Inconsistency and Ambiguity Within the International Classification of Disease 10 Procedure Coding System for Hip Fractures.

BACKGROUND: The International Statistical Classification of Diseases (ICD), 10th Revision Procedure Coding System (PCS) was created to increase the granularity of procedural coding. These codes are entered by hospital coders from information derived from the medical record. Concern exists that this increase in complexity could lead to inaccurate data. METHODS: Medical records and ICD-10-PCS codes were reviewed for operatively treated geriatric hip fractures from January 2016 through February 2019 at a tertiary referral medical center. Definitions for each of the 7-unit figures from the 2022 American Medical Association's ICD-10-PCS official codebook were compared to the medical, operative, and implant records. RESULTS: There were 56% (135 of 241) of PCS codes that had ambiguous, partially incorrect, or frankly incorrect figures within the code. One or more inaccurate figures were noted in 72% (72 of 100) of fractures treated with arthroplasty compared to 44.7% (63 of 141) treated with fixation (P < .01). There was at least 1 frankly incorrect figure contained in 9.5% (23 of 241) of codes. Approach was coded ambiguously for 24.8% (29 of 117) of pertrochanteric fractures. Device/implant codes were partially incorrect in 34.9% (84 of 241) of all hip fracture PCS codes. Hemi and total hip arthroplasties were partially incorrect in 78.4% (58 of 74) and 30.8% (8/26) of device/implant codes, respectively. Significantly more femoral neck (69.4%, 86 of 124) than pertrochanteric fractures (41.9%, 49 of 117) had 1 or more incorrect or partially correct figures (P < .01). CONCLUSION: Despite the increased granularity of ICD-10-PCS codes, the application of this system is inconsistent and often incorrect when applied to hip fracture treatments. The definitions in the PCS system are difficult to be utilized by coders and do not reflect the operation performed.

Extensor Mechanism Disruption Remains a Challenging Problem.

BACKGROUND: Extensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking. METHODS: Patients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan-Meier curves, and factors for success were determined with logistic regressions. RESULTS: Of fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion. CONCLUSIONS: This multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects.

PURPOSE: Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor. METHODS: Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW. RESULTS: Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW. CONCLUSIONS: In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

A Multidisciplinary Transitional Pain Management Program Is Associated With Reduced Opioid Dependence After Primary Total Joint Arthroplasty.

BACKGROUND: Overprescription of opioids after total joint arthroplasty (TJA) increases risks of opioid dependence, overdose, and death. The authors hypothesized that a multidisciplinary, perioperative pain management program (the Transitional Pain Service or TPS) for TJA would lead to fewer patients becoming opioid dependent. METHODS: A TPS was implemented at a Veterans Affairs Medical Center focused on nonopioid pain management, cessation support, and prospective data tracking. A historical control, interventional study design was used to assess opioid use at 90 days post-discharge. Secondary analysis of the implementation group included post-operative outcome scores, time to opioid cessation, and median opioid tablets consumed at 90 days. RESULTS: Fewer patients in the TPS group demonstrated persistent opioid use at 90 days post-discharge (0.7% vs 9.9%; P = .004). Independent predictors of total opioid tablet prescriptions included TPS (ß = -19.41; 95% confidence interval [CI] -35.37 to -3.47), number of tablets prescribed at discharge (ß = 1.08; 95% CI 0.86-1.31), and TKA surgery (ß = 16.84; 95% CI 4.58-29.10). Under the TPS, median tablets consumed was 20.5 for THA and 36.5 for TKA; median time to cessation was shorter in THA (7 days; 95% CI 2-10) when compared to TKA (13 days; 95% CI 11-16). CONCLUSION: In opioid-naïve veterans undergoing TJA, the TPS was associated with a 93% reduction in opioid dependence and a 60% reduction in opioid tablet prescriptions at 90 days post-discharge. Under the TPS, median 90-day opioid consumption was 20.5 and 36.5 tablets for THA and TKA, respectively. Widespread adoption of similar programs may greatly reduce opioid use and dependence in orthopedic patients nationally. LEVEL OF EVIDENCE: III.

