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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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Michael P. Kelly, Michael A. Kallen, Christopher I. Shaffrey, Justin S. Smith, Douglas C. Burton, Christopher P. Ames, Virginie Lafage, Frank J. Schwab, Han Jo Kim, Eric O. Klineberg, Shay Bess and the International Spine Study Group

. ESs and SRMs were also similar for PROMIS-PF, SRS-22r Activity, and SF-36 PCS, though they were lower than the pain measurements, indicating less responsiveness to change within the ASD cohort. All function-domain measurements exhibited moderate ES (range 0.52–0.75). TABLE 2. Scores at baseline and 2-year follow-up Domain Baseline (n = 425) 2 Yrs Postop (n = 425) Measures of pain  SF-36 BP 8 (2–11) 6 (2–11)  SRS-22r Pain 2.4 (1.0–5.0) 3.4 (1–5)  PROMIS-PI 63.5 (37.8–76.0) 56.6 (37.8–76) Measures of function  SF-36 PF 17 (10–30) 21 (10–30)  SRS-22r Activity 3.0 (1

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Krishna Kumar, Rahul Nath and Gordon M. Wyant

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Cormac O. Maher and Fraser C. Henderson

(eds): Neurosurgical Operative Atlas. Park Ridge, IL : American Association of Neurological Surgeons , 1991 , pp 467 – 471 Hood RS: Extreme lateral lumbar disc herniation, in Rengachary SS, Wilkins RH (eds): Neurosurgical Operative Atlas. Park Ridge, IL: American Association of Neurological Surgeons, 1991, pp 467–471 19. Huskisson EC : Visual analogue scales , in Melzack R (ed): Pain Measurement and Assessment. New York : Raven Press , 1983 , pp 33 – 37 Huskisson EC: Visual analogue scales, in

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Don M. Long, David L. Filtzer, Mohammed BenDebba and Nelson H. Hendler

. New York : Raven Press , pp 659 – 666 Fordyce WE: Environmental factors in the genesis of low back pain, in Bonica JJ, Liebeskind JC, Albe-Fessard DG (eds): Advances in Pain Research and Therapy, Vol 3. New York: Raven Press, pp 659–666 16. Fordyce WE , Lansky D , Calsyn DA , et al : Pain measurement and pain behavior. Pain 18 : 53 – 69 , 1984 Fordyce WE, Lansky D, Calsyn DA, et al: Pain measurement and pain behavior. Pain 18: 53–69, 1984 17. Frymoyer J : Alternatives in spinal

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Christopher R. Honey, A. Jon Stoessl, Joseph K. C. Tsui, Michael Schulzer and Donald B. Calne

–38, 1995 5. Fahn S , Elston RL , Members of the UPDRS Development Committee : Unified Parkinson's Disease Rating Scale , in Fahn S , Marsden CD , Goldstein M , et al (eds): Recent Developments in Parkinson's Disease , ed 2 . New York : MacMillan , 1987 , pp 153 – 163 Fahn S, Elston RL, Members of the UPDRS Development Committee: Unified Parkinson's Disease Rating Scale, in Fahn S, Marsden CD, Goldstein M, et al (eds): Recent Developments in Parkinson's Disease, ed 2. New York: MacMillan, 1987, pp 153–163 6. Flaherty SA : Pain measurement

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Beatrice Cioni, Mario Meglio, Luigi Pentimalli and Massimiliano Visocchi

: Hanley & Belfus, 1991, pp 71–82 7. Chapman CR , Casey KL , Dubner R , et al : Pain measurement: an overview. Pain 22 : 1 – 31 , 1985 Chapman CR, Casey KL, Dubner R, et al: Pain measurement: an overview. Pain 22: 1–31, 1985 8. Davidoff G , Roth E , Guarracini M , et al : Function-limiting dysesthetic pain syndrome among traumatic spinal cord injury patients: a cross-sectional study. Pain 29 : 39 – 48 , 1987 Davidoff G, Roth E, Guarracini M, et al: Function

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J. Scott Richards, Samuel L. Stover and Theresa Jaworski

compromise the quality of their responses were excluded. Demographic data were recorded on admission. Neurological level and extent of injury were recorded on admission and again 1 year postinjury, using both the American Spinal Injury Association standards 1 and the Frankel grading system. 11 For persons in whom the bullet was still present, the location of the projectile(s) was determined radiographically. Pain measurements were gathered for the duration of the project at the same time and on the same day of the week by the same interviewer using a standardized

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Mario Meglio, Beatrice Cioni and Gian Franco Rossi

, et al : Pain measurement: an overview. Pain 22 : 1 – 31 , 1985 Chapman CR, Casey KL, Dubner R, et al: Pain measurement: an overview. Pain 22: 1–31, 1985 5. Cook AW , Oygar A , Baggenstos P , et al : Vascular disease of extremities. NY State J Med 76 : 366 – 368 , 1976 Cook AW, Oygar A, Baggenstos P, et al: Vascular disease of extremities. NY State J Med 76: 366–368, 1976 6. Dimitrijevic MR , Faganel J : Spinal cord stimulation for the treatment of movement disorders

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Kyu Ho Lee, Jun Kim and Jin Mo Chung

Brain Res 33: 445–453, 1978 10. Carmon A , Mor J , Goldberg J : Evoked cerebral responses to noxious thermal stimuli in humans. Exp Brain Res 25 : 103 – 107 , 1976 Carmon A, Mor J, Goldberg J: Evoked cerebral responses to noxious thermal stimuli in humans. Exp Brain Res 25: 103–107, 1976 11. Chapman CR , Casey KL , Dubner R , et al : Pain measurement: an overview. Pain 22 : 1 – 31 , 1985 Chapman CR, Casey KL, Dubner R, et al: Pain measurement: an overview. Pain 22: 1