Does Preoperative Narcotic Use Adversely affect Outcomes and Complications after Spinal Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups

Accepted Manuscript

Does Preoperative Narcotic Use Adversely affect Outcomes and Complications afterSpinal Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups

Addisu Mesfin, MD Lawrence G. Lenke, MD Keith H. Bridwell, MD Usman Akhtar, BAJennifer M. Jupitz, BS Jeremy L. Fogelson, MD Stuart Hershman, MD Han Jo Kim,MD Linda A. Koester, BS

PII: S1529-9430(14)00357-X

DOI: 10.1016/j.spinee.2014.03.049

Reference: SPINEE 55844

To appear in: The Spine Journal

Received Date: 4 October 2013

Revised Date: 10 March 2014

Accepted Date: 25 March 2014

Please cite this article as: Mesfin A, Lenke LG, Bridwell KH, Akhtar U, Jupitz JM, Fogelson JL,Hershman S, Kim HJ, Koester LA, Does Preoperative Narcotic Use Adversely affect Outcomes andComplications after Spinal Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups,The Spine Journal (2014), doi: 10.1016/j.spinee.2014.03.049.

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http://dx.doi.org/10.1016/j.spinee.2014.03.049

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Does Preoperative Narcotic Use Adversely affect Outcomes and Complications after Spinal Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups

Addisu Mesfin, MD*; Lawrence G. Lenke, MD**; Keith H. Bridwell, MD**; Usman Akhtar, BA**; Jennifer M. Jupitz, BS**; Jeremy L. Fogelson, MD#; Stuart Hershman, MD##; Han Jo

Kim, MD###; Linda A. Koester, BS** *Department of Orthopaedic Surgery, University of Rochester, Rochester, NY. **Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO. #Department of Neurosurgery, Mayo Clinic, Rochester, NY. ## Florida Spine Specialists, Ft. Lauderdale, FL ###H ospital for Special Surgery, New York, NY Research was performed at Washington University School of Medicine, St. Louis, MO Institutional Review Board (IRB) approval was received for this study. Conflicts of Interest and Source of Funding: None of the authors received financial support in relation to this manuscript. Washington University, Department of Orthopaedic Surgery – Spine Service receives grant monies from Axial Biotech and DePuy Spine. Dr. Lenke shares numerous patents with Medtronic (unpaid). He receives substantial royalties from Medtronic and modest royalties from Quality Medical Publishing. Dr. Lenke also receives or has received reimbursement related to meetings/courses from AMCICO, AOSpine, COA, BroadWater, DePuy, Dubai Spine Society, Medtronic, SDSG, SOSORT, The Spinal Research Foundation, SRS, SSF. Corresponding Author: Lawrence G. Lenke, MD Washington University School of Medicine Department of Orthopaedic Surgery 660 S Euclid Ave, Campus Box 8233 Saint Louis, MO 63110 TEL: (314) 747-2535, FAX: (314) 747-2599 E-mail: [email protected]

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Does Preoperative Narcotic Use Adversely affect Outcomes and Complications after Spinal 2

Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups 3

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ACCEPTED MANUSCRIPTNarcotic use after spinal deformity surgery

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STRUCTURED ABSTRACT 1

Background Context: The role of preoperative narcotic use and its influence on outcomes 2

following spinal deformity surgery is unknown. It is important to determine what patient factors 3

and co-morbidities can affect the success of spinal deformity surgery, a challenging surgery with 4

high rates of complications at baseline. 5

Purpose: Evaluate if preoperative narcotic use persists following spinal deformity surgery, and 6

whether the outcomes are adversely affected by preoperative narcotic use. 7

Study Design/Setting: Retrospective evaluation of prospectively collected data 8

Patient Sample: 253 adult patients (230 females/23 males) undergoing primary spinal deformity 9

surgery were enrolled from 2000 to 2009. 10

Outcome Measures: Pre-operative and post-operative narcotic use. Changes in Oswestry 11

Disability Index (ODI), Scoliosis Research Society (SRS) pain and SRS total score. 12