The Impact of Smoking in Workers' Compensation Patients Receiving Spinal Cord Stimulation.

The objective of this study was to determine the impact of smoking on clinical outcomes in workers' compensation (WC) patients receiving spinal cord stimulation (SCS). One hundred and ninety-six patients from the Ohio Bureau of Workers' Compensation were identified who received SCS with implantation occurring between 2007-2012. Patients were divided into smokers (n = 120) and nonsmokers (n = 76). Population characteristics before and after implantation were analyzed between the two groups. A multivariate logistic regression was run to determine predictors of return to work (RTW) status. Our regression determined smoking (p = 0.006; odds ratio [OR] = 0.260) and body mass index (p = 0.036; OR = 0.905) to be negative predictors of RTW status. After implantation, smokers were less likely to RTW after 6 months and had higher pain scores after 6 and 12 months. Both smokers and nonsmokers had significance reductions in opioid use after SCS implantation. (Journal of Surgical Orthopaedic Advances 30(3):185-189, 2021).

The Role of Antiseptic Irrigation Solutions and Topical Antibiotics in Total Joint Arthroplasty.

Prosthetic joint infections (PJI) are devastating complications. Antiseptic irrigation fluids have shown promising in vitro results in eradicating planktonic bacteria and decreasing biofilm burden. Topical antibiotics, specifically vancomycin, represents another potentially cost-effective way to prevent acute postoperative PJI. We provide a review of the current literature and recommendations on these measures. Overall, a current lack of high-powered, prospective studies exists to definitively support the use of any specific antiseptic solution or topical antibiotic in primary or revision total joint arthroplasty. Some studies support the use of dilute povidone-iodine lavage when combined with vancomycin powder. Data also exists to support the cost effectiveness of povidone-iodine, with the necessary risk reduction to justify its cost. Contradictory evidence exists demonstrating no differences in PJI rates with these measures and possibly higher rates of aseptic wound complications associated with vancomycin power. Further study is warranted. (Journal of Surgical Orthopaedic Advances 30(4):226-230, 2021).

Time to Surgery Affects Return to Work Rates for Workers' Compensation Patients With Single-Level Lumbar Disk Herniation.

The optimal timing of lumbar diskectomy in patients with lumbar disk herniation and radiculopathy has not been studied in the workers' compensation (WC) population. A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disk herniation between 2005 and 2012. The primary outcome was whether subjects return to work (RTW). To determine the impact time to surgery had on RTW status, the authors performed a multivariate logistic regression analysis. They compared other secondary outcomes using chi-square and t tests. The authors identified 1287 WC patients with single-level disk herniation and radiculopathy. Average time from injury to surgery was 364 days (range, 2-2710 days). The WC patients with shorter duration of radiculopathy before diskectomy had higher RTW rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses (P<.05). A multivariate logistic regression model showed that time to surgery was an independent, negative predictor of RTW (odds ratio [OR], 0.97 per month; P<.01). Legal representation (OR, 0.56; P<.01), psychological comorbidity (OR, 0.32; P=.01), and mean household income (OR, 1.01 per $1000; P<.01) also significantly affected RTW status. These results confirm that the duration of radiculopathy due to single-level lumbar disk herniation has a predictive value for the WC population undergoing diskectomy. Within 12 weeks of injury, post-diskectomy patients do reasonably well, with 70.0% of subjects returning to work. [Orthopedics. 2021;44(1):e43-e49.].

Displaced Femoral Neck Fractures in Workers' Compensation Patients Aged 45-65 Years: Is It Best to Fix the Fracture or Replace the Joint?

