Background & Aims

Over 50% of patients undergoing lumbar spine surgery experience acute postoperative pain, defined as a numeric pain rating scale (NPRS) of ?4 [[1]. Acute postoperative pain is associated with an increased risk of complications, and chronic postsurgical pain [[2–5]. Despite the use of a multimodal analgesic regimen, some patients experience refractory pain, defined as a NPRS of ?7 and the need for escape medication, such as esketamine, benzodiazepines or clonidine. Preoperative risk stratification could contribute to the prevention of unfavorable outcomes by identifying patients who will develop this refractory pain after lumbar spine surgery. In this study we aimed to identify predictive factors which could be used to preoperatively identify these patients.

Methods

We performed a retrospective analysis of prospectively collected data conducted at a Dutch tertiary orthopedic hospital. Baseline and outcome data from patients who underwent lumbar spine surgery between July 2012 and December 2022 were included in this study. A total of 105 variables were considered potential predictive variables for the primary outcome refractory pain after lumbar spine surgery (yes/no). Lasso regression analysis was performed to determine relevant predictive variables. The data are presented as univariate as well as adjusted odds ratio (OR). Data were adjusted for all relevant predictive variables in the lasso regression model.

Results

Data from 1,156 patients (40% male) who underwent lumbar spine surgery were included in the analysis. Baseline data analyses showed: mean age 57 years (range 17-85); BMI 26.5kg/m² (range 17-44); mean preoperative back NPRS 6.9 (SD 2.1), and preoperative leg NPRS 6.4 (SD 2.7). The prevalence of patients with refractory pain was 19.6% (n=228). Lasso regression identified 13 predictive variables for refractory pain after lumbar spine surgery: preoperative opioid use, circumferent surgery, younger age, instrumented surgery, high risk for invalidating low back pain, high back NPRS, return to work, duration of back pain, sport status, anxiety, back pain before age of 45, catastrophizing, and previous therapy for back pain. Preoperative opioid use was the strongest predictor with an unadjusted OR of 1.98 (95%-CI 1.47-2.67) – adjusted OR was 1.84 (SE 0.17). The prevalence of preoperative opioid use was 49.1% in the refractory pain vs 32.9% in the manageable pain group (p < 0.001).

Conclusions

This risk prediction study identified preoperative opioid use as the most important predictive variable for refractory postoperative pain after lumbar spine surgery, as is consistent with previous research [6,7]. This highlights the need to reduce opioid prescribing for chronic non-cancer pain, especially in the preoperative setting. Preoperative tapering of opioids can directly improve surgical outcomes, as has been shown in total joint arthroplasty[8]. However, evidence into tailored strategies to reduce pre- and postoperative opioid use are lacking. Future research should focus on making an inventory of evidence-based opioid tapering strategies, as well as taking into account costs and impact analysis.

References

1 Nielsen RV, Fomsgaard JS, Dahl JB, et al. Insufficient pain management after spine surgery. Dan Med J. 2014;61:A4835.
2 Rivas E, Cohen B, Pu X, et al. Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials. Anesthesiology. 2022;136:115–26.
3 Fletcher D, Stamer UM, Pogatzki-Zahn E, et al. Chronic postsurgical pain in Europe: An observational study. Eur J Anaesthesiol. 2015;32:725–34.
4 Gilron I, Carr DB, Desjardins PJ, et al. Current methods and challenges for acute pain clinical trials. Pain Rep. 2019;4:1–12.
5 Van Boekel RLM, Warlé MC, Nielen RGC, et al. Relationship between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study. Ann Surg. 2019;269:856–65.
6 Yang MMH, Riva-Cambrin J, Cunningham J, et al. Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery. J Neurosurg Spine. 2021;34:3–12.
7 Yerneni K, Nichols N, Abecassis ZA, et al. Preoperative Opioid Use and Clinical Outcomes in Spine Surgery: A Systematic Review. Neurosurgery. 2020;86:E490–507.
8 Nguyen LCL, Sing DC, Bozic KJ. Preoperative Reduction of Opioid Use Before Total Joint Arthroplasty. Journal of Arthroplasty. 2016;31:282–7.

Presenting Author

Ilse H. van de Wijgert

Poster Authors

Ilse van de Wijgert

MD

Sint Maartenskliniek

Lead Author

Kris Vissers

MD

Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center

Lead Author

Rianne van Boekel

Radboud University

Lead Author

Martijn W. Heijmans PhD

Amsterdam UMC

Lead Author

Miranda L. van Hooff

PhD

Department of Research, Sint Maartenskliniek, the Netherlands

Lead Author

Topics

  • Models: Acute Pain