Methods: Preoperative, 2-year postoperative and latest follow-up pain medication use were 13

collected along with ODI, SRS pain and SRS scores. Preoperative insurance status, surgical and 14

hospitalization demographics and complications were collected. All patients had a minimum 2-15

year follow-up (average, 47.4 months). 16

Results. 168 patients (NoNarc) were taking no pain meds/NSAIDs only preoperative. 85 patients 17

(Narc) were taking mild/moderate/heavy narcotics prior to surgery. The average age was 48.2 18

for the NoNarc versus 53.6 for the Narc group (p<0.005). There were significantly more patients 19

with degenerative than adult scoliosis in the Narc group (47 vs. 28, p<0.001; mild 19 vs. 24, 20

p<0.02; moderate 6 vs. 14, p<0.0003; heavy 3 vs. 10, p<0.0002). Insurance status 21

(private/Medicare/Medicaid) was similar between the groups (p=0.39). At latest follow-up, 22

137/156 (88%) prior NoNarc patients were still not taking narcotics while 48/79 (61%) prior 23

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Narc patients were now off narcotics (p<0.001). Significant postoperative improvements were 1

seen in Narc versus NoNarc with regard to ODI (26-15 vs. 44-30.3, p<0.001), SRS pain (3.36-2

3.9 vs. 2.3-3.38, p<0.001) and overall SRS outcomes scores (3.36-4 vs. 2.78-3.68, p<0.001). A 3

comparison of change in outcomes scores between the two groups showed a higher improvement 4

in SRS pain scores for the Narc versus NoNarc group (p<0.001). 5

Conclusion. In adults with degenerative scoliosis taking narcotics a significant decrease in pain 6

medication use was noted following surgery. All outcome scores significantly improved 7

postoperative in both groups. However, the Narc group had significantly greater improvements 8

in SRS pain scores versus the NoNarc group. 9

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INTRODUCTION 1

Adult spinal deformity encompasses idiopathic scoliosis that has progressed into 2

adulthood, degenerative scoliosis and sagittal imbalance as an iatrogenic result of a prior surgery 3

or due to post-traumatic kyphosis and degenerative disc disease.1-4 Adult scoliosis can be 4

asymptomatic with an incidence of 68% noted in a cohort of volunteers.5 However, back pain, 5

radiculopathy and poor quality of life associated with the deformity can lead patients to seek a 6

surgical alternative. Non-operative management includes physical therapy, nerve root or epidural 7

injections, facet blocks, non-steroidal anti-inflammatories (NSAIDs) and oral narcotic 8

medications. With the growth of the aging population, an increase in those patients electing 9

surgical intervention for spinal deformity is anticipated.2 10

Narcotics or opioids were initially limited to severe painful conditions such as cancer.6 11

However, over the last two decades narcotics have become acceptable for chronic pain as well as 12

for acute pain relief.6 Primary care providers are increasingly using narcotics in the management 13

of back pain with up to 61% of acute back pain patients receiving a course of opioids.7 In low 14

back pain workers’ compensation patients, a correlation between early narcotic use and increased 15

disability time has been noted.6 The effects of narcotic use in outcomes following orthopaedic 16

procedures have been documented.8-11 However, the role of preoperative (pre-op) narcotic use on 17

outcomes following spinal deformity surgery have not been evaluated. 18

The purpose of this study was to determine if preoperative narcotic use persisted 19

following spinal deformity surgery, and whether clinical outcomes are adversely affected in 20

those using narcotics as compared to those patients not taking narcotics preoperatively. 21

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MATERIAL AND METHODS 1

Adult patients (≥18-year-old) operated on by two surgeons for primary adult spinal 2

deformity at one institution from January 2000 to December 2009 were enrolled in this study. 3

Pain medication use by each patient was categorized as (0) no pain medication; (1) 4

NSAID/Tylenol; (2) mild narcotic: Darvocet/Ultram; (3) moderate narcotics: Oxycodone, 5

