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Micheal Raad, Andrew B. Harris, Varun Puvanesarajah, Mostafa H. El Dafrawy, Floreana N. Kebaish, Brian J. Neuman, Richard L. Skolasky, David B. Cohen, and Khaled M. Kebaish

OBJECTIVE

Patients’ expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients’ preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

METHODS

The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to “I expect my back pain to improve” were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society–22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

RESULTS

Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

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Mark Ren, Barry R. Bryant, Andrew B. Harris, Khaled M. Kebaish, Lee H. Riley III, David B. Cohen, Richard L. Skolasky, and Brian J. Neuman

OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

METHODS

Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5–82), high-dose use (aOR 7.3, 95% CI 1.1–48), and long-term use (aOR 17, 95% CI 2.2–123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8–10,546) but not long-term use (aOR 4.0, 95% CI 0.18–91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8–261) but not at 6 months (aOR 4.3, 95% CI 0.95–24).

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

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Rafa Rahman, Alvaro Ibaseta, Jay S. Reidler, Nicholas S. Andrade, Richard L. Skolasky, Lee H. Riley III, David B. Cohen, Daniel M. Sciubba, Khaled M. Kebaish, and Brian J. Neuman

OBJECTIVE

The authors conducted a study to analyze associations between changes in depression/anxiety before and 12 months after spine surgery, as well as changes in scores using the Patient-Reported Outcomes Measurement Information System (PROMIS) at the same time points.

METHODS

Preoperatively and 12 months postoperatively, the authors assessed PROMIS scores for depression, anxiety, pain, physical function, sleep disturbance, and satisfaction with participation in social roles among 206 patients undergoing spine surgery for deformity correction or degenerative disease. Patients were stratified according to preoperative/postoperative changes in depression and anxiety, which were categorized as persistent, improved, newly developed postoperatively, or absent. Multivariate regression was used to control for confounders and to compare changes in patient-reported outcomes (PROs).

RESULTS

Fifty patients (24%) had preoperative depression, which improved in 26 (52%). Ninety-four patients (46%) had preoperative anxiety, which improved in 70 (74%). Household income was the only preoperative characteristic that differed significantly between patients whose depression persisted and those whose depression improved. Compared with the no-depression group, patients with persistent depression had less improvement in all 4 domains, and patients with postoperatively developed depression had less improvement in pain, physical function, and satisfaction with social roles. Compared with the group of patients with postoperatively improved depression, patients with persistent depression had less improvement in pain and physical function, and patients with postoperatively developed depression had less improvement in pain. Compared with patients with no anxiety, those with persistent anxiety had less improvement in physical function, sleep disturbance, and satisfaction with social roles, and patients with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. Compared with patients with postoperatively improved anxiety, patients with persistent anxiety had less improvement in pain, physical function, and satisfaction with social roles, and those with postoperatively developed anxiety had less improvement in pain, physical function, and satisfaction with social roles. All reported differences were significant at p < 0.05.

CONCLUSIONS

Many spine surgery patients experienced postoperative improvements in depression/anxiety. Improvements in 12-month PROs were smaller among patients with persistent or postoperatively developed depression/anxiety compared with patients who had no depression or anxiety before or after surgery and those whose depression/anxiety improved after surgery. Postoperative changes in depression/anxiety may have a greater effect than preoperative depression/anxiety on changes in PROs after spine surgery. Addressing the mental health of spine surgery patients may improve postoperative PROs.

CLASSIFICATION OF EVIDENCE Type of question: causation; study design: prospective cohort study; evidence: class III.

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David B. Cohen

Infections in the spine can lead to a wide range of problems for both the patient and physician. There is perhaps no more devastating complication than the neurological consequences of a cauda equina syndrome due to spinal infection. A variety of organisms and origins can make diagnosis and treatment of spinal infection a difficult task. Both pyogenic and nonpyogenic organisms can cause vertebral involvement and can result in an epidural abscess with neurological compromise. Nonetheless, these two types of infections vary greatly in terms of associated patient demographics, clinical course, and treatments. The purpose of this paper was to review these types of infections and summarize treatment recommendations for this difficult condition.