Postoperative Opioid Use and Prescribing Patterns among Patients Undergoing Cervical Laminectomy with Instrumented Fusion versus Cervical Laminoplasty with Reconstruction.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare patterns in opioid usage and prescriptions between patients who undergo cervical laminectomy with instrumented fusion (LF) vs cervical laminoplasty with reconstruction (LP) within single surgeon and national database cohorts. METHODS: We identified patients with cervical myelopathy undergoing primary LF or LP in both a single-surgeon series cohort (2004-2018) and a nationally representative cohort drawn from the IBM® Marketscan® database (2014-2016). We recorded opioid usage within 6 months of surgery and identified differences in unadjusted opioid use rates between LF and LP patients. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative opioid use. RESULTS: Without adjusting for covariates, LF patients had a higher rate of 6-month opioid use in the single-surgeon cohort (15.7% vs 5.1%, P = .02). After adjusting for covariates, LF patients had higher odds of 6-month postoperative opioid use (OR 2.8 [95% CI 1.0-7.7], P = .04). In the national cohort, without adjusting for covariates, there was no significant difference in 6-month opioid use between LF and LP patients. Even after adjusting for covariates, we found no significant difference in odds. CONCLUSIONS: Findings from a single-surgeon cohort reveal that LF is associated with a higher rate of 6-month opioid use than LP. This is at odds with findings from a national database cohort, which suggested that LP and LF patients have similar rates of opioid usage at 6-months postoperatively. To prevent overuse of narcotics, surgeons must consider the distinct pain requirements associated with different procedures even in treatment of the same condition.

Postoperative C5 Palsy Following Cervical Laminectomy With Instrumented Fusion Versus Cervical Laminoplasty With Reconstruction: Single Surgeon and National Inpatient Cohort Analyses.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to investigate whether cervical laminectomy with instrumented fusion (LF) and cervical laminoplasty with reconstruction (LP) are associated with different rates C5 palsy (C5P) at 1-month follow-up in a single surgeon and nationally representative cohort. SUMMARY OF BACKGROUND DATA: LF and LP both carry a well-known risk of nerve root injury that most commonly presents as C5P which can reduce patient satisfaction, patient function, and impede patient recovery. The procedure type that is more frequently associated with C5P remains largely unclear. METHODS: We identified patients undergoing primary LF or LP procedures for the treatment of cervical myelopathy in both a single-surgeon series cohort (2004-2018; Mount Sinai Hospital) and a nationally representative cohort drawn from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017). For the single-surgeon cohort, C5P within 1 month of surgery was recorded. For the NSQIP cohort, peripheral nerve injury (PNI) within 1 month of surgery was recorded and used as a proxy for C5P. Postoperative complications including C5P were compared between cohorts. Multivariable logistic regression was used to evaluate the association between procedure type and postoperative C5P or PNI. RESULTS: Without adjusting for covariates, LF patients had a higher rate of 1-month C5P in the single-surgeon cohort (8% vs. 0%, P=0.01). An adjusted odds ratio could not be obtained due to the absence of C5P in the LP group. In the national cohort, LP patients had a significantly higher rate of 1-month PNI on unadjusted analysis (11% vs. 16%, P<0.001). After adjusting for covariates, we found no significant difference in odds of 1-month PNI between LF and LP (adjusted odds ratio=0.84, P=0.07). CONCLUSIONS: Overall, the single-surgeon series suggest that cervical LF is associated with significantly higher rates of postoperative C5P as compared with LP. These findings are not corroborated by nationally representative data, which showed no difference in PNI rates between LF and LP. A surgeon's training and experience likely contribute to which procedure has a higher propensity for a C5P as a complication. Regardless, both LF and LP patients should be closely monitored for new-onset C5P during follow-up visits. LEVEL OF EVIDENCE: Level III.

Accelerometry Data Delineate Phases of Recovery and Supplement Patient-Reported Outcome Measures Following Lumbar Laminectomy.

