Patient satisfaction in outpatient spine & orthopedic surgery: Multimodal pain management is key

Anuja Vaidya -  

Becker's Healthcare hosted a webinar on Dec. 15, featuring Paul Jeffords, MD, a spine surgeon at Atlanta-based Resurgens Spine Center and section chief of orthopedic surgery at Emory Saint Joseph's Hospital, discussed moving complex spine and orthopedic cases from the hospital to the outpatient setting.

"In the future, healthcare is going to focus on value not on volume, as we have all heard," said Dr. Jeffords. "We want to improve patient outcomes and improve the overall health of patients and patient experience. For the appropriate patients and procedures, there will be a need to provide quality care at a lower cost and this is possible in an outpatient setting."


According to Dr. Jeffords, studies show a definite trend of moving more complex spine cases into an outpatient setting, such as minimally invasive TLIFs and MIS posterior lumbar interbody fusions as well as more one-two level spine surgeries rather than just traditional procedures like laminectomies and discectomies.


When moving complex cases into the outpatient setting, there are many factors that providers must consider, including adequate pain management, which can help reduce costs, length-of-stay and readmissions.


Effective pain management can help reduce the cost of performing these more complex spine surgeries. For example, an open single level fusion procedure cost $78,444 with a length of stay of 4.8 days, whereas an MIS single level fusion procedure costs $70,000; and MIS with adequate pain management costs $40,000.


Additionally, new readmission data also shows that pain relief is one of the most common causes of unplanned readmissions. A retrospective review of a large multicenter clinical registry evaluating readmissions after lumbar spine operations found that inadequate pain relief was the cause of 22.4 percent of the readmissions.  


Also, another retrospective review of ACDF procedures that intended to identify factors contributing to increased hospital length-of-stay found that the most common complication was uncontrolled postoperative pain, occurring in 13 percent of the cases.


Most patients continue to report at least some level of postoperative pain, said Dr. Jeffords, and this affects patient satisfaction. Postoperative pain prolongs surgical recovery time, increases length of stay and impacts the patient's view of the procedure.


Opioids are commonly used to provide pain relief, and while they are inexpensive and effective, there are several downsides to using opioids. Opioid-related adverse events include constipation, nausea and vomiting, urinary retention, pruritus and respiratory depression. According to a study of 402 surgical patients undergoing orthopedic procedures, 54.2 percent of patients experienced more than one of these adverse effects, and 25.6 percent experienced more than two.


Additionally, studies show that opioid-related adverse events increases length of stay by 3.4 days on average and increases hospitalization cost by approximately $4,707. Thus, to reduce costs and LOS, providers can explore options beyond opioids.


When treating postoperative pain in the outpatient setting, it is important that providers choose the right patient and also develop a pain relief regimen that is easy to implement, has minimal side effects and facilitates mobility, said Dr. Jeffords. Additionally, the regimen needs to be cost-effective.


"For outpatient spine surgery, you want to have a multimodal approach," said Dr. Jeffords. "Include different methods and medications to keep pain at bay. Combine steroids with narcotics or gabapentinoids and anti-inflammatory drugs for better results."


According to Dr. Jeffords, the following could be added to a mulimodal pain regimen for outpatient spine surgery:


•    Nonsteroidal anti-inflammatory drugs, which can help reduce pain and have traditionally been used for postoperative pain, however, these drugs have been shown to be slow healing.
•    Gabapentinoids, which facilitate central desensitization of pain by reducing the pain signals being sent out by the nerves.
•    Epidural local anesthetics, an effective way of reducing postoperative pain and opioid use.
•    Epidural opioids, which can also help reduce some side effects of oral opioids.
•    Continuous local infusion devices, such as the ON-Q infusion pain pump, but these are not ideal for complex outpatient surgery as they tend to be bulky and cumbersome.
•    Exparel, which is liposome injection of bupivacaine, has been shown to decrease pain in postoperative care as well as reduce the number of patients who required opioids. One study showed that 77.78 percent of patients who were given Exparel did not need opioids. Also, studies have shown that the pain scores for patients treated with Exparel was lower at every follow up point than patients who were treated with a drug other than Exparel.


Traditionally, pain care in the outpatient setting involved giving patients weak opioids for mild to moderate pain; potent opioids for moderate to severe pain; and increase the amount of opioids if pain increases. However, a multimodal pain care approach posits treating patients with mild to moderate pain with acetaminophen, NSAIDs or coxibs as well as local analgesic infiltration. If the pain increases to moderate to severe, intermittent opioid analgesics can be included. And if the pain increases beyond that, peripheral neural blockade and additional opioids can be given to the patient.


"A multimodal pain care approach that combines different medications and are delivered differently is necessary when moving cases from the inpatient to the outpatient setting. Don't just stick to narcotics. A multimodal regimen is safer and more effective than relying on narcotics alone," said Dr. Jeffords.


Also, use of local anesthesia for outpatient spine surgery has been shown to be safe. While it is not common for spine surgeons to use local anesthesia for spine surgery, studies have shown that it is a safe and effective alternative when a patient's major comorbidities rule out general anesthesia.


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