Factors Associated With Total Discharge Opioid Prescription Morphine Milligram Equivalent Amounts Following Primary Anterior Cervical Spine Surgery.

BACKGROUND: Opioid overuse is a substantial cause of morbidity and mortality in the United States, and orthopaedic surgeons are the third highest prescribers of opioids. Postoperative prescribing patterns vary widely, and there is a paucity of data evaluating patient and surgical factors associated with discharge opioid prescribing patterns after elective anterior cervical surgery (ACS). The purpose of this study was to evaluate the volume of postoperative opioids prescribed and factors associated with discharge opioid prescription volumes after elective ACS. METHODS: We retrospectively identified patients aged 18 years and older who underwent elective primary anterior cervical diskectomy and fusion (ACDF), cervical disk arthroplasty (CDA), or hybrid procedure (ACDF and CDA at separate levels) at a single institution between 2015 and 2021. Demographic, surgical, and opioid prescription data were obtained from patients' electronic medical records. Univariate and multivariate analyses were conducted to assess for independent associations with discharge opioid volumes. RESULTS: A total of 313 patients met inclusion criteria, including 226 (72.2%) ACDF, 69 (22.0%) CDA, and 18 (5.8%) hybrid procedure patients. Indications included radiculopathy in 63.6%, myelopathy in 19.2%, and myeloradiculopathy in 16.3%. The average age was 57.2 years, and 50.2% of patients were male. Of these, 88 (28.1%) underwent one-level, 137 (43.8%) underwent two-level, 83 (26.5%) underwent three-level, and 5 (1.6%) underwent four-level surgery. Younger age (P = 0.010), preoperative radiculopathy (P = 0.029), procedure type (ACDF, P < 0.001), preoperative opioid use (P = 0.012), and discharge prescription written by a midlevel provider (P = 0.010) were independently associated with greater discharge opioid prescription volumes. CONCLUSION: We identified wide variability in prescription opioid discharge volumes after ACS and patient, procedure, and perioperative factors associated with greater discharge opioid volumes. These factors should be considered when designing protocols and interventions to reduce and optimize postoperative opioid use after ACS.

Operative spinal trauma: Thromboprophylaxis with low molecular weight heparin or a direct oral anticoagulant.

Essentials Operative spine trauma patients are at increased risk of venous thromboembolism (VTE). Direct oral anticoagulants (DOACs) may have a favorable efficacy and safety in spine trauma. Patients on DOACs had lower rates of VTE in comparison to low molecular weight heparin. DOACs did not augment the risk of surgical bleeding (transfusion, decompressive procedures). BACKGROUND: Spinal trauma patients are at high risk for venous thromboembolism (VTE). OBJECTIVE: To compare the impacts of direct oral anticoagulants (DOACs) and low molecular weight heparin (LMWH) as thromboprophylactic agents on outcomes in operative spinal trauma patients. METHODS: A 2-year (2015-2016) retrospective cohort analysis of such patients (spine Abbreviated Injury Scale [AIS] ≥ 3 and other AIS < 3) who received LMWH or DOACs was performed. Propensity score matching (1:2 ratio) followed stratification into two groups. Outcomes included rates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE), packed red blood cell (pRBC) transfusion, operative interventions for spinal cord decompression, and mortality. RESULTS: Of 6036 patients, 810 (270 receiving DOACs; 540 receiving LMWH) were matched. The mean age was 62 ± 15 years, 58% were male, and the median Injury Severity Score was 12 (10-18). Matched groups were similar in demographics, injury parameters, emergency department vital signs, hospital stay, rates of inferior vena cava filter placement, and timing of initiation of thromboprophylaxis. The overall rate of in-hospital DVT was 5.6%, the overall rate of in-hospital PE was 1.6%, and the mortality rate was 2.5%. DOAC patients were less likely to develop DVT (1.8% vs 7.4%) and PE (0.3% vs 2.1%). There were no differences in postprophylaxis pRBC transfusion requirements, postprophylaxis decompressive procedures on the spinal cord, or mortality. CONCLUSION: In operative spinal trauma patients, thromboprophylaxis with DOACs appears to be associated with lower rates of DVT and PE. Further prospective clinical trials should evaluate the role of DOACs in preventing VTE events in spinal trauma patients.

Postoperative proton therapy for chordomas and chondrosarcomas of the spine: adjuvant versus salvage radiation therapy.

STUDY DESIGN: Retrospective comparative cohort series. OBJECTIVE: The aim of this study was to evaluate patients treated with proton therapy for chordoma and chondrosarcoma of the spine in the postoperative setting and to report local control, relapse-free, and overall survival outcomes. SUMMARY OF BACKGROUND DATA: Margin-negative resection of spinal chordomas and chondrosarcomas can be challenging, so adjuvant radiotherapy is often recommended. However, delivery of adequate radiotherapy is complicated by the relative radioresistance of these tumors, necessitating high doses, as well as the proximity of the spinal cord and exiting nerve roots increasing the risk for toxicity. Proton radiotherapy has favorable physical properties for avoiding nearby nontarget structures and is increasingly used for such lesions. METHODS: Nineteen patients who underwent postoperative proton therapy at a single institution from 2006 to 2012 were identified including 13 with chordoma and 6 with chondrosarcoma. Surgical approach varied by tumor location in the cervical (n = 3), thoracic (n = 1), lumbar (n = 2), or sacral (n = 13) spine. Eight patients were categorized as receiving "early adjuvant" and 11 patients as receiving "salvage" treatment, as determined by initiation of radiation therapy after primary surgery or local recurrence, respectively. The median radiation dose delivered was 70 Gy relative biologic effectiveness (range: 56-78 Gy relative biologic effectiveness). RESULTS: For the entire cohort, 2-year local control, relapse-free survival, and overall survival were 58%, 51.9%, and 93.3%, respectively. The early adjuvant group had significantly higher 2-year local control (80% vs. 45.5%; P = 0.024). CONCLUSION: Patients referred early for primary adjuvant radiation therapy after surgery had higher rates of disease control than those referred for salvage treatment of recurrent disease. Recurrence rates in our cohort were higher overall than other published series, indicating that even higher radiation doses may be helpful for further improving local control in the presence of gross or recurrent disease. LEVEL OF EVIDENCE: 3.

Virtual reality simulators: valuable surgical skills trainers or video games?

BACKGROUND: Virtual reality (VR) and physical model (PM) simulators differ in terms of whether the trainee is manipulating actual 3-dimensional objects (PM) or computer-generated 3-dimensional objects (VR). Much like video games (VG), VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. In this study, we aimed to determine whether a relationship exists between VR, PM, and VG platforms. METHODS: VR and PM simulators for laparoscopic camera navigation ([LCN], experiment 1) and flexible endoscopy ([FE] experiment 2) were used in this study. In experiment 1, 20 laparoscopic novices played VG and performed 0° and 30° LCN exercises on VR and PM simulators. In experiment 2, 20 FE novices played VG and performed colonoscopy exercises on VR and PM simulators. RESULTS: In both experiments, VG performance was correlated with VR performance but not with PM performance. Performance on VR simulators did not correlate with performance on respective PM models. CONCLUSIONS: VR environments may be more like VG than previously thought.