine surgery. Materials And Methods:A total of 583 patients undergoing spine surgery for a structural lesion were evaluated. Self-reported preoperative narcotic consumption was obtained and converted to morphine equivalents at the initial preoperative visit. LOS was recorded upon discharge and presence/type of a postoperative complication within 30/90 days was obtained. A multivariable logistic and linear regression analysis was performed for the incidence of complications and length of stay controlling for clinically important covariates. Results:Narcotic use was not associated with 30- or 90-day complications; however, smoking status was significantly associated with 30-day complications. Increased preoperative narcotic use was significantly associated with increased LOS, as was age, type of surgery, and depression. Conclusions:Increased preoperative narcotic use and depression are associated with increased LOS in patients undergoing spine surgery. We calculated that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days. Narcotic use was not associated with 30- or 90-day postoperative complications. As reimbursement is bundled before surgery, providing interventions for patients with treatable causes for increased length of stay can save cost overall.

Olecranon fractures: factors influencing re-operation

PurposeWe evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures.MethodsFour hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF.ResultsOne hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group.ConclusionsOur results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.

What Patient Characteristics Could Potentially Affect Patient Satisfaction Scores During Spine Clinic

Study Design. Prospective study. Objective. Assess which patient factors are associated with patient satisfaction scores in the outpatient spine clinic setting. Summary of Background Data. Patient satisfaction has become an important component of quality assessments, and thereby pay-for-performance metrics, made by government, hospitals, and insurance providers. Methods. During a 7-month period, 200 patients were contacted via phone within 3 weeks of a new patient encounter with 1 of 11 spine providers. A standardized patient satisfaction phone survey consisting of 25 questions, answered using a 1–10 scale, was then administered. Patient demographics, medical/social history, and previous treatment were prospectively recorded. Potential associations between these patient factors and 3 outcomes of interest were investigated: (1) provider satisfaction, (2) overall clinic visit satisfaction, and (3) overall quality of care during clinic visit. Results. Younger age, less formal education, and smoking were associated with diminished provider satisfaction, overall clinic visit satisfaction, and perceived overall quality of care (P ⩽ 0.0001). Male patients were significantly less satisfied with their clinic visit compared with females (P = 0.029). Those treated under a workers compensation claim were significantly less satisfied with their provider and overall quality of care (P ⩽ 0.02). Marital status, working status, mental health history, travel distance, pain characteristics, previous treatments, and current narcotic use were not significant determinants of patient satisfaction (P > 0.05). Conclusion. This study found that those patients who were younger, with less formal education, and active smokers had lower patient satisfaction scores. Because patient satisfaction is increasingly being used in assessments of quality of care, it is essential that these factors be considered when evaluating a given providers practice. This information is important to providers by helping guide individualized patient interactions while in clinic, as well as, the various agencies collecting satisfaction scores allowing them to account for potential sampling bias. Level of Evidence: 1

Are Low Patient Satisfaction Scores always Due to the Provider? Determinants of Patient Satisfaction Scores During Spine Clinic Visits.

Study Design. A prospective study. Objective. The aim of this study was to investigate the impact of various components on patient satisfaction scores Summary of Background Data. Patient satisfaction has become an important component of quality assessments. However, with many of these sources collecting satisfaction data reluctant to disclose detailed information, little remains known about the potential determinants of patient satisfaction. Methods. Two hundred patients were contacted via phone within 3 weeks of new patient encounter with 11 spine providers. Standardized patient satisfaction phone survey consisting of 25 questions (1–10 rating scale) was administered. Questions inquired about scheduling, parking, office staff, teamwork, wait-time, radiology, provider interactions/behavior, treatment, and follow-up communication. Potential associations between these factors and three main outcome measures were investigated: (1) provider satisfaction, (2) overall clinic visit satisfaction, and (3) quality of care. Results. Significant associations (P < 0.0001) with provider satisfaction, overall clinic visit satisfaction, and perceived overall quality of care were found with appointment scheduling, parking, office staff, teamwork, wait time, radiology, provider interactions/behavior, treatment, and follow-up communication. Nurse-practitioner/resident involvement was positively associated with scores (P ⩽ 0.03). A “candy-man” effect was not noted, as pain medication prescribing did not play a significant role in satisfaction (P > 0.05). In multivariate regression analysis, explanation of medical condition/treatment (P = 0.002) and provider empathy (P = 0.04) were significantly associated with provider satisfaction scores, while the amount of time spent with the provider was not. Conversely, teamwork of staff/provider and follow-up communication were significantly associated with both overall clinic visit satisfaction and quality of care (P ⩽ 0.03), while provider behaviors or satisfaction were not. Conclusion. Satisfaction with the provider was associated with better explanations of the spine condition/treatment plan and provider empathy, but was not a significant factor in either overall clinic visit satisfaction or perceived quality of care. Patients’ perception of teamwork between staff and providers along with reliable follow-up communication were found to be significant determinants of overall patient satisfaction and perceived quality of care. Level of Evidence: 3

Repeat spine imaging in transferred emergency department patients.

