October 27, 2022

Devices that generate objective data allow providers to tailor post-op treatments more safely and accurately.

Engineering and medical researchers from The Ohio State University (OSU) are developing a digital health system approach that is designed to enhance the decision-making of providers who treat patients recovering from spine surgery.

These providers rely on their patients to let them know when they are feeling pain and discomfort, which can lead to numerous and potentially unnecessary expensive tests and treatments. "You simply can't only ask people how they feel about their back," says William Marras, PhD, CPE, executive director of the Spine Research Institute at OSU. "People are asked to rate how they feel on a scale of 1 to 10, but since you don't have pain receptors in the disc, what does that mean?"

The goal of the new OSU technology is to bring objective metrics to the table to better inform treatment decisions. Dr. Marras, whose lab has studied daily living forces on the spine for decades and developed the first wearable back sensor 30 years ago, says the team is working to enable providers to look at not only how people feel about their back pain, but also quantitatively measure how their motions are different and what that means in terms of biomechanics.

The OSU researchers believe that objective functional assessments may be a better indicator of when it's safe for patients to return to normal activities after spinal fusion surgery. "Our technology is able to look at, one, whether or not you have a back impairment, and two, what is its status?" says Dr. Marras. "Is it getting better, is it getting worse, is it progressing or is it off the scales? When you're doing damage to the back, and particularly the discs, you don't know when the damage occurs because we have very few nerve receptors in the disc. You could be doing damage and people would never know."

Take a deeper dive into the OSU project through the team's published study in Clinical Biomechanics.

The rapid-onset drug could provide sustained post-op pain relief.

An examination of research into the intraoperative use of the long-acting opioid methadone in spine patients shows a potentially promising future for its use in same-day surgical settings.

The article, published in Journal of Pain Research, notes that methadone could play a key role in the growth of outpatient spine by providing reliable, sustained postoperative analgesia. Methadone, a rapid-onset drug that produces up to three days of pain relief at a dosage of 20mg, might prove useful for patients who suffer from significant prolonged preoperative pain in addition to the discomfort their procedures will cause during the first few days of recovery.

Intraoperative methadone has been effectively used in complex inpatient and shorter-stay spine surgeries, but barriers remain to its use in ambulatory surgery. The barriers include concern about post-op respiratory depression, which the article notes would carry greater consequences for patients who are discharged on the day of their procedures. The authors note, however, that respiratory depression would most likely occur within 45 minutes of administration.

Other concerns include methadone's association with significant cardiac arrythmias, and conscious or unconscious biases among patients and providers due to the drug's primary application as a treatment for opioid use disorder.

Patient selection, already critical for successful outpatient spine surgery, would be even more important if intraoperative methadone is in the procedural mix. "Patients with significant cardiac or pulmonary comorbidities, morbid obesity and known history of obstructive sleep apnea would be at higher risk for respiratory depression," states the article.

On the plus side, say the authors, methadone is inexpensive, does not add to anesthesia time and requires no specialized equipment or additional training. The drug could also decrease the number of opioids prescribed to patients to take at home, which would reduce the number of unused pills in home medicine cabinets that could be diverted for misuse.

The authors note that more studies are needed to assess the risks and benefits of intraoperative methadone use for same-day spine surgery. However, methadone could become a promising tool for improved pain control as outpatient centers schedule increasingly complex procedures.

Relationships help guide patients to prompt treatment

Medtronic
Dr. Ali Valimahomed

Prompt identification of patients and close relationships with referring physicians can make a positive difference in outcomes for treating painful vertebral compression fractures (VCFs). That's according to Dr. Ali Valimahomed, a pain management and rehabilitation physician who practices with Gramercy Pain Center in Holmdel, N.J.

For appropriate patients with VCFs, Valimahomed favors vertebral augmentation via balloon kyphoplasty. Balloon kyphoplasty (BKP) is a minimally invasive surgical procedure for the treatment of spinal fractures due to osteoporosis, cancer or benign tumors.

"For me, it's someone who is having significant pain — at least 5-out-of-10 in an outpatient setting or severe pain in the hospital, like 8-out-of-10 — not responding to conservative care and bracing, or someone who has had a progressive fracture with loss of height," Valimahomed says. "Some of the patients we see are on high-level opioids and are not responding to conservative care. VCFs really impact their quality of life. It's one of the most rewarding procedures we can do in our profession. It's something I really enjoy doing."

Valimahomed does rounds at two area hospitals, where he has developed a working understanding with emergency room physicians.

"If there is someone with a compression fracture, we tell them we'll get them in at the clinic the following day or within a couple days," he says. "That way, they can prevent these patients from being admitted and we can triage them."

Although the complication rate for BKP is low, as with most surgical procedures serious adverse events, some of which can be fatal, can occur including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; and leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs and/or heart.

Valimahomed also has treated patients he identified by visiting sub-acute rehabilitation centers.

"Not everyone follows the same kind of treatment, so oftentimes patients get discharged to sub-acute rehabs, don't have a surgeon or pain physician who is doing BKPs, or for whatever reason they decided not to treat them. You find patients who aren't doing well, aren't able to participate in therapy, the pain is a barrier to rehab, you're not able to mobilize the patients. That's where we have been able to step in. The centers I go to, they call me when they are having issues with patients. I get them back into rehab so they can mobilize."

Learn more about balloon kyphoplasty at medtronic.com/kyphoplasty.