Protocolization of Post-Transforaminal Lumbar Interbody Fusion Pain Control with Elimination of Benzodiazepines and Long-Acting Opioids.

BACKGROUND: The opioid epidemic continues to worsen with a concomitant increase in opioid-related mortality. In response, the Department of Defense and Veterans Health Agency recommended against the use of long-acting opioids (LAOs) and concurrent use of opioids with benzodiazepines. Subsequently, we eliminated benzodiazepines and LAOs from our postoperative pain control regimen. OBJECTIVE: To evaluate the impact of removing benzodiazepines and LAOs on postoperative pain in single-level transforaminal lumbar interbody fusion (TLIF) patients. METHODS: A retrospective cohort study of single-level TLIF patients from February 2016-March 2018 was performed. Postoperative pain control in the + benzodiazepine cohort included scheduled diazepam with or without LAOs. These medications were replaced with nonbenzodiazepine, opioid-sparing adjuncts in the -benzodiazepine cohort. Pain scores, length of hospitalization, trigger medication use, and opioid use and duration were compared. RESULTS: Among 77 patients, there was no difference between inpatient pain scores, but the -benzodiazepine cohort experienced a faster rate of morphine equivalent reduction (-18.7%, 95% CI [-1.22%, -36.10%]), used less trigger medications (-1.55, 95% CI [-0.43, -2.67]), and discharged earlier (0.6 d; 95% CI [0.01, 1.11 d]). As outpatients, the -benzodiazepine cohort was less likely to receive opioid refills at 2 wk (29.2% vs 55.8%, P = .021) and 6 mo postoperatively (0% vs 13.2%, P = .039), and was less likely to be using opioids by 3 mo postoperatively (13.3% vs 34.2%, P = .048). CONCLUSION: Replacement of benzodiazepines and LAOs in the pain control regimen for single-level TLIFs did not affect pain scores and was associated with decreased opioid use, a reduction in trigger medications, and shorter hospitalizations.

Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury - An Illustrative Case of Why Size Matters.

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

Performance of Cervical Arthroplasty at a Pseudarthrosed Level of a MultiLevel Anterior Cervical Discectomy and Fusion: Case Report.

OBJECTIVE: To present a conversion from an anterior cervical discectomy and fusion (ACDF) to cervical arthroplasty in a 40-year-old, active duty member and perform a review of the literature. METHODS: A helicopter pilot in the U.S. Army underwent a three-level ACDF in 2010 at a nonmilitary institution for symptoms of bilateral upper-extremity radiculopathy. His symptoms resolved; however, per regulations, he was grounded. The patient recently presented at our clinic for evaluation of axial neck and intrascapular pain with radiographic evaluation revealing pseudarthrosis at C6-7 with segmental motion without facet joint degeneration. Surgery was performed to remove the existing allograft and replace it with an artificial disc, thus restoring a motion segment. RESULTS: Postoperative imaging reveals appropriate placement of the artificial disc and range of motion at C6-7 with the patient reporting improvement in neck pain. He has since been granted a waiver to return to active flight status. CONCLUSIONS: Revision of ACDF to arthroplasty is an exceedingly rare procedure with only two cases reported in the literature. Here, the authors demonstrate use of the procedure for a military career-specific application. When facet joint degeneration or ankylosis is absent, restoration of motion can successfully, and safely, be achieved.