Department of Orthopedic Surgery, Vanderbilt University, School of Medicine Medical Center East, South Tower, Suite 4200, Nashville, TN 37232-8774, USA.
Department of Orthopedic Surgery, Vanderbilt University, School of Medicine Medical Center East, South Tower, Suite 4200, Nashville, TN 37232-8774, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave. So. T4224 Medical Center North, Nashville, TN 37232-2380, USA.
Spine J. 2018 May;18(5):788-796. doi: 10.1016/j.spinee.2017.09.009. Epub 2017 Sep 28.
Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain.
We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection.
This study is a retrospective analysis of a prospective longitudinal registry database.
A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study.
Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection.
Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases.
A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg-19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold.
Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.
慢性阿片类药物治疗与脊柱手术后患者报告的结局（PROs）恶化有关。然而，关于硬膜外类固醇注射治疗根性疼痛后阿片类药物使用与 PROs 之间的关系，文献很少。
我们评估了注射前阿片类药物使用与脊柱硬膜外类固醇注射后 PROs 之间的关系。
这是一项对前瞻性纵向登记数据库进行的回顾性分析。
本研究共纳入了 392 名在我院因退行性脊柱结构疾病接受硬膜外类固醇注射（ESI）的患者，符合纳入标准。
患者的残疾（Oswestry 残疾指数/颈部残疾指数[ODI/NDI]）、生活质量（EuroQol-5D[EQ-5D]）和疼痛（背部疼痛、颈部疼痛、腿部疼痛和手臂疼痛的数字评分量表评分[NRS-BP/NP/LP/AP]）等 PROs，在基线时和注射后 3 个月及 12 个月进行评估。
采用多变量比例优势逻辑回归模型来检验注射前阿片类药物使用与注射后 PROs 的关系。采用贝叶斯马尔可夫链蒙特卡罗参数估计逻辑回归，以探讨注射前阿片类药物使用的可能截断值，超过该值，硬膜外类固醇注射的效果（以 ODI/NDI 的最小临床重要差异[MCID]衡量）会降低。
共分析了 276 名接受 ESI 后完成 12 个月随访的患者。队列的平均注射前每日吗啡等效剂量（MEA）为 14.7mg（95%置信区间[CI]12.4mg-19.1mg）。仅在注射后 3 个月时，注射前阿片类药物使用与残疾（优势比[OR]1.03，p=.03）和腿部/手臂疼痛（OR1.01，p=.04）评分恶化的可能性略高相关。虽然 55.5mg/天的截断值可能是一个重要的阈值，但我们未发现注射前阿片类药物使用与 ODI/NDI 的 MCID 之间存在显著关联。
对于退行性脊柱疾病，硬膜外类固醇注射前增加阿片类药物使用并不影响长期结果。注射前 MEA 约为 50mg/天可能代表一个阈值，超过该值，硬膜外类固醇注射治疗背部和颈部相关残疾的 3 个月效果会降低。硬膜外类固醇注射是一种治疗使用阿片类药物患者疼痛的有效治疗方法，可作为阿片类药物独立的多模式治疗策略的一部分。