Tylenol #3, Percocet; (4) heavy narcotic: Oxycontin, Methadone, Dilaudid, Morphine, Fentanyl 6

patch. 7

Our inclusion criteria were age ≥18, documentation of pain medication usage, primary 8

surgery, minimum 2-year follow-up and presence of spinal deformity. Our exclusion criteria 9

were age < 18, lack of preoperative pain medication documentation, revision surgery and < 2-10

year follow-up. Based on the inclusion and exclusion criteria we enrolled 253 patients (230 11

females, 23 males). 12

Adult idiopathic scoliosis (121, 47.8%) was the most common diagnosis, followed by 13

degenerative scoliosis (n = 110, 43.5%), congenital scoliosis (n = 11, 4.3%), Scheuermann’s 14

kyphosis (n = 5, 2%), fixed sagittal imbalance (n = 2, 0.8%), neuromuscular scoliosis (n = 1, 15

0.4%), syndromic scoliosis (n = 1, 0.4%), ankylosing spondylitis deformity (n = 1, 0.4%) and 16

post-traumatic deformity (n = 1, 0.4%). All patients had a minimum five levels of fusion 17

performed for their deformity condition. 18

To compare clinical outcomes associated with narcotic use versus no narcotic use, 19

patients were grouped into two groups. The NoNarc group was composed of patients taking no 20

pain medications (0) or taking NSAID/Tylenol (1) only. The Narc group was composed of 21

patients using mild/moderate/heavy narcotics (2-4). 22

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Pain medication usage was documented at the following time points: preoperative, 2-year 1

follow-up and latest follow-up. Oswestry Disability Index (ODI) and Scoliosis Research Society 2

(SRS) pain domain score and overall outcomes scores were recorded at preoperative and 2-year 3

follow-up. 4

Demographic information such as age, sex, and type of insurance were collected. 5

Insurance status prior to surgery was categorized as: (1) private insurance or self-pay; (2) 6

medicare; (3) medicaid, (4) workers’ compensation. Surgical information including estimated 7

blood loss (EBL), levels instrumented and hospitalization information including length of 8

hospitalization and discharge to rehabilitation were also collected. Major and minor surgical and 9

medical complications per previously published criteria were also collected.14 10

11

Statistical Methods 12

The Fisher’s exact test was used for comparison of the categorical variables and student t 13

test was used for comparison of the continuous variables. Significance was set at p < 0.05 and 14

commercially available statistical software (SAS 9.2, Cary, NC) was used. 15

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RESULTS 1

The 253 patients were categorized based on their preoperative pain medication usage: (1) 2

no pain med, n = 68; (2) NSAID/Tylenol, n = 100; (3) mild narcotic, n = 46; (4) moderate 3

narcotic, n = 24; (5) heavy narcotic, n = 15. Groups 1 and 2 were combined into the NoNarc 4

group, n = 168. Groups 3, 4 and 5 were combined into the Narc group, n = 85. At latest follow-5

up 235 patients, 156 NoNarc patients and 79 Narc patients had complete documentation of pain 6

medication use along with all outcome scores, the 18 remaining patients had incomplete 7

postoperative pain medication documentation or had one of the components of the outcome score 8

missing. 9

The mean age for the NoNarc group was 48.2 years (range, 18-77) versus 53.6 years 10

(range, 18-80; p < 0.005) for the Narc group (Table 1). Thus, the Narc group was significantly 11

older than the NoNarc group. Sex distribution was not significantly different, with 152 12

females/16 males in the NoNarc versus 78 females/7 males in the Narc group, p = 0.74. 13

Insurance status was also not significantly different between the two groups. The insurance 14

distributions for the NoNarc group were 117 private/49 medicare/2 medicaid and for the Narc 15

group were 52 private/32 medicare/1 medicaid (p = 0.39). There were no workers’ compensation 16

patients. Within the Narc group there were significantly more patients with degenerative 17

scoliosis than adult scoliosis (47 vs 28, p<0.001). 18

Mean levels instrumented were 12.1 for Group NoNarc and 11.9 for Group Narc and 19

were not significantly different (p = 0.366), (Table 1). EBL was 1114 ml for Group NoNarc and 20