BACKGROUND: Optimal surgical management of displaced femoral neck fractures (dFNFs) in subjects 45-65 years old is unclear. We evaluated days out of work (dOOW), medical and indemnity costs, and secondary outcomes at 2 years between internal fixation (IF), hemiarthroplasty (HA), and total hip arthroplasty (THA) among workers' compensation (WC) subjects with isolated dFNFs aged 45-65. METHODS: We retrospectively identified 105 Ohio Bureau of WC subjects with isolated subcapital dFNFs aged 45-65 with 2 years of follow-up. In total, 37 (35.2%) underwent IF, 23 (21.9%) THA, and 45 (42.9%) HA from 1993 to 2017. Linear regression was used to determine if surgery type was predictive of dOOW postoperatively and to evaluate inflation-adjusted net medical and indemnity costs at 2 years. RESULTS: IF subjects were younger (52.9) than THA (58.5, P < .001) and HA (58.4, P < .001) subjects. Mean dOOW for THA subjects at 6 months, 1 year, and 2 years was 90.8, 114.6, and 136.6. This was significantly lower than IF (136.3, 182.0, 236.6) and HA (114.6, 153.3, 247.6) subjects at all time points. Medical costs were similar. Mean indemnity costs were 3.0 and 2.4 times higher among IF (P < .001) and HA (P = .007) groups compared to THA, respectively. Rates of postoperative permanent disability awards were 13.0%, 43.2%, and 35.6% for the THA, IF, and HA groups (P = .050). IF and HA subjects had a 24.3% and 11.1% revision rate. Overall, 77.8% and 100% of the IF and HA revisions were conversions to THA. CONCLUSION: WC subjects aged 45-65 with dFNFs treated with THA had fewer dOOW, lower indemnity costs, and less disability at 2 years. Longer follow-up will help determine the durability and long-term outcomes of these surgeries.

Shorter Time to Surgery Is Associated With Better Outcomes for Spondylolisthesis in the Workers' Compensation Population.

This study sought to determine the impact of time to surgery on clinical outcomes in patients with spondylolisthesis in the workers' compensation (WC) population. There is conflicting evidence regarding the effect of time to surgery on patients with spondylolisthesis. Patients receiving WC are known to have worse outcomes following spine surgery compared with the general population. A total of 791 patients from the Ohio Bureau of Workers' Compensation were identified who underwent lumbar fusion for spondylolisthesis between 1993 and 2013. The patients were divided into those who had surgery within 2 years of injury date and after 2 years. Confounding factors were corrected for in a multivariate logistic regression to determine predictors of return to work (RTW) status. Multivariate logistic regression determined that longer time to surgery (P=.003; odds ratio, 0.89 per year), age at index fusion (P=.003; odds ratio, 0.98 per year), and use of physical therapy before fusion (P=.008; odds ratio, 0.54) were negative predictors of RTW status. Patients who had surgery within 2 years were more likely to RTW and have fewer days absent from work, lower medical costs, and fewer sessions of psychotherapy, physical therapy, and chiropractor care. The authors demonstrated that for WC patients with spondylolisthesis, longer time to surgery was a negative predictor of RTW status. Patients who had surgery within 2 years of injury date were significantly more likely to RTW compared with after 2 years. [Orthopedics. 2020;43(3):154-160.].

Multilevel Lumbar Fusion Is a Risk Factor for Lower Return to Work Rates Among Workers' Compensation Subjects With Degenerative Disc Disease.

Discogenic fusion is associated with variable outcomes, especially if multiple levels are fused. This study sought to determine the impact of fused levels on return to work (RTW) status in a workers' compensation (WC) setting. Nine hundred thirty-seven subjects were selected for study. The primary outcome was the ability to RTW within 2 years following fusion and to sustain this level for greater than 6 months. Many secondary outcomes were collected. A multivariate logistic regression model was used to determine the impact of multilevel fusion on RTW status. Of the multilevel fusion group, 21.7% met the RTW criteria versus 28.1% of the single-level fusion group (p < .028). Multilevel fusion was a negative predictor of RTW status (p < .041; OR 0.71). Additional negative predictors included prolonged time out of work, male gender, chronic opioid analgesia, and legal representation. Multilevel fusion led to poor clinical outcomes while overall RTW rates were low, which suggests a limited role of discogenic fusion within the WC setting. (Journal of Surgical Orthopaedic Advances 27(3):209-218, 2018).

