Abdominal aortic calcification is an independent predictor of perioperative blood loss in posterior spinal fusion surgery.

OBJECTIVE: Abdominal aortic calcification (AAC), often found incidentally on lateral lumbar radiographs, is increasingly recognized for its association with adverse outcomes in spine surgery. As a marker of advanced atherosclerosis affecting cardiovascular dynamics, this study evaluates AAC's impact on perioperative blood loss in posterior spinal fusion (PSF). METHODS: Patients undergoing PSF from March 2016 to July 2023 were included. Estimated blood loss (EBL) and total blood volume (TBV) were calculated. AAC was assessed on lateral lumbar radiographs according to the Kauppila classification. Predictors of the EBL-to-TBV ratio (%EBL/TBV) were examined via univariable and multivariable regression analyses, which adjusted for parameters such as hypertension and aspirin use. RESULTS: A total of 199 patients (47.2% female) were analyzed. AAC was present in 106 patients (53.3%). AAC independently predicted %EBL/TBV, accounting for an increase in blood loss of 4.46% of TBV (95% CI 1.17-7.74, p = 0.008). CONCLUSIONS: This is the first study to identify AAC as an independent predictor of perioperative blood loss in PSF. In addition to its link to degenerative spinal conditions and adverse postoperative outcomes, the relationship between AAC and increased blood loss warrants attention in patients undergoing PSF.

Utility of Ultrasound-Guided Erector Spinae Plane Blocks for Postoperative Pain Management Following Thoracolumbar Spinal Fusion Surgery.

Purpose: The primary objective of this study is to determine if ultrasound-guided erector spinae plane blocks (ESPB) prior to thoracolumbar spinal fusion reduces opioid consumption in the first 24 hours postoperatively. Secondary objectives include ESPB effects on administration of opioids, utilization of intravenous patient-controlled analgesia (IV-PCA), pain scores, length of stay, and opioid related side effects. Methods: A retrospective cohort analysis was performed on consecutive, adult patients undergoing primary thoracolumbar fusion procedures. Demographic and baseline characteristics including diagnoses of chronic pain, anxiety, depression, and preoperative use of opioids were collected. Surgical data included surgical levels, opioid administration, and duration. Postoperative data included pain scores, opioid consumption, IV-PCA duration, opioid-related side effects, ESPB-related complications, and length of stay (LOS). Statistical analysis was performed using chi-squared and t-test analyses, multivariable analysis, and covariate adjustment with propensity score. Results: A total of 118 consecutive primary thoracolumbar fusions were identified between October 2019 and December 2021 (70 ESPB, 48 no-block [NB]). There were no significant demographic or surgical differences between groups. Median surgical time (262.50 mins vs 332.50 mins, p = 0.04), median intraoperative opioid consumption (8.11 OME vs 1.73 OME, p = 0.01), and median LOS (152.00 hrs vs 128.50 hrs, p = 0.01) were significantly reduced in the ESPB group. Using multivariable covariate adjustment with propensity score analysis only intraoperative opioid administration was found to be significantly less in the ESPB cohort. Conclusion: ESPB for thoracolumbar fusion can be performed safely in index cases. There was a reduction of intraoperative opioid administration in the ESPB group, however the care team was not blinded to the intervention. Extensive thoracolumbar spinal fusion surgery may require a different approach to regional anesthesia to be similarly effective as ESPB in isolated lumbar surgeries.

Spine surgery under neuraxial vs. general anesthesia: the current state of comparative outcomes research.

PURPOSE OF REVIEW: The impact of primary anesthetic technique on outcomes after spine surgery is controversial. Given frequent calls for well designed prospective comparative studies of neuraxial anesthesia vs. general anesthesia and recent reports of 'awake spine surgery' successes in the surgical literature, an updated evidence review is indicated. RECENT FINDINGS: Systematic reviews, population-based and retrospective cohort studies suggest few significant differences in important complications or global recovery between anesthetic techniques. On the basis of overall low-to-moderate quality evidence, neuraxial anesthesia is associated with statistically significant benefits for several individual outcomes compared with general anesthesia, including improved intraoperative hemodynamic stability, less postoperative nausea and vomiting, lower early pain scores and shorter length of hospital stay. There are ongoing calls for well designed, adequately powered prospective studies. SUMMARY: Our understanding of the risks, benefits and comparative outcomes between neuraxial anesthesia and general anesthesia for spine surgery is evolving. Although the results derived from this body of literature suggest specific benefits of neuraxial anesthesia, further research is required before widespread recommendations for either technique can be made. Until then, both neuraxial anesthesia and general anesthesia are reasonable choices for lumbar spine surgery of short duration, in appropriately selected patients.

