Joshua T. Anderson

Chronic Opioid Therapy After Lumbar Fusion Surgery for Degenerative Disc Disease in a Workers' Compensation Setting.

Study Design. Retrospective cohort study. Objective. To evaluate prescription opioid use after lumbar fusion for degenerative disc disease in a workers’ compensation (WC) setting. Summary of Background Data. Use of opioids for treating chronic low back pain has increased greatly. Few studies have evaluated risk factors for chronic opioid therapy (COT) among the clinically‐distinct WC population. Methods. We used “Current Procedural Terminology” and “International Classification of Diseases, Ninth Revision” codes to identify 1002 Ohio WC subjects who underwent lumbar fusion for degenerative disc disease from 1993 to 2013. Postoperative COT was defined as being supplied with opioid analgesics for greater than 1 year after the 6‐week acute period after fusion. 575 subjects fit these criteria, forming the COT group. The remaining 427 subjects formed a temporary opioid group. To identify prognostic factors associated with COT after fusion, we used a multivariate logistic regression analysis. Results. Returning to work was negatively associated with COT (P < 0.001; odds ratio [OR] 0.38). COT before fusion (P < 0.001; OR 6.15), failed back syndrome (P < 0.001; OR 3.40), additional surgery (P < 0.001; OR 2.84), clinically diagnosed depression (P < 0.001; OR 2.34), and extended work loss before fusion (P = 0.038; OR 1.61) were positively associated with COT. The rates of postoperative COT associated with these factors were 27.8%, 79.6%, 85.0%, 76.4%, 77.1%, and 61.3%, respectively. Higher preoperative opioid load (P < 0.001) and duration of use (P < 0.001) were positively associated with higher postoperative rates of COT. Within 3 years after fusion, the COT group was supplied with an average of 1083.4 days of opioids and 49.0 opioid prescriptions, 86.2% of which were Schedule II. The COT group had an 11.0% return to work rate,

Prolonged Preoperative Opioid Therapy Associated With Poor Return to Work Rates After Single-level Cervical Fusion for Radiculopathy for Patients Receiving Workers' Compensation Benefits.

27,952 higher medical costs per subject, 43.5% rate of psychiatric comorbidity, 16.7% rate of failed back syndrome, and 27.7% rate of additional lumbar surgery. Conclusion. The majority of the study population was on COT after fusion. COT was associated with considerably worse outcomes. The poor outcomes of this study could suggest a more limited role for discogenic fusion among WC patients. Level of Evidence: 3

Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers’ Compensation Setting

Study Design. Retrospective comparative cohort study. Objective. Examine the effect of prolonged preoperative opioid use on return to work (RTW) status after single-level cervical fusion for radiculopathy. Summary of Background Data. The use of opioids has a dramatic effect in a workers’ compensation population. The costs of claims that involved opioids in the management plan are catastrophic particularly for those undergoing spinal surgical procedure. Materials. Data of patients who underwent single-level cervical fusion for radiculopathy and had received opioid prescriptions before surgery were retrospectively collected from Ohio Bureau of Workers’ Compensation between 1993 and 2011 after work-related injury. Then, based on opioid use duration, short-term use (STO) group (<3 mo), intermediate-term use (ITO) group (3–6 mo), and long-term use (LTO) group (>6 mo) were constructed. A multivariate logistic regression analysis was used to determine whether successful RTW status was achieved. Chi-square and analysis of variance tests were used to compare other secondary outcomes after surgery. Results. Prolonged preoperative opioid use was a negative predictor of successful RTW status (odds ratio = 0.73; 95% confidence interval: 0.55–0.98; P value: 0.04). Prolonged preoperative opioid use was associated with increasingly lower rates of achieving stable RTW status (P < 0.05) and RTW within 1 year after surgery (P < 0.05). The odds of achieving successful RTW status were 0.49 (0.25–0.94) for ITO, and 0.40 (0.24–0.68) for LTO compared with STO group. The odds of RTW less than 1 year after surgery were 0.43 (0.21–0.88) for ITO and 0.36 (0.21–0.62) for LTO compared with STO group. Prolonged preoperative opioid use was also associated with increasingly higher net medical costs (P < 0.01), and disability benefits awarded after surgery (P < 0.01). Conclusion. Prolonged preoperative opioid use was associated with poor functional outcomes after cervical fusion. STO and earlier inclusion of the surgical approach in the management plan may offer better surgical and functional outcomes after cervical fusion. Level of Evidence: 3