Lumbar Discography Is Associated With Poor Return to Work Status Following Lumbar Fusion Surgery in a Workers' Compensation Setting.

Lumbar discography (LD) is used to guide surgical decision making in patients with degenerative disc disease (DDD). Its safety and diagnostic accuracy are under contention. This study evaluates LD's efficacy within the workers' compensation (WC) population. Multivariate logistic regression analysis was used to determine the impact that undergoing LD before lumbar fusion for DDD had on return to work (RTW) rates among 1407 WC subjects. Discography was negatively associated with RTW status (p = .042; OR 0.76); 22.2% (142/641) of LD subjects met the RTW criteria, compared with 29.6% (227/766) of controls. Additional preoperative risk factors included psychological comorbidity (p < .001; OR 0.34), age greater than 50 (p < .005; OR 0.64), male gender (p < .037; OR 0.75), chronic opioid use (p < .001; OR 0.53), legal representation (p < .034; OR 0.72), and fusion technique (p < .043). LD subjects used postoperative narcotics for an average of 123 additional days (p < .001). This raises concerns regarding the utility of discography in the WC population. (Journal of Surgical Orthopaedic Advances 27(1):25-32, 2018).

Preoperative Opioid Use: A Risk Factor for Poor Return to Work Status After Single-level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective comparative case-control study. OBJECTIVES: The objectives of this study are: (1) How preoperative opioid use impacts RTW status after single-level cervical fusion for radiculopathy? and (2) What are other postsurgical outcomes affected by preoperative opioid use? SUMMARY OF BACKGROUND DATA: Opioid use has increased significantly in the past decade. The use of opioids has a drastic impact on workers' compensation population, an at-risk cohort for poorer surgical and functional outcomes than the general population. METHODS AND MATERIALS: Data was retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011. The study population included patients who underwent single-level cervical fusion for radiculopathy as identified by current procedural terminology codes and International Classification of Diseases-9 codes. On the basis of opioid use before surgery, two groups were constructed (opioids vs. non-opioids). Using a multivariate logistic regression model, the effect of preoperative opioid use on return to work (RTW) status after fusion was analyzed and compared between the groups. RESULTS: In the regression model, preoperative opioid use was a negative predictor of RTW status within 3-year follow-up after surgery. Opioid patients were less likely to have stable RTW status [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.38-0.65; P=0.05] and were less likely to RTW within the first year after surgery (OR, 0.50; 95% CI, 0.37-0.66; P=0.05) compared with controls. Stable RTW was achieved in 43.3% of the opioids group and 66.6% of control group (P=0.05). RTW rate within the first year after fusion was 32.5% of opioids group and 57% of control group (P<0.05).Reoperation and permanent disability rates after surgery were higher in the opioid group compared with the control group (P<0.05). CONCLUSIONS: In a workers' compensation, patients with work-related injury who underwent single-level cervical fusion for radiculopathy and received opioids before surgery had worse RTW status, a higher reoperation rate, and higher rate of awarded permanent disability after surgery.

Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD). SUMMARY OF BACKGROUND DATA: The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. METHODS: Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). RESULTS: Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. CONCLUSION: Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. LEVEL OF EVIDENCE: 3.

