Preoperative Spine Evaluation and Assessment

1. Preoperative Opioid Evaluation

Recommendations

Question 1:

Does duration of preoperative opioid use impact postoperative opioid use (duration, morphine milligram equivalents), patient-reported outcomes, or adverse events after spine surgery?

Recommendation:

Longer duration of opioid use before spine surgery is associated with worse outcomes (chronic postoperative opioid use, higher complications, increased of stay, and higher costs and utilization of resources). Strength of Recommendation: Grade B

Question 2:

Does preoperative morphine milligram equivalents impact postoperative opioid use (duration, morphine milligram equivalents), patient-reported outcomes, or adverse events after spine surgery?

Recommendation:

Preoperative opioid use of any dose (yes/no) is associated with risk of longer duration of postoperative opioid use and worse clinical and patient-reported outcomes. Strength of Recommendation: Grade B

Question 3:

Does preoperative weaning of opioids impact postoperative opioid use (duration, morphine milligram equivalents), patient-reported outcomes, or adverse events after spine surgery?

Recommendation:

There is insufficient evidence to support the efficacy of opioid weaning on postoperative opioid use, improving outcomes, or reducing adverse events after spine surgery. Strength of Recommendation: Grade Insufficient

Overview

Opioid use disorders in the United States have rapidly increased, yet little is known about the relationship between preoperative opioid duration and dose and patient outcomes after spine surgery. Likewise, the utility of preoperative opioid weaning is poorly understood. From 2005 to 2014, opioid use disorders increased 6.47% annually in the United States and were reported 25% more often between 2010 and 2014 compared with 2005 to 2009 among patients hospitalized for treatment of spinal conditions.³ In the current opioid crisis, provider prescribing practices and the effects of perioperative opioid use are under intense scrutiny. Despite increasing attention to opioid use, evidence to support best practice regarding preoperative opioid dose and duration in the management of patients with surgical degenerative spine disease is not well known. Likewise, the efficacy of preoperative opioid weaning is poorly understood, although this has been suggested as a potential intervention.

The purpose of this evidence-based clinical practice guideline is to determine if duration and dose of preoperative opioids or preoperative opioid weaning is associated with patient-reported outcomes or adverse events after elective spine surgery for degenerative conditions.

The literature supports higher complications, worse outcome, and lower return to work among patients who use preoperative opioids, and patients who use preoperative opioids for a prolonged period before surgery. In addition, there are limited data to support the efficacy of an opioid wean before spine surgery.

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