Frailty Stratification Using the Modified 5-Item Frailty Index: Significant Variation within Frailty Patients in Spine Surgery.

BACKGROUND: Frailty status has been associated with higher rates of complications after spine surgery. However, frailty patients constitute a heterogeneous group based on the combinations of comorbidities. The objective of this study is to compare the combinations of variables that compose the modified 5-factor frailty index score (mFI-5) based on the number of comorbidities in terms of complications, reoperation, readmission, and mortality after spine surgery. METHODS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database from 2009-2019 was used to identify patients who underwent elective spine surgery. The mFI-5 item score was calculated and patients were classified according to number and combination of comorbidities. Multivariable analysis was used to assess the independent impact of each combination of comorbidities in the mFI-5 score on the risk of complications. RESULTS: A total of 167, 630 patients were included with a mean age of 59.9 ± 13.6 years. The risk of complications was the lowest in patients with diabetes + hypertension (OR = 1.2) and highest in those with the combination of congestive heart failure (CHF), diabetes, chronic obstructive pulmonary disease (COPD), and dependent status (OR = 6.6); there was a high variation in complication rate based on specific combinations. CONCLUSIONS: There is high variability in terms of relative risk of complications based on the number and combination of different comorbidities, especially with CHF and dependent status. Therefore, frailty status encompasses a heterogeneous group and sub-stratification of frailty status is necessary to identify patients with significantly higher risk of complications.

Continuous erector spinae plane catheters leading to unwanted neuraxial spread after spinal fusion surgery: a report of two cases from a terminated prospective randomized clinical trial.

BACKGROUND: Erector spinae plane blocks are used to improve outcomes after spine surgery, but pain frequently outlasts the duration of single injection blocks. We hypothesized continuous erector spinae plane (cESP) catheters would provide superior analgesia. We terminated a prospective double-blinded randomized clinical trial (RCT) comparing outcomes after multilevel spine surgery among patients randomized to saline versus ropivacaine cESP catheters. We present two cases of undesired epidural spread of ropivacaine and discuss etiology, management, and future research directions. CASE PRESENTATION: Nine out of 44 patients (planned) enrolled in the RCT; 6/9 were randomized to receive ropivacaine infusions via bilateral cESP catheters. Two patients underwent uncomplicated posterior lumbar fusion and were recovering well with minimal pain and opioid requirements through postoperative day 1. Both had new-onset urinary retention and bilateral lower extremity numbness, weakness and paresthesias (24 and 30 hours after infusion-start time, respectively). One patient underwent MRI, which was remarkable for an epidural fluid collection compressing the thecal sac. Infusions were stopped, cESP catheters were removed and symptoms fully resolved over the next 3-5 hours. CONCLUSIONS: Unwanted neuraxial spread of local anesthetic from cESP catheters may be a unique consideration after spine surgery, accounted for by unpredictable local anesthetic distribution within disrupted surgical planes. Future studies are indicated to determine optimal catheter regimens together with guidance for extended monitoring in parallel with further studies of efficacy in spine surgery cohorts. TRIAL REGISTRATION NUMBER: NCT05494125.

Up to 10-year surveillance comparison of survivability in single-level cervical disc replacement versus anterior cervical discectomy and fusion in New York.

OBJECTIVE: Cervical disc replacement (CDR) is an alternative treatment to anterior cervical discectomy and fusion (ACDF), which is the current gold standard, for degenerative cervical diseases such as cervical spondylotic myelopathy and cervical radiculopathy. CDR has several theoretical benefits over ACDF, including preservation of motion, earlier return to unrestricted activity, and potentially a lower risk of adjacent-segment disease. Recent literature has reported positive clinical results for CDR, but few studies have investigated the long-term risk of revision surgery of CDR versus ACDF. The purpose of this study was to identify and analyze the epidemiological, clinical, and operative risk factors that affect revision rates following single-level CDR and ACDF procedures. METHODS: A retrospective cohort was extracted from the Statewide Planning and Research Cooperative System using ICD-9 and CPT codes. Inclusion criteria were adult patients undergoing primary, subaxial (C3-7), single-level ACDF or CDR for cervical radiculopathy and/or cervical spondylotic myelopathy between 2005 and 2013. Survivability was defined as the time between the index procedure and the presence of a subsequent discharge record for cervical spinal fusion or disc replacement. Statistical analyses were performed using chi-square tests, t-tests, Cox proportional hazards models, and a Kaplan-Meier plot. RESULTS: A total of 7450 patients were included in this study (6615 ACDF and 835 CDR). When adjusted for patient demographics, the hazard ratios showed no significant differences in the incidence of revision risk between the two cohorts. The CDR cohort had a higher incidence of postoperative dysphagia (p < 0.05). Patients undergoing ACDF had a longer average hospital stay (2.8 vs 1.9 days, p < 0.001). There was no significant difference in time to revision surgery (p = 0.486). CONCLUSIONS: CDR and ACDF have both been shown to be effective treatments for cervical spine disease. CDR patients had a shorter average inpatient hospital stay compared with ACDF patients but tended to experience dysphagia more frequently. There was a tendency toward increased survivability of CDR; however, this was not found to be statistically significant at any time point. The large size and heterogeneity of each cohort and the availability of > 10 years of surveillance data differentiate this study from other published literature. This investigation has limitations inherent to large data analysis studies, including the implementation and inaccuracy of diagnosis and procedural coding; however, this reflects real-world use of coding by practitioners.

