Pain Medication Use after Spine Surgery

Extract

Dear Editor:

Spine surgery is one of the most difficult areas in which to achieve a good clinical outcome after surgery. When compared with the other orthopedic subspecialties, such as joint replacement surgery, a higher percentage of postoperative patients continue to have symptoms that require pain medication utilization and some require further surgeries. Failure rates associated with lumbar fusion surgeries range from 10% to 40% [1]. This high rate of unsuccessful spine surgery has generated the term “failed back surgery syndrome.” Strong indications for spine surgery are instability of the spine and neurological deficits including motor deficit and bladder and bowel dysfunction, while pain remains strictly a relative indication. However, an increasing number of spine surgeries are recently being performed based mainly on pain symptoms.

The use of postoperative pain medication following spine surgery is nearly universal. However, despite the prevalence of use, there is no standardized protocol detailing the type, strength, or duration of pain medication use following specific procedures. Optimally, surgery should relieve the symptoms that brought the patient to surgery, with the termination of pain medication following the acute postoperative period, generally within 1 month. However, pain medication use is often continued long after this recovery period. The reason for pain medication implementation depends on individual circumstances; however, they are often needed for incomplete resolution of the symptoms for which surgery was originally indicated. In fact, previous literature described continuous pain medication use by a significant proportion of patients beyond 1 year after spine surgery. Ali et al. [2] reported that 35% of patients continued to take pain medications for symptoms at 38 months following fusion surgery for adult idiopathic scoliosis. In comparing lumbar disc arthroplasty with fusion for single-level degenerative disc disease, Blumenthal et al. [3] reported a narcotic use rate of 64% in the arthroplasty group and 80.4% in the lumbar fusion cohort at 24 months after surgery. Despite this high narcotic requirement, these patients were within a subgroup of patients that were categorized as a clinical success. Hallet et al. [4] reported that 64–83% of patients with lumbar single-level disc disease were taking at least one oral strong analgesic or anti-inflammatory agent at 2 years after decompression or fusion surgery. Among patients reported as achieving overall success following surgery for single-level lumbar degenerative disc disease at 24 months, Zigler et al. [5] reported that 31% of ProDisc patients and 39% of fusion patients remained on narcotics. While some patients may develop additional spine pathology 5–10 years after surgery, these conditions should not alter the 1–2-year outcomes after surgery. Thus, the surgery may not necessarily be as successful as the outcome measures would indicate in patients showing an improved visual analog scale (VAS) score or clinical outcome measures after surgery, who nevertheless continue to take strong pain medications. Indeed, some other pathologies of the spine might remain or the surgery may not have been indicated for the pathology diagnosed. In fact, Epstein and Hood [6] reported that 47 (17.2%) of 274 spinal consultations seen by a single neurosurgeon were scheduled for “unnecessary surgery.”