Post-operative opioid utilization after surgery for spinal trauma: a retrospective study at a level 1 trauma center

Introduction

In the wake of the opioid epidemic, there has been significant, practice-changing legislation surrounding opioid prescribing (1). As policy and regulation continue to evolve, the literature demonstrates that opioid use in patients with spinal conditions may differ based on many factors, including mental health status, demographics, race/ethnicity, and socioeconomic status (2-9). Prior studies have associated higher perioperative opioid use with younger age (2), male sex (2), black/African American race (4,5), higher body mass index (9), higher socioeconomic status (2,6), mental health conditions (2,7,9), antidepressant use (3), and substance use (e.g., cannabis) (2,9,10) in the elective spine surgical population.

A few studies have specifically studied opioid usage in a spinal trauma population. Tilhou and colleagues (11) studied 65 spine trauma patients in their cohort, finding that spine trauma specifically predicted opioid use disorder, predominantly driven by injury severity, intubation status, and length of stay. Fisher and colleagues (12) analyzed a cohort of 1,578 spine trauma patients, identifying them as having the longest length of stay, highest mean pain scores, and highest morphine milligram equivalents (MME) over a 90-day post-operative period (1,797.15±5,682.6). A recent study used propensity-matched scoring to compare cervical fusions performed for 48 trauma patients with 48 cervical degenerative spine patients, showing that trauma patients consumed fewer opioids than their degenerative counterparts (13). Although this study collected information on injury location and characteristics, these data points were not correlated with opioid use.

Although these studies have laid the groundwork in establishing a better understanding of opioid use in spine trauma patients, additional clarity is needed on injury-specific factors that may predispose to higher or longer-term opioid use in this population. This study aims specifically to evaluate such modifiable and non-modifiable factors that may influence opioid utilization following surgical intervention for spinal trauma. We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-2/rc).

Methods

Ethics statement and study design

This study was conducted at a single, large level 1 trauma center (Grady Memorial Hospital) in the Southeastern United States, utilizing a retrospective chart review model with data extracted from the hospital’s electronic medical record. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Emory University (No. STUDY00006365) and the research committee of Grady Memorial Hospital (No. #000-6365) (Grady Memorial Hospital is a teaching facility for Emory University). Individual consent for this retrospective analysis was waived.

The study comprised individuals (18 years or older) who underwent surgical intervention for traumatic spine injuries between July 17, 2017, and May 21, 2021, within the cervical, thoracic, or lumbar regions. Current procedural terminology (CPT) codes were used to query the hospital medical record for all spine surgeries performed within the time period of the study by the orthopaedic surgery department. CPT codes included 22325, 22326, 22327, 22551, 22554, 22558, 22590, 22595, 22842, 22843, 22844, 63001, 63003, 63005, 63015, 63016, 63017, 63045, 63047, 63050, 63051, 63081, 63085, and 63086. This query resulted in a total of 298 cases. Cases involving surgery for chronic degenerative [92], infectious [19], or oncologic [4] spine diagnoses in the region of injury were excluded. We also excluded any patients with restricted review by the hospital [61], cauda equina syndrome [3], or who were incorrectly coded by the review as no actual surgery was undertaken [10].

Data extraction

Patients meeting the above inclusion criteria were identified, and demographic, perioperative, and postoperative characteristics were extracted from the patient’s medical record, including sex, race, ethnicity, BMI, nature of spinal trauma (e.g., vertebral body burst fracture, central cord syndrome, dislocation, upper cervical trauma, spinopelvic injury), spinal cord injury (SCI) completeness (complete, incomplete, or none) and level (hemiplegia, hemiparesis, quadriplegia, quadriparesis, or none), and recovery status (full, partial, or no motor or sensory), home distance from hospital, length of stay, follow-up, intra-operative status, polytrauma status, intracranial hemorrhage, pelvis/extremity fracture, traumatic vertebral artery injury, rib fracture, craniofacial fractures, abdominal injury, and Charlson comorbidity index. Regarding narcotic usage, narcotic usage at presentation, substance use on presentation, inpatient and outpatient opiate prescriptions, and total daily MME prescribed on discharge and at final follow-up were obtained.

Statistical analysis

Statistical analyses were performed using MATLAB R2023b. Continuous variables (e.g., age, BMI, home distance from hospital, and length of stay) were assessed using bivariate linear regression to evaluate their relationship with MME use at discharge. Categorical variables (e.g., gender, race, ethnicity, spinal segment, SCI completeness, and recovery status) were analyzed using one-way analysis of variance (ANOVA) to compare group differences in MME at discharge and at final follow-up. When significant group differences were identified, Bonferroni-corrected post hoc comparisons were conducted to reduce type I error risk in multiple comparisons to confirm significance.