1236 ml for Group Narc, which was not significantly different (p = 0.114). Length of 21

hospitalization was 8.2 days for Group NoNarc and 8.8 days for group Narc and was not 22

significantly different (p = 0.114). There was a significant difference in discharge to 23

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rehabilitation between the two groups (p < 0.004). Thirty-seven (22%) patients in Group NoNarc 1

were discharged to rehabilitation versus 33 patients in Group Narc (39%). 2

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Complications (Table 2) 4

There were 33 (20%) major complications in Group NoNarc. The most common were 5

pseudarthrosis (5), deep wound infections (4), pulmonary issues (4), proximal junctional 6

kyphosis (3) and adjacent segment disease (3). In Group Narc there were 23 (27%) major 7

complications. The most common were arrhythmias (4), proximal junctional kyphosis (3) and 8

pulmonary embolism (2). There were no significant difference in rates of major complications 9

between the two groups (p =0.09). 10

There were 34 (20%) minor complications in Group NoNarc. The most common were 11

urinary tract infections (7), mental status changes (5), urinary retention (4) and symptomatic iliac 12

screws requiring removal (3). There were 19 (22%) minor complications in group Narc. The 13

most common were deep vein thrombosis (4), incidental durotomies (2) and urinary tract 14

infections (2). There were no significant difference in rates of minor complications between the 15

two groups (p = 0.09). 16

17

Pain medication Use 18

In Group NoNarc (n = 168), at latest follow-up, 156 had complete pain medication use 19

documented. One hundred-thirty seven of the 156 patients (88%) were still not taking narcotics. 20

For the Narc group (n = 85), at latest follow-up, 79 had complete pain medication use 21

documentation. Forty-eight of the79 Narc patients were no longer taking narcotics at latest 22

follow-up (61%), p < 0.001 (Table 3). 23

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We evaluated the frequency of the two common diagnoses (Adult idiopathic scoliosis and 1

Adult degenerative scoliosis) in each subgroup (No pain meds, NSAIDs, mild narcotics, 2

moderate narcotics and heavy narcotics). There were significantly more patients with adult 3

idiopathic scoliosis than degenerative scoliosis in the No pain meds group (46 vs. 15, p<0.0001). 4

No difference in the frequency of adult idiopathic scoliosis vs. degenerative scoliosis in the 5

NSAID groups (48 vs. 46, p=.16). There were significant differences in frequency of adult 6

idiopathic scoliosis versus degenerative scoliosis in all the narcotic subgroups (mild 19 vs. 24, 7

p<0.02; moderate 6 vs. 14, p<0.0003; heavy 3 vs. 10, p<0.0002). 8

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Outcome Scores (Table 4) 10

In all outcome scores (ODI and SRS) Group NoNarc had significantly better pre-11

operative scores than Group Narc. Pre-operatively Group NoNarc’s, mean ODI = 26 (range, 0-12

80) versus Narc group ODI = 44 (range, 6-91), p < 0.001. At 2-year follow-up, both groups had 13

significant improvements in their ODI scores. Group NoNarc’s ODI had improved from 26 to 15 14

(p < 0.001) and Group Narc’s ODI had improved from 44 to 30.3 (p < 0.001). Between the two 15

groups, the degree of improvement in the ODI was not significantly different (p = 0.21). 16

A significant difference in preoperative SRS pain domain scores was also present 17

between the two groups. The NoNarc group’s preoperative SRS mean pain domain score was 18

higher at 3.36 (range, 1.8-5) versus the Narc group’s mean score of 2.3 (range, 1-4.4), p < 0.001. 19

At 2-year follow-up, group NoNarc’s SRS pain score improved from a mean of 3.36 to 3.9 (p< 0 20

.001) and group Narc’s SRS pain score improved from a mean of 2.3 to 3.38 (p < 0.001). The 21

degree of improvement was significantly higher for the Narc group (p < 0.001). 22

