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October 27, 2022
Publish Date: October 26, 2022   |  Tags:   Neurosurgery-Spine

THIS WEEK'S ARTICLES

Wearable Technology Could Standardize Spine Surgery Recovery

Methadone Shows Promise for Use in Outpatient Spine

Balloon Kyphoplasty Delivers Rewarding Results, Pain Physician Says - Sponsored Content

Preparing for Complications of Spine Surgery

Pain Catastrophizing Impacts Spine Outcomes

 

Wearable Technology Could Standardize Spine Surgery Recovery

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

Marras Ohio State News
DIGITAL ASSISTANCE Dr. Marras believes the sensor will allow doctors to go beyond patients' subjective self-reports of post-op pain by quantitatively measuring their motions to better understand the biomechanics at work.

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.

Methadone Shows Promise for Use in Outpatient Spine

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

Methadone INTRAOPERATIVE OPTION? Intraoperative methadone has pain relief potential for outpatient spine surgeries, but perioperative teams must also be aware of the specific risks of providing it in same-day settings.

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.

Balloon Kyphoplasty Delivers Rewarding Results, Pain Physician Says
Sponsored Content

Relationships help guide patients to prompt treatment

Valimahomed 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.

Preparing for Complications of Spine Surgery

Research suggests comorbidities are a better predictor of post-op problems than age.

Patients scheduled to undergo spine surgeries should be closely screened and monitored, regardless of their age, according to a recent analysis of risk factors for perioperative complications.

The researchers, who published their study in Scientific Reports, analyzed outcomes and complication rates in 526 patients who consecutively underwent spinal surgery in a single department at a tertiary spine center between November 2017 and November 2018. The overall postoperative complication rate was 26%, and revision surgery was required in 12% of cases within 30 postoperative days. The most frequent complications included wound healing disorders, re-bleeding and cerebrospinal fluid leakage.

Intraoperative complications, which emerged in nearly 5% of the cases, included accidental Dural lesions, injury of the vertebral artery, premature termination of surgery due to unexpectedly high blood loss or cardiopulmonary instability, accidental rhizotomy and cement leakage. Just over 25% of the patients suffered postoperative complications within 30 days, and almost one in five of those patients had already been discharged when their complications occurred. Other interesting findings included:

  • Surgeries combining cervical and thoracic spine or thoracic and lumbar spine treatments showed significantly more postoperative complications than interventions on the cervical, thoracic or lumbar regions alone.
  • Patients diagnosed with metastatic tumor or atrial fibrillation developed significantly more postoperative complications.
  • Age did not correlate with more complications nor to the probability of undergoing revision surgeries. "This highlights that the comorbidities of the patients, as well as their constitution, should be considered, whereas patients' age is no longer relevant," the researchers write.
  • "Discharge to a location that is not home seems to increase complication rates postoperatively," note the researchers, adding that attempts for early discharge to home should be made, especially with older patients, in the interest of the patients mobilizing earlier and regaining their independence to better prevent complications, readmission and revision surgeries.
  • A low postoperative Karnofsky performance status (KPS) triggers more complications, reduced mobility and less self-sufficiency. The researchers say a lower postoperative KPS could be an independent predictor for overall complications, overall survival and outcomes for patients with spinal metastases.
  • Patients with postoperative anemia showed longer hospital stays and significantly higher risks of postoperative complications. "Screening for and therapy of anemia before elective spine surgery, as well as postoperatively, is therefore recommended," the researchers write.
  • The researchers found that age-adjusted chronically/critically ill patients, metastatic tumor and atrial fibrillation are significant risk factors for postoperative complications. Patients with a higher BMI showed higher odds for revision surgeries.
  • Prevention of postoperative anemia and early mobilization and discharge of patients is preferable when possible.
  • Efforts to reduce the duration of surgeries, alongside reduced blood loss, can reduce intraoperative and postoperative complications.

The researchers say their work highlights the importance of evidence-based operative and nonoperative therapies. "Complication rates after spinal surgeries are still high, especially in patients with metastatic tumor disease and poor clinical status, requiring revision surgeries in several cases," they write. "In light of an increasing number of older patients with a higher number of comorbidities often being referred to tertiary spine centers, surgeons are forced to balance the risks associated with operation against the potential benefits for their patients. Therefore, specific risk factors should be determined to carefully select surgery groups."

Pain Catastrophizing Impacts Spine Outcomes

The cognitive condition identifies patients who are in need of psychological counseling before surgery.

Pediatric patients who exhibit pain catastrophizing before undergoing posterior spinal fusion surgery to treat adolescent idiopathic scoliosis (AIS) are more likely to report persistent post-op discomfort, according to a study published in The Journal of Bone & Joint Surgery. Pain catastrophizing, a pattern of negative thoughts and feelings of helplessness in the presence of soreness, is associated with poor responses to treatments and low patient-reported outcomes of surgery.

The study's authors assessed 189 AIS patients who underwent posterior spinal fusion surgery, 20 of whom experienced pain catastrophizing, with the Scoliosis Research Society Questionnaire-30 (SRS-30). The 30-item tool is designed to measure patients' health-related quality of life based on their self-reported pain, activity levels, function, self-image, mental health and satisfaction with the care they receive. The higher the score, the better the outcome. The researchers say a pre-op SRS-30 pain score of less than 3.5 has good sensitivity for predicting pain catastrophizing in patients.

The patients who exhibited pain catastrophizing in the study had lower self-reported average scores (2.98) before surgery than patients who did not exhibit the cognitive condition (3.95). At two years post-op, the pain-catastrophizing patients experienced significant improvement in most SRS-30 scores, including a clinically relevant jump in pain (3.84), but continued to have lower scores than patients in the non-pain-catastrophizing group.

Preoperative evaluations of pain-related symptoms and psychological factors in patients undergoing scoliosis surgery might be useful in identifying therapeutic targets and risk factors that can be modified to improve outcomes, note the researchers. "Identification of pain catastrophizing in the AIS population could allow specific preoperative psychotherapies to be directed to this problem and benefit these patients," they write. "Our study serves to highlight a specific psychological trait that correlates strongly with patient-reported outcomes and demonstrates a significant effect on the perception of pain before surgery and at two years postoperatively."

The researchers note that systems used to identify pain catastrophizing preoperatively, such as screening for an SRS-30 pain score of less than 3.5, can assist surgeons in making appropriate referrals for psychological counseling and ultimately enable patients to have better postoperative outcomes.

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