Association of Frailty and Preoperative Hypoalbuminemia with the Risk of Complications, Readmission, and Mortality After Spine Surgery.

BACKGROUND: Frailty status and hypoalbuminemia have been associated with higher rates of complications after spine surgery. However, the combination of both conditions has not been fully analyzed. The objective of this study was to assess the effect of frailty and hypoalbuminemia on the risk of complications after spine surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2009 to 2019 was used. Frailty status was calculated using the modified 5-item frailty index (mFI-5). Patients were classified into nonfrail (mFI = 0), pre-frail (mFI = 1), and frail (mFI ≥2) groups and also based on albumin levels into normal (≥3.5 g/dL) and hypoalbuminemia groups (<3.5 g/dL). The latter group was also subclassified into mild and severe hypoalbuminemia groups. Multivariable analysis was used. A Spearman ρ correlation between albuminemia and mFI-5 was also performed. RESULTS: A total of 69,519 patients (36,705 men [52.8%] and 32,814 women [47.2%]) with a mean age of 61.0 ± 13.2 years were included. Patients were classified as nonfrail (n = 24,897), pre-frail (n = 28,897), and frail groups (n = 15,725). Hypoalbuminemia was significantly higher in the frail group (11.4%) compared with the nonfrail group (4.3%). An inverse correlation was observed between albumin levels and frailty status (ρ = -0.139; P < 0.0001). Frail patients with severe hypoalbuminemia had significantly higher risk of complications (odds ratio [OR], 5.0), reoperation (OR, 3.3), readmission (OR, 3.1), and mortality (OR, 31.8) compared with patients without hypoalbuminemia. CONCLUSIONS: The combination of frailty and hypoalbuminemia significantly increases the risk of complications after spine surgery. The prevalence of hypoalbuminemia in the frailty group was significantly higher than in nonfrail patients (11.4% vs. 4.3%). Both conditions should be evaluated preoperatively.

Comparative effectiveness of anesthetic technique on outcomes after lumbar spine surgery: a retrospective propensity score-matched analysis of the National Surgical Quality Improvement Program, 2009-2019.

BACKGROUND: The impact of anesthetic technique on spine surgery outcomes is controversial. Using a large national sample of patients, we compared outcomes after lumbar decompression under regional anesthesia (RA: spinal or epidural) or general anesthesia (GA). METHODS: A retrospective population-based study of American College of Surgeons National Surgical Quality Improvement Program data (2009-2019). Patients were propensity score (PS) matched 3:1 (GA:RA) on demographic and surgical variables. The primary outcome was the association between anesthetic type and any complication (cardiac, pulmonary, renal, transfusion, stroke, infectious, deep vein thrombosis/pulmonary embolus). Secondary outcomes included the association between anesthetic type and individual complications, readmission and length of stay (LOS). Unadjusted comparisons (OR, 95% CI), logistic regression and adjusted generalized linear modeling (parameter estimate, PE, 95% CI) were performed before and after PS matching. RESULTS: Of 1 51 010 cases, 149 996 (99.3%) were performed under GA, and 1014 (0.67%) under RA. After matching, 3042 patients with GA were compared with 1014 patients with RA. On unadjusted analyses, RA was associated with lower odds of complications (OR 0.43, 0.3 to 0.6, p<0.001), shorter LOS (RA: 1.1±3.8 days vs GA: 1.3±3.0 days; p<0.001) and fewer blood transfusions (RA: 3/1014, 0.3% vs GA: 40/3042, 1.3%; p=0.004). In adjusted analyses, RA was associated with fewer complications (PE -0.43, -0.81 to -0.06, p=0.02) and shorter LOS (PE -0.76, -0.90 to -0.63, p<0.001). There was no significant association between anesthetic type and readmission (PE -0.34, -0.74 to 0.05, p=0.09). CONCLUSIONS: Compared with GA, RA was associated with fewer complications, less blood transfusion and shorter LOS after spine surgery. Although statistically significant, the magnitude of effects was small and requires further prospective study.

Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial.

BACKGROUND: Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS: This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS: Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS: Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

Intraoperative Methadone and Short Stay Spine Surgery: Possible Barriers to Implementation and Future Opportunities.

The frequency of shorter stay spine surgery is increasing. Acute pain is a common barrier to discharge following spine surgery. Long-acting opioid medications like methadone have the potential to provide sustained analgesia when given intraoperatively. Methadone has been effectively used in complex spine surgery, cardiac surgery, and more recently applied to ambulatory procedures. In this article, we summarize the pertinent available literature on the use of intraoperative methadone for spine surgery as well as the recent data on intraoperative methadone for ambulatory surgery. The aim of this perspectives article is to describe the potential opportunities for applying intraoperative methadone to shorter stay spine surgery as well as barriers to more widespread use. While there are currently no trials that have specifically studied methadone for shorter stay spine surgery specifically to date, it is a promising area for future research.

Ultrasound-guided fascial plane blocks for spine surgery.

PURPOSE OF REVIEW: The development of truncal and fascial plane blocks has created novel opportunities to apply regional analgesic techniques to patients undergoing spine surgery. This review will summarize recent literature devoted to evaluating candidate blocks for spine surgery, including erector spinae plane block, thoracolumbar interfascial plane block, midpoint transverse process to pleura block, and transversus abdominis plane block. Procedure-specific effects of blocks on patient and healthcare system outcomes will be presented and gaps in care and knowledge will be highlighted. RECENT FINDINGS: The most studied paradigm was bilateral erector spinae plane block for lumbar spine surgery. The most common outcomes assessed were early postoperative pain scores, opioid consumption and related side effects, and length of hospital stay. All candidate blocks were associated with mixed evidence for analgesic and opioid-sparing benefits, and/or reductions in length of hospital stay. The magnitude of these effects was overall small, with many studies showing statistically but not clinically significant differences on outcomes of interest. This may reflect, at least in part, the current state of the (emerging) evidence base on this topic. SUMMARY: Our understanding of the risks, benefits, and value of truncal and fascial plane blocks for spine surgery cohorts is evolving. Although the results derived from this body of literature are encouraging, further research is required before the widespread adoption of specified blocks into spine care can be recommended.

Surgeon-Placed Erector Spinae Plane Catheters for Multilevel Lumbar Spine Fusion: Technique and Outcomes Compared With Single-Shot Blocks.

BACKGROUND: Postoperative pain management of multilevel lumbar fusion remains challenging. There are few reports of opioid-sparing regional analgesia for spine surgery. We present a novel method for surgeon-placed erector spinae plane (ESP) catheters for multilevel lumbar spine fusion and compare pain- and opioid-related outcomes in a matched cohort who received anesthesiologist-placed ESP blocks. METHODS: A retrospective matched pilot study of 18 patients: 6 received intraoperative, bilateral ESP catheters. Tunneled catheters were placed under the intact ESP at the proximal end of the incision. Continuous infusions of ropivacaine (0.2%) were started in the postanesthesia care unit (PACU) after emergence from anesthesia and maintained for 48 hours. Catheter patients were matched 1:2 with 12 patients who received preincision single-shot ESP blocks administered by an anesthesiologist, according to age, gender, American Society of Anesthesiologists class, body mass index, and number of spinal levels fused. All patients were provided opioid intravenous patient-controlled analgesia (IV-PCA). Numeric rating scale pain scores (NRS, 0-10), length of stay (LOS), opioid consumption (oral morphine equivalents, mg), opioid side effects, and complications (motor weakness, local anesthetic toxicity, infection, technical issues, and failure), were compared in the PACU and on the nursing floor. RESULTS: Only 1/6 patients with ESP catheter used opioid IV-PCA, compared with 11/12 who received ESP blocks. There were no differences in total opioid consumption (catheters: 135 ± 141 mg; blocks: 183 ± 112 mg; P = 0.448) or median (interquartile range) LOS (catheters: 73 [50,107] hours; blocks: 90 [72,116] hours, P = 0.708). NRS pain was significantly higher in the PACU after ESP catheters (5.9 ± 1.7) vs ESP blocks (3.3 ± 2.4; P = 0.036), but no differences were found at later timepoints (5.0 ± 1.6 vs 4.3 ± 1.1, respectively; P = 0.383). No catheter-related complications were found. CONCLUSION: Surgeon-placed ESP catheters represent a simple technique to provide regional analgesia, particularly in centers lacking regional anesthesiology services. Risks, benefits, and efficacy compared to other techniques require prospective study.

