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Preoperative Chronic Opioid Therapy Negatively Impacts Long-term Outcomes Following Cervical Fusion Surgery

Kalakoti, Piyush MD; Volkmar, Alexander J. BA; Bedard, Nicholas A. MD; Eisenberg, Joshua M. MD; Hendrickson, Nathan R. MD; Pugely, Andrew J. MD

doi: 10.1097/BRS.0000000000003064

Study Design. Retrospective, observational.

Objective. The aim of this study was to define the impact of preoperative chronic opioid therapy (COT) on outcomes following cervical spine fusions.

Summary of Background Data. Opioid therapy is a commonly practiced method to control acute postoperative pain. However, concerns exist relating to use of prescription opioids, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery.

Methods. A commercial dataset was queried from 2007 to 2015 for patients undergoing primary cervical spine arthrodesis [ICD-9 codes 81.01-81.03]. Primary outcome measures were 1-year and 2-year reoperation rates, emergency department (ED) visits, adverse events, and prolonged postoperative opioid use. Secondary outcomes included short-term outcomes including 90-day complications (cardiac, renal, neurologic, infectious, etc.). COT was defined as a history of opioid prescription filling within 3 months before surgery and was the primary exposure variable of interest. Generalized linear models investigated the association of preoperative COT on primary/secondary endpoints following risk-adjustment.

Results. Overall, 20,730 patients (51.3% female; 85.9% >50 years) underwent primary cervical spine arthrodesis. Of these, 10,539 (n = 50.8%) met criteria for COT. Postoperatively, 75.3% and 29.8% remained on opioids at 3 months and 1 year. Multivariable models identified an association between COT and an increased risk of 90-day ED visit [odds ratio (OR): 1.25; P < 0.001] and wound complications (OR: 1.24; P = 0.036). At 1 year, COT was strongly associated with reoperations (OR: 1.17; P = 0.043), ED visits (OR: 1.31; P < 0.001), and adverse events including wound complications (OR: 1.32; P < 0.001), infections (OR: 1.34; P = 0.042), constipation (OR: 1.11; P = 0.032), neurological complications (OR: 1.44; P = 0.01), acute renal failure (OR: 1.24; P = 0.004), and venous thromboembolism (OR: 1.20; P = 0.008). At 2 years, COT remained a significant risk factor for additional long-term negative outcomes such as reoperations, including adjacent segment disc disease (OR: 1.21; P = 0.005), ED visits (OR: 1.32; P < 0.001), and other adverse events. Preoperative COT was associated with prolonged postoperative narcotic use at 3 months (OR: 1.30; P < 0.001), 1 year (OR: 5.17; P < 0.001), and at 2 years (OR: 5.75; P < 0.001) after cervical arthrodesis.

Conclusion. Preoperative COT is a modifiable risk factor that is strongly associated with prolonged postoperative opioid use. In addition, COT was associated with inferior short-term and long-term outcomes after cervical spine fusion.

Level of Evidence: 3

The study investigates the association between preoperative chronic opioid therapy on long-term outcomes (reoperations, emergency department visits, postoperative opioid use, and adverse events) in patients undergoing primary cervical spine arthrodesis using a commercial claims dataset.

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

Address correspondence and reprint requests to Andrew J. Pugely, MD, Spine Surgery, Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP Iowa City, IA 52242; E-mail:

Received 11 October, 2018

Revised 22 January, 2019

Accepted 23 March, 2019

Piyush Kalakoti and Alexander J. Volkmar contributed equally to the work and are coprimary authors.

A portion of the work was presented as podium (oral) presentations at the 46th Annual meeting of the Cervical Spine Research Society (CSRS) at Scottsdale, AZ and the 33rd Annual Meeting of the North American Spine Society (NASS), Los Angeles, CA.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

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