- Email: [email protected]
Prediction of Clinical Outcomes After Transforaminal Lumbar Interbody Fusions Based on Preoperative Opioid Use
NASS 32nd Annual Meeting Proceedings / The Spine Journal 17 (2017) S111–S165 CONCLUSIONS: Achieving a minimal symptom state or Best Outcome following fusion for lumbar degenerative conditions is more likely in an older patient with a lower baseline ODI undergoing a single-level lumbar fusion for spondylolisthesis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.07.281
230. Prediction of Clinical Outcomes After Transforaminal Lumbar Interbody Fusions Based on Preoperative Opioid Use Alan T. Villavicencio, MD1, Ewell L. Nelson, MD1, Sharad Rajpal, MD2, Sigita Burneikiene, MD1; 1Boulder Neurosurgical Associates, Boulder, CO, USA; 2Boulder Neurosurgical and Spine Associates, Boulder, CO, USA BACKGROUND CONTEXT: Opioid analgesics have become some of the most prescribed drugs in the world, despite the lack of long-term studies evaluating the benefits of opioid medications vs their risks associated with chronic use. In addition, long-term opioid use may be associated with worse long-term clinical outcomes. PURPOSE: The primary objective of this study was to evaluate whether preoperative opioid use predicted inferior clinical outcomes among patients undergoing transforaminal lumbar interbody fusion (TLIF) for symptomatic lumbar degenerative disc disease. STUDY DESIGN/SETTING: Prospective observational study. PATIENT SAMPLE: A total of 93 patients who underwent 1-level to 2-level TLIFs in 2011–2014 were enrolled. OUTCOME MEASURES: Visual analog scale (VAS) scores for lowback pain and leg pain, Oswestry Disability Index scores, and the scores of the mental component summary (MCS) and physical component summary (PCS) on the 36-Item Short-Form Health Survey were used to assess pain, disability, and health-related quality of life outcomes, respectively. METHODS: The patient cohort was divided into 2 groups according to preoperative opioid use or no such use. The clinical scores for the 2 groups were compared preoperatively and at a 12-month follow-up examination. RESULTS: In total, 60 (64.5%) patients took prescribed opioid medications preoperatively. Compared with those not taking opioids preoperatively, these patients had significantly higher VAS scores for low-back pain (p=.016), greater disability (p=.013), and lower PCS scores (p=.03) at the 12-month follow-up. The postoperative MCS scores were also significantly lower (p=.035) in the opioid-use group, but these lower scores were due to significantly lower baseline MCS scores in this group. A linear regression analysis did not detect opioid dose–related effects on leg and back pain, disability, and MCS and PCS scores, suggesting that poorer outcomes are not significantly correlated with higher opioid doses taken by the patients. CONCLUSIONS: The use of opioid medications to control pain before patients underwent lumbar fusion for degenerative lumbar conditions was associated with less favorable clinical outcomes postoperatively. This is the first study that has demonstrated this association in a homogeneous cohort of patients undergoing TLIF. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.07.282
231. Predicting Adverse Events following Posterior Lumbar Fusion: A Comparison of the Charlson Comorbidity Index, Elixhauser’s Comorbidity Measure, and the Modified Frailty Index Nathaniel T. Ondeck, BS1, Daniel D. Bohl, MD, MPH2, Patawut Bovonratwet, BS3, Taylor Ottesen3, Jonathan Cui3, Ryan P. McLynn, BS3, Jonathan N. Grauer, MD1; 1Yale University School of Medicine, New Haven, CT, USA; 2Rush University Medical Center, Chicago, IL, USA; 3New Haven, CT, USA
S155
BACKGROUND CONTEXT: Raised patient expectations, more rigorous quality improvement programs, and evolving outcome-based payments have all led to increased efforts to identify patients at risk for adverse outcomes. The Charlson Comorbidity Index (CCI), Elixhauser’s Comorbidity Measure (ECM), and the modified Frailty Index (mFI) have all been associated with complications following spine procedures; however, their relative clinical utility is unknown. PURPOSE: The present study compares the predictive power of comorbidity indices (CCI, ECM, and mFI) as well as demographic factors (age, body mass index [BMI], and gender) for general health adverse outcomes after posterior lumbar fusion (PLF). STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. PATIENT SAMPLE: Patients undergoing PLF were extracted from the 2013 National Inpatient Sample. This database allowed for the assessment of ECM, which cannot be calculated from other commonly used national databases. OUTCOME MEASURES: Outcomes studied included the occurrence of any adverse