Preoperative Opioid Use: A Risk Factor for Poor Return to Work Status After Single-level Cervical Fusion for Radiculopathy in a Workers’ Compensation Setting

Study Design. A retrospective cohort study. Objective. The aim of this study was to compare outcomes in Workers’ compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability. Summary of Background Data. The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone. Methods. Three hundred sixty-four Ohio WC subjects were identified who underwent primary decompression (DC) or primary decompression and fusion (DC + F) for DLS alone between 1993 and 2013. Our primary outcome was if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for more than 6 months. A number of secondary outcomes were collected and analyzed. Results. The DC cohort had a significantly higher RTW rate [36% (83/227) vs. 25% (54/212); P = 0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that fusion with operative decompression remained a significant negative predictor of RTW status (P = 0.04; odds ratio: 0.58, 95% confidence interval: 0.34–0.99). Within the DC cohort, the rate of postoperative instability and subsequent fusion was 8%. Furthermore, subjects who received an adjunctive fusion cost of the Ohio BWC on average,

Prolonged Preoperative Opioid Therapy in Patients With Degenerative Lumbar Stenosis in a Workers’ Compensation Setting

46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone. Conclusion. Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population. Level of Evidence: 3

Return to Work Rates After Single-level Cervical Fusion for Degenerative Disc Disease Compared With Fusion for Radiculopathy in a Workers' Compensation Setting.

Study Design: Retrospective comparative case-control study. Objectives: The objectives of this study are: (1) How preoperative opioid use impacts RTW status after single-level cervical fusion for radiculopathy? and (2) What are other postsurgical outcomes affected by preoperative opioid use? Summary of Background Data: Opioid use has increased significantly in the past decade. The use of opioids has a drastic impact on workers’ compensation population, an at-risk cohort for poorer surgical and functional outcomes than the general population. Methods and Materials: Data was retrospectively collected from Ohio Bureau of Workers’ Compensation between 1993 and 2011. The study population included patients who underwent single-level cervical fusion for radiculopathy as identified by current procedural terminology codes and International Classification of Diseases-9 codes. On the basis of opioid use before surgery, two groups were constructed (opioids vs. non-opioids). Using a multivariate logistic regression model, the effect of preoperative opioid use on return to work (RTW) status after fusion was analyzed and compared between the groups. Results: In the regression model, preoperative opioid use was a negative predictor of RTW status within 3-year follow-up after surgery. Opioid patients were less likely to have stable RTW status [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.38-0.65; P=0.05] and were less likely to RTW within the first year after surgery (OR, 0.50; 95% CI, 0.37-0.66; P=0.05) compared with controls. Stable RTW was achieved in 43.3% of the opioids group and 66.6% of control group (P=0.05). RTW rate within the first year after fusion was 32.5% of opioids group and 57% of control group (P<0.05). Reoperation and permanent disability rates after surgery were higher in the opioid group compared with the control group (P<0.05). Conclusions: In a workers’ compensation, patients with work-related injury who underwent single-level cervical fusion for radiculopathy and received opioids before surgery had worse RTW status, a higher reoperation rate, and higher rate of awarded permanent disability after surgery.

Return to Work and Multilevel versus Single-level Cervical Fusion for Radiculopathy in a Workers’ Compensation Setting

Study Design. Retrospective cohort study. Objective. To investigate the impact of prolonged opioid use in the preoperative treatment plan of degenerative lumbar stenosis (DLS). Summary of Background Data. Patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. The relative paucity of data on the relationship between preoperative opioid use and clinical outcomes in the workers’ compensation (WC) population necessitates further study of this unique population. Methods. We identified 140 Ohio WC patients who underwent lumbar decompression and had received preoperative opioid prescriptions between 1993 and 2013. Our study cohorts were formed based on opioid use duration, which included short-term use (<3 months) and long-term use (>3 months). Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to determine the impact of the duration of preoperative opioid use on return to work rates. We also compared many secondary outcomes after surgery between both groups. Results. Patients on opioids less than 3 months had a significantly higher RTW rate compared with those who used opioids longer than 3 months [25/60 (42%) vs. 18/80 (23%); P = 0.01]. A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW (OR: 0.35, 95% CI: 0.13–0.89; P = 0.02). Patients who remained on opioid therapy longer than 3 months cost the Ohio Bureau of Workers’ Compensation