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Overall SRS scores were also compared. The NoNarc group had a mean higher 1

preoperative SRS score of 3.36 (range, 1.6-4.6) versus the Narc group mean score of 2.78 (range, 2

1.7-4; p < 0.001). Both groups had a significant improvement in SRS scores at latest follow up (p 3

< 0.001). The NoNarc group’s overall SRS outcomes scores improved from 3.36 to 4 (p < 0.001) 4

and the Narc group’s overall SRS outcomes scores improved from 2.78 to 3.68 (p < 0.001). 5

There was not a significant difference in the degree of improvement of SRS scores between the 6

two groups (p < 0.06). 7

Outcomes Scores based on latest follow-up pain medication use (Table 5) 8

In order to assess the effects of pain medication cessation versus continued use on outcome 9

scores (SRS, ODI), we divided the patients into four groups: Group 1: Pre-op NoNarc/Post-op 10

No Narc; Group 2: Pre-op NoNarc/Post-op Narc; Group 3: Pre-op Narc/Postop No Narc; Group 11

4 Pre-op Narc/Post-op Narc. The results are presented in Table 5. The most notable finding was 12

that Group 2 Pre-op No Narc/Post-op Narc had no significant improvements in SRS/ODI scores 13

post operatively. The remaining groups all had significant improvement in outcome score post 14

operatively. 15

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DISCUSSION 1

Opioids are increasingly being used in the United States for the management of chronic 2

musculoskeletal conditions.14 Specialty societies such as the American Geriatric Society have 3

recommended against NSAIDs use in elderly patients in favor of opioids.15 Correlations between 4

narcotic use and subsequent negative surgical outcomes have been reported in the orthopaedic 5

literature.8,9,11 However, to date no studies have evaluated the role of narcotic use in outcomes 6

following spinal deformity surgery. 7

In the spine literature Lawrence et al8 evaluated 91 patients undergoing anterior cervical 8

arthrodesis. They divided the patients into a narcotic using group (use > 6 months) and non-9

narcotic group and found the narcotic group to have worse functional outcomes following 10

surgery (51% good or excellent outcome vs. 86% good or excellent outcome, p < 0.001).8 11

However, preoperative functional scores are not reported and thus a baseline to compare the 12

degree of improvement is not available. 13

Recently, Zywiel et al11 reported on the role of chronic opioid (>6 month) use in 49 14

patients undergoing total knee arthroplasty in comparison to 49 non-opioid using patients. They 15

found the opioid using group’s Knee Society Outcome Scores to increase from 38 to 79 16

postoperative, meanwhile the non-opioid group had a significantly higher increase, 37 to 92 (p < 17

0.001). They conclude by recommending an opioid withdrawal program for chronic opioid 18

patients before considering surgery.11 19

In light of the findings of the above studies, we sought to evaluate the role of narcotics 20

and outcomes in patients undergoing primary adult spinal deformity at our institution. We found 21

that both non-narcotic (NoNarc) and narcotic (Narc) groups significantly improved in their ODI 22

(p < 0.001), SRS pain domain (p < 0.001) and overall SRS outcomes scores (p < 0.001) 23

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following spinal deformity surgery in comparison to the preoperative scores. Moreover, Group 1

Narc had a significantly higher baseline ODI and SRS scores than Group NoNarc. However, 2

when the difference between the preoperative and postoperative scores was evaluated, the Narc 3

group showed a significantly higher score increase than the NoNarc group for SRS pain (p < 4

0.001) domain. This finding is most likely due to the lower preoperative functional scores of the 5

Narc group and subsequent greater room for improvement available for the Narc group 6

postoperatively. 7

We also performed a separate analysis of the outcome scores based on latest follow-up 8

pain medication use. Interestingly we found the subgroup of patients that were not using 9

narcotics pre-op and were using narcotics at latest follow up to have no significant improvements 10

in their ODI and SRS scores (Table V). Thus in the non-narcotic using patient that is using 11

narcotics at latest follow-up our data suggests one should expect poorer outcome scores and must 12

work in identifying their pain source. If the pain is not due to surgical complications then the 13

patient may be a candidate for a physical therapy regimen or trial to wean off the narcotics. 14