event, severe adverse events, and minor adverse events as well as extended length of hospital stay and discharge to a facility. METHODS: The discriminative ability of CCI, ECM, and mFI (comorbidity indices) as well as age, BMI, and gender (demographic factors) for general health adverse outcomes were assessed using area under the curve (AUC) analyses from receiver operating characteristics curves. RESULTS: A comparison of the AUCs for CCI, ECM, and mFI revealed that ECM statistically outperformed the other comorbidity indices for all 5 outcomes (any adverse event, severe adverse events, minor adverse events, extended length of hospital stay, and discharge to a facility). An analysis of the demographic factors of age, gender, and obesity demonstrated that age had the sole largest discriminative ability for any adverse event, severe adverse events, extended length of hospital stay, and discharge to a facility. Age and gender performed similarly for predicting the occurrence of minor adverse events. A comparison of ECM (the best performing comorbidity index) and age (the best performing demographic factor) revealed that ECM performed superiorly for 4 out of 5 adverse outcomes. CONCLUSIONS: Elixhauser’s Comorbidity Measure (ECM), a less commonly used comorbidity measure than CCI and mFI, was the best performing comorbidity measure for all outcome variables. Age outperformed the other demographic factors for 4 out of 5 adverse outcomes. ECM, which accounts for 31 pre-existing health conditions, outperformed age for 4 of 5 adverse outcomes, indicating that disease burden plays a role in increased risk for adverse events. Overall, this work helps identify which variables and indices best predict adverse outcomes after posterior lumbar fusion surgery in the quest to optimize clinical improvement initiatives. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.07.283
Friday, October 27, 2017 3:50 PM–4:50 PM Operating Room Management 232. Is the Use of Multimodal Anesthesia for Postoperative Pain Control Effective in Patients Undergoing One– or Two-Level Anterior Lumbar Interbody Fusions with Posterior Percutaneous Pedicle Screw Instrumentation? Kamran Majid, MD1, Nirmal Singh, D.ABNM1, Mayur P. Kardile, MD2, Mark Gjolaj3, Calvin C. Kuo, MD1, Alem Yacob, MD, MSc4, Ravi S. Bains, MD1; 1Kaiser Permanente, Oakland, CA, US; 2Regional Spine Surgery Department, Kaiser Permanente Oakland Medical Center, Oakland, CA, US; 3US; 4Yale University School of Medicine, New Haven, CT, US BACKGROUND CONTEXT: Adequate postoperative pain control is an important aspect of spine surgery and is associated with decreased length
230. Prediction of Clinical Outcomes After Transforaminal Lumbar Interbody Fusions Based on Preoperative Opioid Use Alan T. Villavicencio, MD1, Ewell L. Nelson, MD1, Sharad Rajpal, MD2, Sigita Burneikiene, MD1; 1Boulder Neurosurgical Associates, Boulder, CO, USA; 2Boulder Neurosurgical and Spine Associates, Boulder, CO, USA BACKGROUND CONTEXT: Opioid analgesics have become some of the most prescribed drugs in the world, despite the lack of long-term studies evaluating the benefits of opioid medications vs their risks associated with chronic use. In addition, long-term opioid use may be associated with worse long-term clinical outcomes. PURPOSE: The primary objective of this study was to evaluate whether preoperative opioid use predicted inferior clinical outcomes among patients undergoing transforaminal lumbar interbody fusion (TLIF) for symptomatic lumbar degenerative disc disease. STUDY DESIGN/SETTING: Prospective observational study. PATIENT SAMPLE: A total of 93 patients who underwent 1-level to 2-level TLIFs in 2011–2014 were enrolled. OUTCOME MEASURES: Visual analog scale (VAS) scores for lowback pain and leg pain, Oswestry Disability Index scores, and the scores of the mental component summary (MCS) and physical component summary (PCS) on the 36-Item Short-Form Health Survey were used to assess pain, disability, and health-related quality of life outcomes, respectively. METHODS: The patient cohort was divided into 2 groups according to preoperative opioid use or no such use. The clinical scores for the 2 groups were compared preoperatively and at a 12-month follow-up examination. RESULTS: In total, 60 (64.5%) patients took prescribed opioid medications preoperatively. Compared with those not taking opioids preoperatively, these patients had significantly higher VAS scores for low-back pain (p=.016), greater disability (p=.013), and lower PCS scores (p=.03) at the 12-month follow-up. The postoperative MCS scores were also significantly lower (p=.035) in the opioid-use group, but these lower scores were due to significantly lower baseline MCS scores in this group. A linear regression analysis did not detect opioid dose–related effects on leg and back pain, disability, and MCS and PCS scores, suggesting that poorer outcomes are not significantly correlated with higher opioid doses taken by the patients. CONCLUSIONS: The use of opioid medications to control pain before patients underwent lumbar fusion for degenerative lumbar conditions was associated with less favorable clinical outcomes postoperatively. This is the first study that has demonstrated this association in a homogeneous cohort of patients undergoing TLIF. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.07.282