The Timing of Surgery Affects Return to Work Rates in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The objective of this study is to determine how time to surgery affects outcomes for degenerative lumbar stenosis (DLS) in a workers' compensation (WC) setting. SUMMARY OF BACKGROUND DATA: WC subjects are known to be a clinically distinct population with variable outcomes following lumbar surgery. No study has examined the effect of time to surgery in this clinically distinct population. MATERIALS AND METHODS: A total of 227 Ohio WC subjects were identified who underwent primary decompression for DLS between 1993 and 2013. We allocated patients into 2 groups: those that received operative decompression before and after 1 year of symptom onset. Our primary outcome was, if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for >6 months. RESULTS: The early cohort had a significantly higher RTW rate [50% (25/50) vs. 30% (53/117); P=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that time to surgery remained a significant negative predictor of RTW status (P=0.04; odds ratio, 0.48; 95% confidence interval, 0.23-0.91). Patients within the early surgery cohort cost on average, $37,332 less in total medical costs than those who opted for surgery after 1 year (P=0.01). Furthermore, total medical costs accrued over 3 years after index surgery was on average, $13,299 less when patients received their operation within 1 year after symptom onset (P=0.01). CONCLUSIONS: Overall, time to surgery had a significant impact on clinical outcomes in WC subjects receiving lumbar decompression for DLS. Patients who received their operation within 1 year had a higher RTW rate, lower medical costs, and lower costs accrued over 3 years after index surgery. The results presented can perhaps be used to guide surgical decision-making and provide predictive value for the WC population.

Treatment of Recurrent Lumbar Disc Herniation With or Without Fusion in Workers' Compensation Subjects.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine outcomes after reoperation discectomy with or without fusion surgery for recurrent lumbar disc herniation (RLDH) in the workers' compensation (WC) population. SUMMARY OF BACKGROUND DATA: RLDH is estimated to occur in 7% to 24% of patients after discectomy. There are two main surgical options after reherniation: a revision discectomy (RD), or an RD combined with fusion (RDF). METHODS: A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with lumbar spine comorbidities, a smoking history, or multilevel surgery were excluded. One hundred two patients had RD alone for RLDH and 196 had RDF procedures. The primary outcome was whether subjects returned to work (RTW). RESULTS: A total of 298 WC patients met our study criteria, including 230 (77.2%) men and 68 (22.8%) women with an average age of 39.4 years (range 19-66). The RDF group had lower rates of RTW than the RD group (27.0% vs 40.2%; P = 0.03). Multivariate regression analysis showed that reoperation with discectomy and fusion (P = 0.04; odds ratio [OR] = 0.56), psychiatric illness (P < 0.01; OR = 0.19), and opioid analgesic use within 1 month of reoperation (P < 0.01; OR = 0.44) were independent negative predictors of RTW. RDF patients were supplied with opioids for 252.3 days longer (P < 0.01) and incurred $34,914 (31.8%) higher medical costs (P < 0.01) than the RD alone group. CONCLUSION: We analyzed outcomes after operative management of RLDH in the WC population. WC patients receiving RDF had lower RTW rates, higher costs, and a longer duration of postoperative opioid use than those receiving RD alone. This information allows for informed patient management decisions and suggests that fusion should be reserved for patients with clear indications for its use. We are unable to conclude what treatment method is best, but rather we provide a baseline for future studies. LEVEL OF EVIDENCE: 3.

Surgical and Functional Outcomes After Multilevel Cervical Fusion for Degenerative Disc Disease Compared With Fusion for Radiculopathy: A Study of Workers' Compensation Population.

