C5 nerve root palsy (without prior cervical decompression) case series: 9 patients with critical delay to presentation.

BACKGROUND: Distinguishing between cervical nerve root and intrinsic shoulder pathology can be a difficult task given the overlapping and often coexisting symptoms. OBJECTIVE: The objective of this study was to highlight the often-complicated presentation of these symptoms and the subsequent potential for delay in care regarding this subset of patients. METHODS: A total of 9 patients, managed by one of two different surgeons, were identified with a history of C5 nerve root palsy. A chart review was conducted, and the following information was recorded: presenting complaint, time from symptom onset to diagnosis, time from symptom onset to presentation to a spine surgeon, first specialist seen for symptoms, non-spinal advanced imaging and treatment conducted before diagnosis, preoperative and postoperative exam, time to recovery, and type of surgery. RESULTS: We observed an average time from onset of symptoms to presentation to a spine surgeon to be 31.6 weeks. These patients' time to full recovery after cervical decompression was 15 weeks. CONCLUSION: : We observed a critical delay to presentation in this series of patients with C5 nerve palsy. C5 nerve palsy should remain an elemental part of the differential diagnosis in the setting of any shoulder or neck pain presenting with weakness.

Cannabis use is associated with decreased opioid prescription fulfillment following single level anterior cervical discectomy and fusion (ACDF).

Background: Recently, there has been increasing legalization of marijuana within the United States, however data are mixed with respect to its efficacy in treating acute pain. Our goal was to identify a difference in opioid utilization in patients with known cannabis use before anterior cervical discectomy and fusion (ACDF) compared with those that report no cannabis use. Methods: This study was a retrospective case-control design using PearlDiver. Patients who underwent a single level ACDF between January 2010 and October 2020, were included. Patients were placed in the study group if they had a previous diagnosis of cannabis use, dependence, or abuse. Patients were excluded if they were under the age of 18 or if they had filled an opioid prescription within 3 months of their procedure. A control group was then created using a propensity score match on age, gender, and Charleston comorbidity index (CCI), and had no diagnosis of cannabis use. The primary outcome was the number of morphine milliequivalents (MME) dispensed per prescription following surgery. Results: A total of 1,339 patients were included in each group. The number of patients filling prescriptions was lower in the cannabis group than in the control group at 3 days postoperatively (p<.001). The average total MME per day as prescribed was lower in the cannabis group than the control group at 60 days post-op (48.5 vs. 59.4, respectively; p=.018). Conclusions: Patients who had a previous diagnosis of cannabis use, dependence or abuse filled fewer opioid prescriptions postoperatively (at 3 days postoperatively) and required lower doses (reduced average daily MME, at 60 days postoperatively) when compared with the control group.

Acetabular fixation in total hip arthroplasty in the previously irradiated pelvis: a review of basic science and clinical outcomes.

Radiation therapy is a common primary, adjuvant, or palliative treatment for many intrapelvic tumors, including primary gastrointestinal, genitourinary, and hematopoietic tumors, as well as metastatic disease to bone. Radiation has well documented microbiologic and clinical effects on bone ranging from radiation osteitis to early degenerative changes of the hip joint and avascular necrosis of the femoral head. Conventional total hip arthroplasty methods have demonstrated high rates of failure in this population, with historical data describing aseptic loosening rates as high as 44-52%, as radiation have been shown to preferentially diminish osteoblast and osteocyte number and function and limit capacity for both cement interdigitation and biologic bony ingrowth. A review of the clinical literature suggests that patients with prior pelvic irradiation are at higher risk for both septic and aseptic loosening of acetabular components, as well as lower postoperative Harris Hip Score (HHS) when compared to historical controls. With limited evidence, trabecular metal shells with multi-screw fixation and cemented polyethene liners, as well as cemented cup-cage constructs both appear to be durable acetabular fixation options, though the indications for each remains elusive. Further prospective data are needed to better characterize this difficult clinical problem.

Does a relationship exist between preoperative expectations and overall satisfaction in spine surgery patients?-a prospective cohort study.

Background: The role of preoperative patient expectation in spine surgery is not completely understood, but could be essential in predicting patient outcomes. The purpose of this study was to create a standard means to assess patient preoperative expectations and its effect on postoperative satisfaction in the midterm follow-up period. Methods: This is a prospective cohort study design. Forty-five patients undergoing elective cervical or lumbar spine surgery were asked to participate in the study. Using a 10 cm visual analog scale (VAS) score, patients were asked to rate their preoperative pain along with what they expect it to be after surgery. Pre- and postoperative Oswestry Disability Index (ODI) and Neck Disability Index (NDI) were recorded. Overall satisfaction with surgery was recorded along with if they would have surgery again. The patients' preoperative expectations were compared to their postoperative ODI/NDI scores at terminal follow-up around 1 year. Postoperative satisfaction was also correlated as to whether they would have surgery again. Results: Patients who would have surgery again had an average expected decrease in their disability by 37 (±23) compared to 26 (±19) in patients who would not (P=0.201). For patients who would have surgery again, their postoperative pain more closely matched their preoperative expectations. Conclusions: In conclusion, the authors found that patients who were satisfied with their spine surgery improved functionally to a much greater degree from baseline, tended to have higher expectations with regards to level of disability improvement, and had lower expectations with regards to improvement in neck/back pain.

Implementing a Postoperative Opioid-Prescribing Protocol Significantly Reduces the Total Morphine Milligram Equivalents Prescribed.

BACKGROUND: Opioid-prescribing patterns have been implicated as a contributing factor to the opioid epidemic, yet few evidence-based guidelines exist to assist health-care providers in assessing and possibly modifying their prescribing practices. METHODS: Five orthopaedic hand surgeons at a level-I trauma center developed a postoperative prescribing guideline for 25 common hand and upper-extremity outpatient procedures, which were delineated into 5 tiers. Postoperative opioid prescriptions in a 3-month period after implementation of the protocol were compared with those from a 3-month period before implementation of the protocol. RESULTS: There were 231 patients in the pre-implementation group and 287 patients in the post-implementation group. Each individual opioid protocol tier showed a significant decrease in the mean morphine milligram equivalents (MME) prescribed, ranging from a minimum decrease of 97.8% to a maximum decrease of 176.0%. After implementation, adherence to protocol was achieved in 55.1% of patients; the MME amounts prescribed were below protocol for 28.6% and above for 16.4%. The number of additional opioid prescriptions in the 1-month postoperative period was significantly less in the post-implementation group than in the pre-implementation group (p < 0.001). The total number of pills prescribed was reduced by a theoretical equivalent of over three thousand 5-mg oxycodone pills for the 287 patients in the 3-month period. CONCLUSIONS: By utilizing a simple consensus protocol, we have demonstrated success diminishing the number of opioids prescribed without leading to an increase in the number of secondary prescriptions written by our providers. These findings are encouraging and suggest that fewer opioids were left in the possession of patients, leaving fewer pills vulnerable to misuse, abuse, and diversion.