Original ArticlePostoperative Opioid Use Following Single-Level Transforaminal Lumbar Interbody Fusion Compared with Posterolateral Lumbar Fusion
Introduction
Opioid use following spine surgery is a topic of great interest owing to the ongoing opioid epidemic. Opioid overdoses in the United States increased the death rate by 5% from 2018 to 2019, and postoperative opioid use has been associated with increased postoperative complications in patients undergoing spine surgery.1 Opioid-related complications, such as postoperative delirium, are more pronounced in the geriatric population with a propensity for increased opioid consumption in patients with a higher frailty status.2,3 Therefore, identifying ways to minimize postoperative opioids may improve outcomes for patients.4, 5, 6 Transforaminal lumbar interbody fusion (TLIF) and posterolateral lumbar fusion (PLF) are comparable procedures for treating degenerative conditions of the lumbar spine without clear superiority of one technique over the other in regard to magnitude of improvement in patient-reported outcomes, estimated blood loss, or length of operative duration.7, 8, 9, 10, 11, 12, 13, 14 Previous studies have reported on preoperative and postoperative opioid use in patients undergoing lumbar fusion, but the literature lacks comparisons of postoperative opioid use between these 2 procedure types, with the exception of comparing minimally invasive surgery with open surgery.15,16
Previous literature suggests that TLIFs have increased operative duration compared with PLFs, and typically increased operative duration leads to higher complication rates.17, 18, 19 Additional time under anesthesia also may indicate that a patient is at increased risk for prolonged soft tissue retraction during surgical exposure, which may contribute to persistent postoperative pain.20,21 Research has shown differences in pain outcomes and muscle damage with increased retraction during spine surgery, and it is recommended that retractors be relaxed intermittently to limit this effect.22, 23, 24 While postoperative opioid use is likely related to postoperative pain, limited research exists with regard to operative duration on opioid use following spine surgery.25
The Prescription Drug Monitoring Program (PDMP), a government-regulated database for controlled substance prescriptions, was used for this study owing to its ability to reliably quantify preoperative and postoperative opioid prescriptions for patients regardless of the number or affiliation of prescribers.26 Further, as operative duration is greater in TLIF procedures, we elected to examine operative duration independent from our primary outcome measure. The primary purpose of this study was to compare postoperative opioid prescriptions in patients undergoing single-level TLIF versus PLF in opioid-naïve patients, while secondarily determining if operative duration is associated with the number of postoperative opioid prescriptions.
Section snippets
Data Collection and Study Design
A retrospective review of electronic medical records (EMRs) was conducted after institutional review board approval. All patients ≥18 years of age who underwent open single-level TLIF or PLF with concurrent decompression between September 2017 and June 2020 were identified using a Structured Query Language (SQL) search from current procedural terminology codes. The following patients were excluded: patients with incomplete perioperative data, patients with a preoperative diagnosis of tumor
TLIF versus PLF
Of 345 patients who underwent single-level PLF or TLIF, 174 patients (50.4%) were opioid-naïve before surgery (no opioid prescriptions within 1 year of surgery) and thus met inclusion criteria; 101 (58.0%) opioid-naïve patients underwent PLF and 73 (42.0%) underwent TLIF. The TLIF group was significantly younger (60.8 years vs. 63.8 years, P = 0.048), but there were no significant differences in sex, operative duration, BMI, smoking status, age-adjusted Charlson comorbidity index, diabetic
Discussion
Previous literature comparing TLIF and PLF procedures has focused on PROMs and surgical complications related to these procedures, but there is limited research comparing postoperative opioid usage between procedures. Our results demonstrate that significantly more opioids are prescribed to patients undergoing single-level TLIFs compared with single-level PLFs. Additionally, more prescribers, pharmacies, opioid use days, number of pills, and total MME are used by patients undergoing TLIFs.
Conclusions
Opioid-naïve patients undergoing single-level TLIF received more postoperative opioid prescriptions and used a larger amount of MME compared with patients undergoing PLF. Operative duration did not significantly affect the number of postoperative opioid prescriptions filled regardless of procedure type. However, there was a trend toward inferior ODI and VAS back score at the 3-month postoperative time point in the TLIF group. This trend suggests that TLIFs may provoke higher pain levels and
CRediT authorship contribution statement
Gregory R. Toci: Investigation, Formal analysis, Writing – original draft. Mark J. Lambrechts: Investigation, Formal analysis, Writing – original draft. Jeremy C. Heard: Data curation, Formal analysis, Writing – review & editing. Brian A. Karamian: Writing – review & editing. Nicholas M. Siegel: Data curation. Michael V. Carter: Data curation. John G. Curran: Data curation. Jose A. Canseco: Writing – review & editing. I. David Kaye: Resources, Writing – review & editing. Barrett I. Woods:
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.