STUDY DESIGN: Retrospective cohort comparative study. OBJECTIVE: To evaluate presurgical and surgical factors that affect return to work (RTW) status after multilevel cervical fusion, and to compare outcomes after multilevel cervical fusion for degenerative disc disease (DDD) versus radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical fusion provides more than 90% of symptomatic relief for radiculopathy and myelopathy. However, cervical fusion for DDD without radiculopathy is considered controversial. In addition, multilevel fusion is associated with poorer surgical outcomes with increased levels fused. METHODS: Data of cervical comorbidities was collected from Ohio Bureau of Workers' Compensation for subjects with work-related injuries. The study population included subjects who underwent multilevel cervical fusion. Patients with radiculopathy or DDD were identified. Multivariate logistic regression was performed to identify factors that affect RTW status. Surgical and functional outcomes were compared between groups. RESULTS: Stable RTW status within 3 years after multilevel cervical fusion was negatively affected by: fusion for DDD, age > 55 years, preoperative opioid use, initial psychological evaluation before surgery, injury-to-surgery > 2 years and instrumentation.DDD group had lower rate of achieving stable RTW status (P= 0.0001) and RTW within 1 year of surgery (P= 0.0003) compared with radiculopathy group. DDD patients were less likely to have a stable RTW status [odds ratio, OR = 0.63 (0.50-0.79)] or RTW within 1 year after surgery [OR = 0.65 (0.52-0.82)].DDD group had higher rate of opioid use (P= 0.001), and higher rate of disability after surgery (P= 0.002). CONCLUSION: Multiple detriments affect stable RTW status after multilevel cervical fusion including DDD. DDD without radiculopathy was associated with lower RTW rates, less likelihood to return to work, higher disability, and higher opioid use after surgery. Multilevel cervical fusion for DDD may be counterproductive. Future studies should investigate further treatment options of DDD, and optimize patient selection criteria for surgical intervention. LEVEL OF EVIDENCE: 3.

Prolonged Preoperative Opioid Therapy in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the impact of prolonged opioid use in the preoperative treatment plan of degenerative lumbar stenosis (DLS). SUMMARY OF BACKGROUND DATA: Patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. The relative paucity of data on the relationship between preoperative opioid use and clinical outcomes in the workers' compensation (WC) population necessitates further study of this unique population. METHODS: We identified 140 Ohio WC patients who underwent lumbar decompression and had received preoperative opioid prescriptions between 1993 and 2013. Our study cohorts were formed based on opioid use duration, which included short-term use (<3 months) and long-term use (>3 months). Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to determine the impact of the duration of preoperative opioid use on return to work rates. We also compared many secondary outcomes after surgery between both groups. RESULTS: Patients on opioids less than 3 months had a significantly higher RTW rate compared with those who used opioids longer than 3 months [25/60 (42%) vs. 18/80 (23%); P = 0.01]. A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW (OR: 0.35, 95% CI: 0.13-0.89; P = 0.02). Patients who remained on opioid therapy longer than 3 months cost the Ohio Bureau of Workers' Compensation $70,979 more than patients who were on opioid therapy for less than 3 months (P < 0.01). CONCLUSION: Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS. LEVEL OF EVIDENCE: 3.

Return to Work and Multilevel Versus Single-Level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: Examine the impact of multilevel fusion on return to work (RTW) status and compare RTW status after multi- versus single-level cervical fusion for patients with work-related injury. SUMMARY OF BACKGROUND DATA: Patients with work-related injuries in the workers' compensation systems have less favorable surgical outcomes. Cervical fusion provides a greater than 90% likelihood of relieving radiculopathy and stabilizing or improving myelopathy. However, more levels fused at index surgery are reportedly associated with poorer surgical outcomes than single-level fusion. METHODS: Data was collected from the Ohio Bureau of Workers' Compensation (BWC) between 1993 and 2011. The study population included patients who underwent cervical fusion for radiculopathy. Two groups were constructed (multilevel fusion [MLF] vs. single-level fusion [SLF]). Outcomes measures evaluated were: RTW criteria, RTW <1year, reoperation, surgical complication, disability, and legal litigation after surgery. RESULTS: After accounting for a number of independent variables in the regression model, multilevel fusion was a negative predictor of successful RTW status within 3-year follow-up after surgery (OR = 0.82, 95% CI: 0.70-0.95, P <0.05).RTW criteria were met 62.9% of SLF group compared with 54.8% of MLF group. The odds of having a stable RTW for MLF patients were 0.71% compared with the SLF patients (95% CI: 0.61-0.83; P: 0.0001).At 1 year after surgery, RTW rate was 53.1% for the SLF group compared with 43.7% for the MLF group. The odds of RTW within 1 year after surgery for the MLF group were 0.69% compared with SLF patients (95% CI: 0.59-0.80; P: 0.0001).Higher rate of disability after surgery was observed in the MLF group compared with the SLF group (P: 0.0001) CONCLUSION.: Multilevel cervical fusion for radiculopathy was associated with poor return to work profile after surgery. Multilevel cervical fusion was associated with lower RTW rates, less likelihood of achieving stable return to work, and higher rate of disability after surgery. LEVEL OF EVIDENCE: 3.

