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

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


Spine. 2019;44(18):1279-1286. 

In This Article

Abstract and Introduction


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 opioid crisis in the United States has emerged as a national public health concern. In 2016 to 2017, over 11 million Americans misused prescription opioids and its overdosing claimed over 42,000 lives.[1] The economic implications relating to opioid abuse are equally colossal. Between 2001 and 2017, the opioid crisis drained the national treasury in excess of $1 trillion and is projected to cost another $500 billion by 2020 in health care costs, lost wages and tax revenues, spending in social services, rehabilitation, and criminal justice.[2] Despite its deleterious impact, opioid therapy remains one of the most common methods to control acute postoperative pain. However, concerns relating to overwhelming use of prescription narcotics, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery, have been a contentious issue. In alignment with the federal and state regulatory policies in curtailing lenient opioid prescribing practices, national medical organizations have released provider guidelines on opioid use for patients seeking care for orthopedic and spinal disorders.[3]

As a specialty, orthopedic surgeons are ranked third highest in terms of provider volume contributing to opioid pills that are prescribed to adults.[4] his plausibly stems from the intrinsic nature of orthopedic procedures—requiring deep tissue dissection and bone manipulation, often predisposes to release of inflammatory mediators and upregulation of pain receptors, warranting adequate postsurgical pain control strategies. In context to complex spine surgery, requirements for postoperative opioids vary based upon levels of surgical fusion and disease processes. However, postoperative opioid requirements and outcomes can vary based on preoperative opioid dosing.[5–8] Recent studies noted that 45.3% and 42.4% of patients on preoperative chronic opioid therapy (COT) undergoing cervical and lumbar spine arthrodesis will continue to incur atypical opioid requirements at 1 year following surgery.[7,8] In single-level and two-level posterior lumbar fusions, preoperative opioid use was associated with a higher risk for wound complications, readmissions, postoperative use, and resource utilization [increased emergency department (ED) visits, injections, costs].[9] In context to cervical spine surgery, limited literature exists that comprehensively assesses the impact of COT on outcomes. Single-institutional and multicentric studies are limited and are largely biased by smaller sample size and inherent selection bias.[10–14] A retrospective post-hoc analysis from two prospective, multicentric trials investigating the relationship of preoperative opioid strength and outcomes after anterior cervical decompressive surgery noted no association between preoperative narcotic intake and poor outcomes for single-level cervical disease,[14] albeit contrary to previous studies and existing consensus on opioid use with outcomes.[10–12] A paucity of literature and conflicting reports necessitates a comprehensive evaluation of the impact of preoperative opioids with outcomes using a national cohort.

Further, recent investigation using the Military Health Data Repository noted spinal conditions as the most frequently associated diagnosis with initial opioid prescription in both civilian and military population.[15] In conjunction with multi-fold increase in total spinal fusions as witnessed in the recent past[16] and the forecasted projections for 2030 and 2040 depicting 47% and 76% increment (from 2014) in utilization rates,[17] it is pertinent to standardize multimodal pain management strategies to limit opioid overuse. In context to cervical spine fusions, projections for utilization rates are anticipated to increase by 34% and 54% in 2030 and 2040, respectively.[17] With this likely uptrend, it is critical to test and quantify the association of preoperative COT on outcomes following cervical fusions.

Therefore, the current study seeks to elucidate the risk of preoperative COT on short and long-term outcomes, including reoperations, resource utilization (ED visits, injections), adverse events, and postoperative opioid usage in patients undergoing cervical spine arthrodesis. We hypothesize that insights from a national cohort can confer generalizability in understanding risk of chronic preoperative opioid use with outcomes, aid in the formulation of practice recommendations, and provide impetus to the development of standardized preoperative opioid weaning protocols.