Longitudinal Trends of Patient Demographics and Morbidity of Different Approaches in Lumbar Interbody Fusion: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program Database.

OBJECTIVE: The aims of this study were to determine the time trend of demographics, complications, and outcomes for patients undergoing posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF) or anterior lumbar interbody fusion/lateral lumbar interbody fusion (ALIF/LLIF) and to compare the differences in the time trends between both procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing PLIF/TLIF and ALIF/LLIF procedures. Outcomes were analyzed for differences between 2 time periods in the PLIF/TLIF and ALIF/LLIF cohorts separately (2009-2013 and 2015-2019). Longitudinal time trends of the 2 procedures were determined by difference-in-differences (DID) analysis. Statistical significance was defined as P < 0.05. RESULTS: For both approaches, there was an increase in age and American Society of Anesthesiologists class over time, accompanied by a significant decrease in blood transfusions and morbidity. The DID analysis showed a greater change in age (DID:-1.8%; P < 0.001), and more patients were rated American Society of Anesthesiologists class 3 (DID: -2.4%; P = 0.033) in the ALIF/LLIF cohort than in the PLIF/TLIF cohort. Length of stay declined significantly over time in both cohorts, with a greater reduction observed for patients who underwent ALIF/LLIF than for patients who underwent PLIF/TLIF (DID: 0.2%; P = 0.014). There were no changes in readmission rates over time in either cohort (PLIF/TLIF DID: 0.6%; P = 0.080; ALIF/LLIF DID: -0.2%; P = 0.696). CONCLUSIONS: Time trends for PLIF/TLIF and ALIF/LIIF showed a significant increase in the number of older patients with complex medical status undergoing surgery. Despite these trends, there were decreases in overall postoperative morbidity, incidence of blood transfusion, and length of stay, without increasing readmission. These results suggest general improvement in surgical and perioperative management of lumbar fusion over time with greater gains found in ALIF/LLIF-specific care than in PLIF/TLIF.

Hip and Knee Arthroplasty.

Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases.

Purpose: Presumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery. Patients and Methods: We included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018-July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration). Results: We did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed. Conclusion: Ultrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients.

OBJECTIVE: Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS: The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. RESULTS: In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS: A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Impact of ultrasound-guided erector spinae plane block on outcomes after lumbar spinal fusion: a retrospective propensity score matched study of 242 patients.

BACKGROUND: We evaluated the impact of bilateral ultrasound-guided erector spinae plane blocks on pain and opioid-related outcomes within a standardized care pathway for lumbar fusion. METHODS: A retrospective propensity score matched cohort study. Clinical data were extracted from the electronic medical records of patients who underwent lumbar fusion (January 2019-July 2020). Propensity score matching based on common confounders was used to match patients who received or did not receive blocks in a 1:1 ratio. Primary outcomes were Numeric Rating Scale pain scores (0-10) and opioid consumption (morphine equivalent dose) in the first 24 hours after surgery (median (IQR)). Secondary outcomes included length of stay and opioid-related side effects. RESULTS: Of 1846 patients identified, 242 were matched and analyzed. Total 24-hour opioid consumption was significantly lower in the erector spinae plane block group (30 mg (0, 144); without-blocks: 45 mg (0, 225); p=0.03). There were no significant differences in pain scores in the postanesthesia care unit (with blocks: 4 (0, 9); without blocks: 4 (0,8); p=0.984) or on the nursing floor (with blocks: 4 (0,8); without blocks: 4 (0,8); p=0.134). Total length of stay was 5 hours shorter in the block group (76 hours (21, 411); without blocks: 81 (25, 268); p=0.001). Fewer patients who received blocks required postoperative antiemetic administration (with blocks: n=77 (64%); without blocks: n=97 (80%); p=0.006). CONCLUSIONS: Erector spinae plane blocks were associated with clinically irrelevant reductions in 24-hour opioid consumption and no improvement in pain scores after lumbar fusion. The routine use of these blocks in the setting of a comprehensive care pathway for lumbar fusion may not be warranted.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.