Study Design. Retrospective study. Objective. Assess frequency of repeat spine imaging in patients transferred with known spine injuries from outside hospital (OSH) to tertiary receiving institution (RI). Summary of Background Data. Unnecessary repeat imaging after transfer has started to become a recognized problem with the obvious issues related to repeat imaging along with potential for iatrogenic injury with movement of patients with spine problems. Methods. Consecutive adult patients presenting to a single 1-level trauma center with spine injuries during a 51-month period were reviewed (n = 4500), resulting in 1427 patients transferred from OSH emergency department. All imaging and radiology reports from the OSH were reviewed, as well as studies performed at RI. A repeat was the same imaging modality used on the same spine region as OSH imaging. Results. The overall rate of repeat spine imaging for both OSH imaging sent and not sent was 23%, and 6% if repeat spine imaging via traumagram (partial/full-body computed tomography [CT]) was excluded as a repeat. The overall rate of repeat CT was 29% (7% dedicated spine CT scans and 22% part of nondedicated spine CT scan). An observation of only those patients with OSH imaging that was sent and viewable revealed that 23% underwent repeat spine imaging with 23% undergoing repeat spine CT and 41% repeat magnetic resonance imaging. In those patients with sent and viewable OSH imaging, a lack of reconstructions prompted 14% of repeats, whereas inadequate visualization of injury site prompted 8%. In only 8% of the repeats did it change management or provide necessary surgical information. Conclusion. This study is the first to investigate the frequency of repeat spine imaging in transfers with known spine injuries and found a substantially high rate of repeat spine CT with minimal alteration in care. Potential solutions include only performing scans at the OSH necessary to establish a diagnosis requiring transfer and improving communication between OSH and RI physicians. Level of Evidence: 4

The homeless orthopaedic trauma patient: follow-up, emergency room usage, and complications.

Objectives: To review homeless patients with orthopaedic trauma injuries and examine their emergency room (ER) usage, follow-up rates, and complication rates. Design: Retrospective chart review. Setting: Patients presenting to a level 1 trauma center with orthopaedic trauma injuries from 2001 to 2010. Patients/Participants: Sixty-three uninsured homeless patients and 63 uninsured nonhomeless patients with orthopaedic trauma injuries were included. Intervention: Homeless patients with orthopaedic trauma were identified through ER intake sheets and current procedural terminology code searches. Main Outcome Measurements: ER usage, orthopaedic clinic follow-up, and complications. Results: After the index visit to the ER for their orthopaedic trauma injuries, homeless patients demonstrated more ER visits and had fewer orthopaedic clinic follow-up visits than nonhomeless patients (P < 0.001). There were no significant differences among the type of complications (none, infection, hardware failure, and nonunion) between the homeless and the nonhomeless patients (P = 0.23). Operative homeless patients returned to the orthopaedic clinic for follow-up more than nonoperative homeless patients (mean = 5.4, SD = 7.6; and mean = 1.2, SD = 1.5, respectively; P < 0.001). Conclusions: Our data are the first to examine the problems associated with homelessness in the patient with orthopaedic trauma and demonstrate an increased challenge in the follow-up care. The orthopaedic surgeon must consider these issues in managing this complex patient population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Obesity Correlate With Worse Patient-Reported Outcomes Following Elective Anterior Cervical Discectomy and Fusion?

BACKGROUND Studies have investigated the impact of obesity in thoracolumbar surgery; however, the effect of obesity on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF) is unknown. OBJECTIVE To examine the relationship between obesity and PROs following elective ACDF. METHODS Consecutive patients undergoing ACDF for degenerative conditions were evaluated. Patients were divided into groups with a body mass index ≥35. The EuroQol-5D, Short-Form 12 (SF-12), modified Japanese Orthopaedic Association score, and Neck Disability Index were used. Correlations between PROs and obesity were calculated at baseline and 1 year. RESULTS A total of 299 patients were included, with 80 obese (27%) and 219 nonobese (73%). patients At baseline, obesity was associated with worse myelopathy (modified Japanese Orthopaedic Association score: 10.7 vs 12.2, P = .01), general physical health (SF-12 physical component scale score: 28.7 vs 31.8, P = .02), and general mental health (SF-12 mental component scale score: 38.9 vs 42.3, P = .04). All PROs improved significantly following surgery in both groups. There was no difference in absolute scores and change scores for any PRO at 12 months following surgery. Furthermore, there was no difference in the percentage of patients achieving a minimal clinically important difference for the Neck Disability Index (52% vs 56%, P = .51) and no difference in patient satisfaction (85% vs 85%, P = .85) between groups. CONCLUSION Obesity was not associated with less improvement in PROs following ACDF. There was no difference in the proportion of patients satisfied with surgery and those achieving a minimal clinically important difference across all PROs. Obese patients may therefore achieve meaningful improvement following elective ACDF. ABBREVIATIONS ACDF, anterior cervical discectomy and fusionBMI, body mass indexEQ-5D, EuroQol-5DMCID, minimal clinically important differenceMCS, mental component scalemJOA, modified Japanese Orthopaedic AssociationNDI, Neck Disability IndexNRS, Numerical Rating ScalePCS, physical component scalePROs, patient-reported outcomesSF-12, Short Form 12.