Multivariable logistic regression was performed to identify independent predictors of opioid discontinuation at final follow-up, categorizing participants into two groups (weaned vs. not weaned). Variables with a P<0.20 on bivariate analysis were initially considered for inclusion in the multivariable logistic regression model. A stepwise manual reduction process was then applied to refine the model, iteratively removing non-significant variables to improve model fit while retaining the most clinically and statistically relevant predictors. Adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated to quantify the strength of association between each predictor and the likelihood of opioid discontinuation. Model performance was assessed using a Chi-square comparison to a constant model. All analyses excluded missing data on a per-variable basis.

Results

A total of 109 patients were available for study: average age 51.71±18.00 years, 76 male and 33 female, average BMI 27.97±6.16 kg/m², and average follow-up of 578.93±655.61 days. The average home distance from the hospital was 67.27±186.35 miles. Additional demographics are provided in Tables 1,2. There were 5 total deaths in the patient cohort. Total daily MME upon discharge was 44.67±34.14 mg, which was significantly different from the daily MME on final follow-up of 7.86±19.33 mg (P=0.004).

Further characteristics of the nature of spinal traumas sustained, associated neurologic statuses, and associated injuries are included in Table 3. Of the 109 patients, 66 (60.6%) sustained cervical injuries, 18 (16.5%) thoracic injuries, and 25 (22.9%) lumbar injuries. Among the patients, 68 (62.4%) sustained some element of SCI or nerve root deficit. Of these 68 patients with some degree of neurologic deficit, 39 (57.4%) achieved some element of motor or sensory recovery. SCI completeness and recovery characteristics showed significant trends with total daily MME at discharge. Bonferroni-corrected post hoc analyses displayed in Tables 4-6 revealed that patients with incomplete spinal cord injuries had significantly higher MME at discharge compared to those with complete injuries (58.18 vs. 31.73 mg, P=0.006). Similarly, partial motor and sensory recovery was associated with higher opioid use at discharge compared to no recovery (59.30 vs. 31.54 mg, P=0.03). Among spinal segments, cervical-level injuries were associated with lower MME at final follow-up compared to thoracic injuries (P<0.001).

Furthermore, the average length of stay in the hospital was 20.18±23.31 days. A total of 5 perioperative complications were noted, including two intraoperative loss of neuromonitoring signals (1.8%), 1 post-operative C5 palsy (0.9%), 1 post-operative epidural hematoma (0.9%), and 1 patient (0.9%) who had 2 procedural abortions due to hemodynamic instability. No additional spinal injury characteristic or associated injury showed bivariate significance with daily MME at discharge or at final follow-up, including associated dislocation, vertebral burst fracture, or polytrauma. Additionally, although the initial analysis of SCI level showed statistical significance, this association was not maintained after Bonferroni correction in the subgroup analysis (see Table S1).

Table 7 provides opioid use characteristics for the patient cohort. All 109 (100%) of the patients were placed on some form of narcotic for inpatient pain control, with fentanyl (107, 98.2%) being the most common medication prescribed. Of the patients, 93 (85.3%) were discharged with some form of narcotic prescription, with oxycodone (65, 59.6%) being the most common medication prescribed. Only 4 patients (3.7%) were prescribed naloxone on discharge. Only 3 patients (2.8%) presented with a history of narcotic usage at baseline. Five patients (4.6%) had a history of substance use on presentation.

Follow-up MME data were available for 85 of the 93 patients discharged with opioid prescriptions. Of these, 64 patients (75.3%) were successfully weaned off opioids, while 21 patients (24.7%) continued opioid use at final follow-up. Multivariable logistic regression shown in Table 8 identified cervical spinal injury (OR =4.96, 95% CI: 1.22–20.15), complete SCI (OR =0.23, 95% CI: 0.07–0.75), and older age (OR =0.97 per year, 95% CI: 0.94–0.99) as independent predictors of opioid weaning at final follow-up. The final multivariable logistic regression model demonstrated good overall fit compared to the constant-only model (χ² =24.9, df =6, P<0.001).

In addition, patients who died during the study period had significantly higher MME at discharge compared to those who survived (156.00 vs. 44.12 mg, P=0.001), and this difference persisted at final follow-up (P=0.008), as demonstrated in Table 9. Patients who reported narcotic use at initial presentation also demonstrated significantly higher MME at discharge (P=0.003), suggesting that both baseline opioid exposure and mortality risk may be associated with elevated short-term opioid requirements.

