Elsamadicy Aladine A, Adogwa Owoicho, Fialkoff Jared, Vuong Victoria D, Mehta Ankit I, Vasquez Raul A, Cheng Joseph, Bagley Carlos A, Karikari Isaac O
Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA.
J Spine Surg. 2017 Jun;3(2):155-162. doi: 10.21037/jss.2017.04.04.
Patient reported outcomes and length of hospital stay (LOS) are being used as a proxy for hospital care. An extra day of hospitalization costs thousands of health care dollars. The choice of intraoperative pain medications has been associated with decreased pain scores in other surgical subspecialties. However, the effects of immediate post-operative patient-controlled analgesics (PCA)/intravenous (IV) pain medication on patient care are not well understood in spine surgery. The aim of this study is to determine the effects of different immediate post-operative pain medications on post-operative complications profile, LOS, and patient reported outcomes (PROs) after elective spine surgery.
The medical records of 230 patients (morphine: n=98, fentanyl: n=61, hydromorphone: n=71) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized by the immediate post-operative pain medication they were on, with the most common medications being PCA/IV morphine, fentanyl, and hydromorphone. Patient demographics, comorbidities, and post-operative complication rates were collected. All patients had retrospectively collected outcomes measures and a minimum of 6-month follow up. Patient reported outcomes instruments [Oswestry Disability Index (ODI), SF-36 and Neck/Back/Leg-Pain Visual Analog Scale (VAS-NP/BP/LP)] were completed before surgery, then at 3- and 6-month after surgery.
Baseline characteristics were similar in all cohorts. Operative variables were also similar in all cohorts, with no difference in operative time, estimated blood loss (EBL), or fusion levels. Complication rates were similar between cohorts, with the fentanyl-cohort having an increased percentage of urinary tract infection (UTI) than the morphine and hydromorphone cohorts (16.39% 5.15% 5.63%, P=0.0277). The morphine-cohort had a decreased LOS than the fentanyl and hydromorphone cohorts (4.18 5.56 5.69 days, P=0.0376). There was a significant difference in the number of feet first ambulated by the patient post-operatively for the morphine and hydromorphone cohorts than the fentanyl-cohort (morphine: 118.44±18.15 fentanyl: 59.26±20.78 hydromorphone: 125.91±19.85, P=0.0420). There was no significant differences in 30-day hospital readmission rates between the cohorts, morphine-cohort did trend lower than the other cohorts (morphine: 5.10 fentanyl: 11.48 hydromorphone: 11.27, P=0.2492). There were no significant differences in PROs between the two cohorts in ODI, SF-36, and VAS-NP/BP/LP at baseline, 3- and 6-month.
Our study demonstrates that the choice of immediate post-operative pain medication can make a difference in the hospital course for patients. Identifying these types of factors might help increase patient care and reduce health care costs.
患者报告的结果和住院时间（LOS）正被用作医院护理的替代指标。多住一天院会花费数千美元的医疗费用。在其他外科专科中，术中疼痛药物的选择与疼痛评分降低有关。然而，脊柱手术中术后即刻患者自控镇痛（PCA）/静脉注射（IV）疼痛药物对患者护理的影响尚未得到充分了解。本研究的目的是确定不同的术后即刻疼痛药物对择期脊柱手术后的术后并发症情况、住院时间和患者报告结果（PROs）的影响。
回顾了一家大型学术医疗中心230例行择期脊柱手术患者的病历（吗啡组：n = 98，芬太尼组：n = 61，氢吗啡酮组：n = 71）。患者根据术后即刻使用的疼痛药物进行分类，最常用的药物是PCA/IV吗啡、芬太尼和氢吗啡酮。收集患者的人口统计学资料、合并症和术后并发症发生率。所有患者均回顾性收集了结局指标，并进行了至少6个月的随访。患者报告结局工具[Oswestry功能障碍指数（ODI）、SF - 36和颈/背/腿痛视觉模拟量表（VAS - NP/BP/LP）]在手术前、术后3个月和6个月完成。
所有队列的基线特征相似。所有队列的手术变量也相似，手术时间、估计失血量（EBL）或融合节段无差异。各队列之间的并发症发生率相似，芬太尼组的尿路感染（UTI）百分比高于吗啡组和氢吗啡酮组（16.39% 5.15% 5.63%，P = 0.0277）。吗啡组的住院时间比芬太尼组和氢吗啡酮组短（4.18 5.56 5.69天，P = 0.0376）。术后患者首次行走的步数，吗啡组和氢吗啡酮组与芬太尼组相比有显著差异（吗啡组：118.44±18.15 芬太尼组：59.26±20.78 氢吗啡酮组：125.91±19.85，P = 0.0420）。各队列之间30天再入院率无显著差异，吗啡组的趋势低于其他队列（吗啡组：5.10 芬太尼组：11.48 氢吗啡酮组：11.27，P = 0.2492）。在基线、术后3个月和6个月时，ODI、SF - 36和VAS - NP/BP/LP方面，两组队列之间的PROs无显著差异。
我们的研究表明，术后即刻疼痛药物的选择对患者的住院过程有影响。识别这些类型的因素可能有助于改善患者护理并降低医疗成本。