BACKGROUND: Patient-reported outcome measures (PROMs) are traditionally used to track recovery of patients after spine surgery. Wearable accelerometers have adjunctive value because of the continuous, granular, and objective data they provide. We conducted a prospective study of lumbar laminectomy patients to determine if time-series data from wearable accelerometers could delineate phases of recovery and compare accelerometry data to PROMs during recovery tracking. METHODS: Patients with lumbar stenosis for whom lumbar laminectomy was indicated were prospectively recruited. Subjects wore accelerometers that recorded their daily step counts from at least 1 week preoperatively to 6 months postoperatively. Subjects completed the Oswestry Disability Index and the 12-Item Short Form Health Survey preoperatively and at 2 weeks, 1 month, 3 months, and 6 months postoperatively. Daily aggregate median steps and individual visit-specific median steps were calculated. The Pruned Linear Exact Time method was used to segment aggregate median steps into distinct phases. Associations between visit-specific median steps and PROMs were identified using Spearman rank correlation. RESULTS: Segmentation analysis revealed 3 distinct postoperative phases: step counts rapidly increased for the first 40 days postoperatively (acute healing), then gained more slowly for the next 90 days (recovery), and finally plateaued at preoperative levels (stabilization). Visit-specific median steps were significantly correlated with PROMs throughout the postoperative period. PROMs significantly exceeded baseline at 6 months postoperatively, while step counts did not (all P < 0.05). CONCLUSIONS: Continuous data from accelerometers allowed for identification of 3 distinct stages of postoperative recovery after lumbar laminectomy. PROMs remain necessary to capture subjective elements of recovery.

Relationship Between Baseline Patient-reported Outcomes and Demographic, Psychosocial, and Clinical Characteristics: A Retrospective Study.

INTRODUCTION: Alternative payment models in total lower extremity joint replacement (TJR) increasingly emphasize patient-reported outcomes (PROs) to link the latter to value-based payments. It is unclear to what extent demographic, psychosocial, and clinical characteristics are related to PROs measured preoperatively with the commonly used Hip/Knee Osteoarthritis Outcome Scores (HOOS/KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) questionnaires. We aim to identify (1) the preoperative relationship between HOOS/KOOS and VR-12 scores and several demographic, psychosocial, and clinical patient characteristics and (2) the best modifiable factors for optimization, which may result in improved baseline PROs before TJR. METHODS: All TJR cases performed in 2017 at the two highest-volume hospitals within an urban academic health system were queried. Preoperative HOOS/KOOS and VR-12 surveys were administered through an e-collection platform. VR-12 physical and mental component scores (PCS, MCS) were generated. Patient information was extracted from the electronic health record. Bivariate and multivariate regression analyses were performed. Odds ratios (ORs) and 95% confidence intervals were reported. RESULTS: In univariate analysis, patients with HOOS/KOOS, VR-12 PCS, and MCS in the ≤25th percentile group were more likely to have an ASA score of ≥3 compared with those with higher scores. In multivariate analysis, increased and decreased odds of low HOOS/KOOS were associated with a one-unit increase in Charlson Comorbidity Index (OR, 1.16) and VR-12 MCS (OR, 0.97), respectively. Increased odds of low baseline VR-12 PCS and MCS were associated with ASA class ≥3 (OR, 1.65 and 1.40). Decreased odds of a low MCS were associated with an increase in HOOS/KOOS (OR, 0.98) (P ≤ 0.05 for all). CONCLUSION: Of the factors that are associated with low baseline PRO scores, preoperatively addressing mismanaged comorbidities, mental health, and physical function were identified as the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Preoperative Patient-Reported Outcomes and Clinical Characteristics as Predictors of 90-Day Cost/Utilization and Complications.

BACKGROUND: With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients. METHODS: All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed. RESULTS: In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P < .05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge, >75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P < .01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost. CONCLUSION: Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.