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Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery

Presented at the 2020 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Michael M. H. Yang, Jay Riva-Cambrin, Jonathan Cunningham, Nathalie Jetté, Tolulope T. Sajobi, Alex Soroceanu, Peter Lewkonia, W. Bradley Jacobs, and Steven Casha

OBJECTIVE

Thirty percent to sixty-four percent of patients experience poorly controlled pain following spine surgery, leading to patient dissatisfaction and poor outcomes. Identification of at-risk patients before surgery could facilitate patient education and personalized clinical care pathways to improve postoperative pain management. Accordingly, the aim of this study was to develop and internally validate a prediction score for poorly controlled postoperative pain in patients undergoing elective spine surgery.

METHODS

A retrospective cohort study was performed in adult patients (≥ 18 years old) consecutively enrolled in the Canadian Spine Outcomes and Research Network registry. All patients underwent elective cervical or thoracolumbar spine surgery and were admitted to the hospital. Poorly controlled postoperative pain was defined as a mean numeric rating scale score for pain at rest of > 4 during the first 24 hours after surgery. Univariable analysis followed by multivariable logistic regression on 25 candidate variables, selected through a systematic review and expert consensus, was used to develop a prediction model using a random 70% sample of the data. The model was transformed into an eight-tier risk-based score that was further simplified into the three-tier Calgary Postoperative Pain After Spine Surgery (CAPPS) score to maximize clinical utility. The CAPPS score was validated using the remaining 30% of the data.

RESULTS

Overall, 57% of 1300 spine surgery patients experienced poorly controlled pain during the first 24 hours after surgery. Seven significant variables associated with poor pain control were incorporated into a prediction model: younger age, female sex, preoperative daily use of opioid medication, higher preoperative neck or back pain intensity, higher Patient Health Questionnaire–9 depression score, surgery involving ≥ 3 motion segments, and fusion surgery. Notably, minimally invasive surgery, body mass index, and revision surgery were not associated with poorly controlled pain. The model was discriminative (C-statistic 0.74, 95% CI 0.71–0.77) and calibrated (Hosmer-Lemeshow goodness-of-fit, p = 0.99) at predicting the outcome. Low-, high-, and extreme-risk groups stratified using the CAPPS score had 32%, 63%, and 85% predicted probability of experiencing poorly controlled pain, respectively, which was mirrored closely by the observed incidence of 37%, 62%, and 81% in the validation cohort.

CONCLUSIONS

Inadequate pain control is common after spine surgery. The internally validated CAPPS score based on 7 easily acquired variables accurately predicted the probability of experiencing poorly controlled pain after spine surgery.

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Robert J. Rothrock, Yi Li, Eric Lis, Stephanie Lobaugh, Zhigang Zhang, Patrick McCann, Patricia Mae G. Santos, T. Jonathan Yang, Ilya Laufer, Mark H. Bilsky, Adam Schmitt, Yoshiya Yamada, and Daniel S. Higginson

OBJECTIVE

To characterize the clinical outcomes when stereotactic body radiation therapy (SBRT) alone is used to treat high-grade epidural disease without prior surgical decompression, the authors conducted a retrospective cohort study of patients treated at the Memorial Sloan Kettering Cancer Center between 2014 and 2018. The authors report locoregional failure (LRF) for a cohort of 31 cases treated with hypofractionated SBRT alone for grade 2 epidural spinal cord compression (ESCC) with radioresistant primary cancer histology.

METHODS

High-grade epidural disease was defined as grade 2 ESCC, which is notable for radiographic deformation of the spinal cord by metastatic disease. Kaplan-Meier survival curves and cumulative incidence functions were generated to examine the survival and incidence experiences of the sample level with respect to overall survival, LRF, and subsequent requirement of vertebral same-level surgery (SLS) due to tumor progression or fracture. Associations with dosimetric analysis were also examined.

RESULTS

Twenty-nine patients undergoing 31 episodes of hypofractionated SBRT alone for grade 2 ESCC between 2014 and 2018 were identified. The 1-year and 2-year cumulative incidences of LRF were 10.4% (95% CI 0–21.9) and 22.0% (95% CI 5.5–38.4), respectively. The median survival was 9.81 months (95% CI 8.12–18.54). The 1-year cumulative incidence of SLS was 6.8% (95% CI 0–16.0) and the 2-year incidence of SLS was 14.5% (95% CI 0.6–28.4). All patients who progressed to requiring surgery had index lesions at the thoracic apex (T5–7).

CONCLUSIONS

In carefully selected patients, treatment of grade 2 ESCC disease with hypofractionated SBRT alone offers a 1-year cumulative incidence of LRF similar to that in low-grade ESCC and postseparation surgery adjuvant hypofractionated SBRT. Use of SBRT alone has a favorable safety profile and a low cumulative incidence of progressive disease requiring open surgical intervention (14.5%).

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010