Additional findings of our study include the Narc group to be significantly older than the 15

NoNarc group (48.2 vs. 53.6, p < 0.005). This could be due to a longer duration of symptoms the 16

Narc group has been experiencing as well as the higher number of patients with degenerative 17

scoliosis (n=47) compared to idiopathic scoliosis (n=28). Degenerative scoliosis presents at an 18

older age and with radicular symptoms and stenosis that can be managed with narcotics. On sub-19

group analysis, adult idiopathic scoliosis was associated with no-pain medication use while 20

degenerative scoliosis was more frequent in the narcotic groups. There were significant higher 21

frequency of degenerative scoliosis diagnoses in the mild/moderate/heavy narcotics groups as 22

compared to idiopathic scoliosis. Since degenerative scoliosis responds well to decompression 23

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and stabilization it is plausible than the cessation of narcotic use is due to pain relief from 1

surgery. Although length of hospitalization was equivalent between the two groups (8.2 vs. 8.8, p 2

= 0.114), there was a significantly greater number of Group Narc patients that were discharged to 3

rehabilitation (p < 0.004). We suspect the higher rate of discharge to rehabilitation in Group Narc 4

is most likely due to the older age of this group. Insurance status, however, was equivalent 5

between the two groups, with private insurance being the most common type. 6

7

Complications, major and minor, were equivalent between the two groups. Similar to 8

other studies on major complications in spinal deformity patients, pseudarthrosis, deep wound 9

infections and proximal junctional kyphosis were common surgical complications.14 Common 10

major medical complications were arrhythmias and pulmonary issues. The equivalent rate of 11

complications between the two groups is different than other orthopaedic studies. Zywiel et al. 12

found higher rates of complications following total knee arthroplasty in the opioid group 13

compared to the non-opioid group.11 Even though we had a spectrum of mild/moderate/heavy 14

narcotic using group, most of the Group Narc patients were using mild narcotics. We can 15

postulate there may be higher rates of complications if most of our patients were using heavier 16

narcotics. In Zywiel et al. ‘s study their inclusion criteria for their opioid group was a minimum 17

of 4 hydrocodones or 3 oxycodones per day which compared to our Narc group indicates higher 18

numbers of moderate and potentially heavier narcotic using patients.11 19

There are multiple factors that play a role in improved postoperative patient outcomes. 20

Skolasky et al16 recently reported high patient activation to be associated with better recovery 21

after lumbar spine surgery. Hibbard et al17, who advanced the concept of patient activation, 22

found activated patients take responsibility for their health, strive to prevent health declines, and 23

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have increased collaboration with health care providers to help maintain their function. Skolasky 1

et al16 rated the activation of 65 patients scheduled to undergo lumbar spine surgery. The patients 2

were rated as Stage I for low patient activation and rated up to stage IV for high patient 3

activation.15 They found the highly activated patients (Stage IV) to have significantly less pain (p 4

= 0.049) and less disability (p = 0.035) than low activated patients.16 Patient activation is a 5

similar concept as health locus of control, how individuals perceive their abilities to control life 6

events. 7

We acknowledge certain limitations to our study. Although we grouped patients based on 8

the severity of narcotic use (mild/moderate/severe), the narcotic medications were not converted 9

to a Morphine-equivalent dose (MED). MEDs are listed as mg/day and provide a means of 10

standardizing the different narcotic usage (mild/moderate/severe) into one measurement.12 11

However, MEDs are ideal for prospective studies, and are challenging to perform within the 12

limitations of a retrospective study. We intend to conduct a prospective study and will use MEDs 13

for that study. We also did not have any workers’ compensation-related patients in our study. 14