Prolonged Preoperative Opioid Therapy Associated With Poor Return to Work Rates After Single-Level Cervical Fusion for Radiculopathy for Patients Receiving Workers' Compensation Benefits.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: Examine the effect of prolonged preoperative opioid use on return to work (RTW) status after single-level cervical fusion for radiculopathy. SUMMARY OF BACKGROUND DATA: The use of opioids has a dramatic effect in a workers' compensation population. The costs of claims that involved opioids in the management plan are catastrophic particularly for those undergoing spinal surgical procedure. MATERIALS: Data of patients who underwent single-level cervical fusion for radiculopathy and had received opioid prescriptions before surgery were retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011 after work-related injury. Then, based on opioid use duration, short-term use (STO) group (<3 mo), intermediate-term use (ITO) group (3-6 mo), and long-term use (LTO) group (>6 mo) were constructed. A multivariate logistic regression analysis was used to determine whether successful RTW status was achieved. Chi-square and analysis of variance tests were used to compare other secondary outcomes after surgery. RESULTS: Prolonged preoperative opioid use was a negative predictor of successful RTW status (odds ratio = 0.73; 95% confidence interval: 0.55-0.98; P value: 0.04). Prolonged preoperative opioid use was associated with increasingly lower rates of achieving stable RTW status (P < 0.05) and RTW within 1 year after surgery (P < 0.05). The odds of achieving successful RTW status were 0.49 (0.25-0.94) for ITO, and 0.40 (0.24-0.68) for LTO compared with STO group. The odds of RTW less than 1 year after surgery were 0.43 (0.21-0.88) for ITO and 0.36 (0.21-0.62) for LTO compared with STO group. Prolonged preoperative opioid use was also associated with increasingly higher net medical costs (P < 0.01), and disability benefits awarded after surgery (P < 0.01). CONCLUSION: Prolonged preoperative opioid use was associated with poor functional outcomes after cervical fusion. STO and earlier inclusion of the surgical approach in the management plan may offer better surgical and functional outcomes after cervical fusion. LEVEL OF EVIDENCE: 3.

Neck Pain, Preoperative Opioids, and Functionality After Cervical Fusion.

The use of opioids among patients with workers' compensation claims is associated with tremendous costs, especially for patients who undergo spinal surgery. This study compared return-to-work rates after single-level cervical fusion for degenerative disk disease between patients who received opioids before surgery and patients who underwent fusion with no previous opioid use. All study subjects qualified for workers' compensation benefits for injuries sustained at work between 1993 and 2011. The study population included 281 subjects who underwent single-level cervical fusion for degenerative disk disease with International Classification of Diseases, Ninth Revision, and Current Procedural Terminology code algorithms. The opioid group included 77 subjects who received opioids preoperatively. The control group included 204 subjects who had surgery with no previous opioid use. The primary outcome was meeting return-to-work criteria within 3 years of follow-up after fusion. Secondary outcome measures after surgery, surgical details, and presurgical characteristics for each cohort also were collected. In 36.4% of the opioid group, return-to-work criteria were met compared with 56.4% of the control group. Patients who took opioids were less likely to meet return-to-work criteria compared with the control group (odds ratio, 0.44; 95% confidence interval, 0.26-0.76; P=.0028). Return-to-work rates within the first year after fusion were 24.7% for the opioid group and 45.6% for the control group (P=.0014). Patients who used opioids were absent from work for 255 more days compared with the control group (P=.0001). The use of opioids for management of diskogenic neck pain, with the possibility of surgical intervention, is a negative predictor of successful return to work after fusion in a workers' compensation population. [Orthopedics. 2017; 40(1):25-32.].