Vertebroplasty and Return to Work for Thoracolumbar Fractures Within the Workers’ Compensation Population

70,979 more than patients who were on opioid therapy for less than 3 months (P < 0.01). Conclusion. Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS. Level of Evidence: 3

Clinical Depression Is a Strong Predictor of Poor Lumbar Fusion Outcomes Among Workers' Compensation Subjects

Study Design. A retrospective comparative cohort study. Objective. To compare return to work (RTW) rates for patients who underwent single-level cervical fusion for radiculopathy compared with fusion for degenerative disc disease (DDD) as an indication for surgery. Summary of Background Data. Studies have shown that workers’ compensation subjects have less favorable surgical and functional outcomes compared with the general population. Cervical decompression and fusion have provided great results with relieving radicular symptoms. Fusion for DDD, however, remains controversial. Methods. We retrospectively collected data of 21 169 subjects with cervical comorbidities who filed their claims for work-related injuries with Ohio Bureau of Workers’ Compensation (BWC) between 1993 and 2011. The primary outcome was whether subjects met RTW criteria within 3-year follow-up after fusion. The secondary outcome measures and data on presurgical characteristics and secondary outcomes of each cohort were also collected. Results. Successful RTW status was affected by a number of presurgical risk factors: DDD as an indication for surgery, age of more than 50 years, out of work for more than 6 months, psychological evaluation, opioid use, legal litigation, and permanent disability. The DDD group had lower rate of successful RTW status (50.9%) and was less likely to have a sustained RTW status (odds ratio = 0.61, 95% confidence interval: 0.48–0.79, P = 0.0001) compared with the radiculopathy group (successful RTW rate 62.9%). RTW rate within 1 year after surgery was lower in the DDD group (39.9%) compared with the radiculopathy group (53.1%; P = 0.0001). DDD patients were absent 112 days more on average after surgery compared with radiculopathy patients (P = 0.0003). Conclusion. Cervical fusion for DDD is associated with lower rate of successful RTW status when compared with fusion for radiculopathy in a workers compensation setting. The decision to include surgical intervention in the management plan of cervical DDD should be approached with caution as the surgical outcome might not necessarily lead to improved postsurgical functionality and achieve sustained early RTW. Level of Evidence: 4

Can Internet Information on Vertebroplasty be a Reliable Means of Patient Self-education?

Study Design. Retrospective comparative cohort study. Objective. Examine the impact of multilevel fusion on return to work (RTW) status and compare RTW status after multi- versus single-level cervical fusion for patients with work-related injury. Summary of Background Data. Patients with work-related injuries in the workers’ compensation systems have less favorable surgical outcomes. Cervical fusion provides a greater than 90% likelihood of relieving radiculopathy and stabilizing or improving myelopathy. However, more levels fused at index surgery are reportedly associated with poorer surgical outcomes than single-level fusion. Methods. Data was collected from the Ohio Bureau of Workers’ Compensation (BWC) between 1993 and 2011. The study population included patients who underwent cervical fusion for radiculopathy. Two groups were constructed (multilevel fusion [MLF] vs. single-level fusion [SLF]). Outcomes measures evaluated were: RTW criteria, RTW <1year, reoperation, surgical complication, disability, and legal litigation after surgery. Results. After accounting for a number of independent variables in the regression model, multilevel fusion was a negative predictor of successful RTW status within 3-year follow-up after surgery (OR = 0.82, 95% CI: 0.70–0.95, P <0.05). RTW criteria were met 62.9% of SLF group compared with 54.8% of MLF group. The odds of having a stable RTW for MLF patients were 0.71% compared with the SLF patients (95% CI: 0.61–0.83; P: 0.0001). At 1 year after surgery, RTW rate was 53.1% for the SLF group compared with 43.7% for the MLF group. The odds of RTW within 1 year after surgery for the MLF group were 0.69% compared with SLF patients (95% CI: 0.59–0.80; P: 0.0001). Higher rate of disability after surgery was observed in the MLF group compared with the SLF group (P: 0.0001) Conclusion. Multilevel cervical fusion for radiculopathy was associated with poor return to work profile after surgery. Multilevel cervical fusion was associated with lower RTW rates, less likelihood of achieving stable return to work, and higher rate of disability after surgery. Level of Evidence: 3