Discussion

Our data reveals several noteworthy trends and associations that contribute to a deeper understanding of post-operative pain management in this patient population. The observed decrease in MME at final follow-up compared to discharge highlights an encouraging trend towards reduced opioid reliance over time. Although one study has pointed out that MME prescribed at discharge influences the post-operative narcotic usage longitudinally (12), our results suggest that spine surgical trauma patients may be successfully transitioning to alternative pain management strategies or experiencing improved pain control as they progress in their recovery, supported by the ability to wean 75.3 percent of the patients prescribed at discharge with opioids. This mirrors some of the trends noted by Pohl and colleagues in their propensity-matched cohort of 48 cervical trauma patients (13), as well as a similar study in the spine surgical elective population (7). Our findings contribute to this body of evidence, emphasizing that patients can achieve meaningful reductions in opioid use over time—highlighting a favorable trend in opioid stewardship and post-operative pain management strategies.

Our study also underscores the influence of specific clinical factors on post-operative opioid utilization. Notably, patients with incomplete SCI exhibited higher MME at discharge compared to those with complete SCI. One study looking into a cohort of 100 patients following SCI did not find a trend between pain scores and level or completeness of SCI, although they did note that patients with quadriplegia experienced more neuropathic pain below the level of SCI (14). A second study looking at a cohort of 90 patients with SCI similarly did not find a difference in pain levels and SCI completeness or level (15). In contrast, a third study did note somewhat similar trends to ours: more fentanyl and oxycodone administration for patients with motor incomplete injuries compared with motor complete injuries, although this was in the immediate post-operative period (16).

Although prior studies have not directly correlated the nature of SCI and pain longitudinally, our analysis revealed some correlation between incomplete and higher MME use, indicating that the extent of neurological impairment may influence opioid requirements post-operatively. This association underscores the nuanced interplay between pain perception, neurological status, and opioid responsiveness, necessitating individualized treatment strategies tailored to the unique needs of each patient. Interestingly, variables such as BMI, length of stay, and Charlson comorbidity index were not significantly associated with opioid consumption in our model, suggesting that neurological factors may more strongly influence post-operative opioid use than overall patient comorbidity.

Several other trends were similar to those previously reported in the literature. Oxycodone was the most frequently prescribed opioid post-operatively in our group, which is corroborated by a paper in the SCI literature (17). The observed relationship between post-operative motor and sensory recovery in a cervical spine trauma cohort and increased MME usage adds another layer of complexity to the pain management paradigm in spinal trauma patients. Patients experiencing partial motor and sensory recovery exhibited higher opioid consumption, suggesting that improvements in neurological function may coincide with heightened pain sensitivity or altered pain processing mechanisms (18). This highlights the importance of ongoing assessment and adjustment of pain management strategies throughout the rehabilitation process to optimize outcomes and minimize opioid-related risks. These findings may help guide clinicians in anticipating opioid needs in spinal trauma patients, particularly those with incomplete injuries, and support the need for individualized, neurologically informed management.

While our study provides valuable insights into opioid utilization patterns following surgical interventions for spine trauma, it is essential to acknowledge several limitations. The retrospective nature of the study and reliance on electronic medical records may introduce inherent biases and limitations in data collection, particularly in a trauma population where background medical and psychiatric history may be limited. The study’s single-center design may limit the generalizability of our findings to broader patient populations. Additionally, the dataset did not describe insurance status, cause of death, or reasons for discharge without opioid prescriptions, which limits the interpretation of these outcomes. The inability to assess the chronicity of opioid use or pre-injury opioid exposure also restricts conclusions regarding long-term dependency. Moreover, the relatively small sample size may limit the statistical power.

Future research endeavors should aim to address these limitations and further explore the multifaceted factors influencing opioid utilization in spinal trauma patients. Prospective studies with larger sample sizes and multi-center collaborations could provide more robust evidence to guide clinical practice and inform tailored pain management strategies. Moreover, investigations into non-pharmacological interventions and multidisciplinary approaches to pain management are warranted to enhance patient outcomes and mitigate the risks associated with opioid use.

Conclusions

In conclusion, our study underscores the wide variability in opioid utilization following spine trauma surgery and highlights the importance of personalized pain management strategies informed by patient-specific injury characteristics. Our findings demonstrated that incomplete SCI, younger age, and partial motor or sensory recovery are associated with increased opioid use. In contrast, cervical-level injuries and complete spinal cord injuries are independently associated with successful weaning off opioids. These results underscore the role of neurologic injury characteristics in shaping postoperative analgesic needs—more so than traditional systemic indicators such as comorbidity burden or length of hospitalization. By identifying these associations, our findings support more targeted, neurologically informed opioid prescribing strategies for patients after spine trauma. Furthermore, these insights contribute to the evidence base for postoperative pain management and may supplement analgesic protocols across other surgical populations with anatomically comparable anatomic and neurologic considerations.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-2/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-2/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-2/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-2/coif). A.H.M. was a paid consultant of NuVasive and Stryker. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional review board of Emory University (No. STUDY00006365) and the research committee of Grady Memorial Hospital (No. #000-6365) (Grady Memorial Hospital is a teaching facility for Emory University). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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