Workers’ compensation patients taking narcotics have been noted to have worse outcomes6,10 15

and in a recent study, 76% (n = 550) of workers’ compensation patients that underwent lumbar 16

spine fusion were found to still be taking narcotics.18 Thus, it could be argued that if workers’ 17

compensation patients were part of our study cohort, the outcomes in the Narc group may have 18

been worse. However, spinal deformity is not a common presentation of workers’ compensation. 19

The mechanism of injury that leads to a workers’ compensation claim contributes to 20

degenerative disc disease, disc herniations and radiculopathy rather than spinal deformity. Since 21

the majority of the patients were females, as is usually encountered in spine deformity surgery, 22

the results may not be extrapolated to males. Lastly, we did not report any data on tobacco use. 23

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A recent study has noted that smokers report a higher pain scores in VAS rating compared to 1

non-smokers. 19 2

In conclusion, the use of narcotics in the United States for musculoskeletal conditions 3

continues to increase. Adult deformity requiring surgical intervention will also continue to 4

increase as the population ages. Our study, the first to our knowledge, to evaluate the role of 5

narcotics in outcomes following spinal deformity surgery found that both narcotic and non-6

narcotic groups have improved health-related quality of life outcomes following spinal deformity 7

surgery. Non-narcotic groups had significantly higher baseline ODI and SRS scores than the 8

narcotic groups. We also found that 61% of the preoperative narcotic group no longer taking 9

narcotics at latest follow-up. Since degenerative scoliosis was the most common diagnosis 10

among the narcotic group the cessation of the narcotics could be due resolution of radicular and 11

stenotic symptoms as a result of surgery. Thus, in selected primary degenerative scoliosis 12

patients taking narcotics, narcotic use may not be as much of a negative predictor of outcome as 13

has been previously perceived. 14

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Table 1. Demographic, surgical and hospitalization data for Group NoNarc and Group Narc

NoNarc Narc P Value

Age (years) 48.2 53.6 p<0.005

Insurance (Private/

Medicare/Medicaid)

117/49/2 52/32/1 p=0.39

EBL (ml) 1114 1236 p=0.114

Levels instrumented 12.1 11.9 p=0.366

Length of hospitalization

(days)

8.2 8.8 p=0.114

Discharge to rehab 37 (22%) 33 (39%) p<0.004

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Table 2. Major and minor complications in Group NoNarc and Narc

NoNarc Narc P Value

Major Complications 33 (20%) 23 (27%) p=0.09

Minor Complications 34 (20%) 19 (22%) p=0.35

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Table 3. Change in non-narcotic and narcotic use at latest follow-up

NoNarc Narc P Value

NoNarc 137 (88%) 48 (61%) P<0.001

Narc 19 31

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Table 4. ODI and SRS scores for Group NoNarc and Group Narc at preoperative (pre-op) and

two year follow-up.

Group NoNarc

Group Narc P Value

ODI Pre-op 26 44 p<0.001

ODI 2 year follow-up

15 30.3 p<0.001

SRS Pain Domain pre-op

3.36 2.3 p<0.001

SRS Pain Domain 2 year follow-up

3.9 3.38 p<0.001

SRS Score pre-op

3.36 2.78 p<0.001

SRS Score 2year follow-up

4.0 3.68 p<0.001

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Table 5. ODI and SRS scores based on latest follow-up pain medication use

ODI Pre-op

ODI 2 year follow-up

P value SRS Score pre-op

SRS Score 2year follow-up

P value

Group 1 Pre-op NoNarc/ Post-op No Narc

25.8 13.2 p<0.001 3.75 4.1 p<0.001

Group 2 Pre-op NoNarc/ Post-op Narc

32.8 38.1 p=0.14 3.13 3.24 p=0.33

Group 3 Pre-op Narc/Post-op No Narc

42.8 25.2 p<0.001 2.86 3.86 p<0.001

Group 4 Pre-op Narc/Post-op Narc

46.5 38.5 P<0.002 2.7 3.4 p<0.001

Documents

Does Preoperative Narcotic Use Adversely affect Outcomes and Complications after Spinal Deformity Surgery? A Comparison of Non-Narcotic to Narcotic Using Groups