231. Predicting Adverse Events following Posterior Lumbar Fusion: A Comparison of the Charlson Comorbidity Index, Elixhauser’s Comorbidity Measure, and the Modified Frailty Index Nathaniel T. Ondeck, BS1, Daniel D. Bohl, MD, MPH2, Patawut Bovonratwet, BS3, Taylor Ottesen3, Jonathan Cui3, Ryan P. McLynn, BS3, Jonathan N. Grauer, MD1; 1Yale University School of Medicine, New Haven, CT, USA; 2Rush University Medical Center, Chicago, IL, USA; 3New Haven, CT, USA
S155
BACKGROUND CONTEXT: Raised patient expectations, more rigorous quality improvement programs, and evolving outcome-based payments have all led to increased efforts to identify patients at risk for adverse outcomes. The Charlson Comorbidity Index (CCI), Elixhauser’s Comorbidity Measure (ECM), and the modified Frailty Index (mFI) have all been associated with complications following spine procedures; however, their relative clinical utility is unknown. PURPOSE: The present study compares the predictive power of comorbidity indices (CCI, ECM, and mFI) as well as demographic factors (age, body mass index [BMI], and gender) for general health adverse outcomes after posterior lumbar fusion (PLF). STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. PATIENT SAMPLE: Patients undergoing PLF were extracted from the 2013 National Inpatient Sample. This database allowed for the assessment of ECM, which cannot be calculated from other commonly used national databases. OUTCOME MEASURES: Outcomes studied included the occurrence of any adverse event, severe adverse events, and minor adverse events as well as extended length of hospital stay and discharge to a facility. METHODS: The discriminative ability of CCI, ECM, and mFI (comorbidity indices) as well as age, BMI, and gender (demographic factors) for general health adverse outcomes were assessed using area under the curve (AUC) analyses from receiver operating characteristics curves. RESULTS: A comparison of the AUCs for CCI, ECM, and mFI revealed that ECM statistically outperformed the other comorbidity indices for all 5 outcomes (any adverse event, severe adverse events, minor adverse events, extended length of hospital stay, and discharge to a facility). An analysis of the demographic factors of age, gender, and obesity demonstrated that age had the sole largest discriminative ability for any adverse event, severe adverse events, extended length of hospital stay, and discharge to a facility. Age and gender performed similarly for predicting the occurrence of minor adverse events. A comparison of ECM (the best performing comorbidity index) and age (the best performing demographic factor) revealed that ECM performed superiorly for 4 out of 5 adverse outcomes. CONCLUSIONS: Elixhauser’s Comorbidity Measure (ECM), a less commonly used comorbidity measure than CCI and mFI, was the best performing comorbidity measure for all outcome variables. Age outperformed the other demographic factors for 4 out of 5 adverse outcomes. ECM, which accounts for 31 pre-existing health conditions, outperformed age for 4 of 5 adverse outcomes, indicating that disease burden plays a role in increased risk for adverse events. Overall, this work helps identify which variables and indices best predict adverse outcomes after posterior lumbar fusion surgery in the quest to optimize clinical improvement initiatives. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.07.283
Friday, October 27, 2017 3:50 PM–4:50 PM Operating Room Management 232. Is the Use of Multimodal Anesthesia for Postoperative Pain Control Effective in Patients Undergoing One– or Two-Level Anterior Lumbar Interbody Fusions with Posterior Percutaneous Pedicle Screw Instrumentation? Kamran Majid, MD1, Nirmal Singh, D.ABNM1, Mayur P. Kardile, MD2, Mark Gjolaj3, Calvin C. Kuo, MD1, Alem Yacob, MD, MSc4, Ravi S. Bains, MD1; 1Kaiser Permanente, Oakland, CA, US; 2Regional Spine Surgery Department, Kaiser Permanente Oakland Medical Center, Oakland, CA, US; 3US; 4Yale University School of Medicine, New Haven, CT, US BACKGROUND CONTEXT: Adequate postoperative pain control is an important aspect of spine surgery and is associated with decreased length