Dataset Information

Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery.

ABSTRACT:

Background

Managing postoperative pain is important for patients and surgeons. However, there is concern over opioid dependency. Cubital tunnel decompression is among the most common upper extremity surgeries. Our study aimed to analyze opioid use after cubital tunnel decompression to guide postoperative opioid prescribing.

Methods

We prospectively collected opioid consumption for 16 consecutive months (February 2016 to June 2017) for cubital tunnel decompression patients. Data on demographics, insurance type, surgery performed, functional questionnaires (Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH]), and electrodiagnostics (electromyography) were collected. Opioid consumption was reported at first postoperative visits.

Results

One hundred patients consumed a mean of 50 morphine equivalent units (MEUs) (range, 0-300), or 7 oxycodone 5-mg pills, postoperatively. Cubital tunnel release (CuTR) patients consumed fewer than ulnar nerve transposition (UNT) patients (40.4 vs 62.5 MEUs or 5.4 vs 8.3 pills, P = .08). Patients undergoing submuscular UNT consumed more than CuTR (115.0 vs 40.4 MEUs or 15.3 vs 5.4 pills, p = 0.003) and more than subcutaneous UNT patients (37.8 MEU or 5.0 pills, p = 0.03). Medicare patients consumed less than privately insured (42.7 vs 54.1 MEUs, 5.7 vs 7.2 pills, P = .02) and less than workers' compensation patients (76.8 MEU or 10.2 pills, P = .04). Older patients consumed fewer than younger patients ( P = .03). Postoperative QuickDASH score was positively related to opioid intake ( P = .009).

Conclusions

Patients consumed 7 oxycodone 5-mg pills after cubital tunnel decompression. Younger, privately insured, and workers' compensation patients, and those with worse functional scores and those undergoing UNT (specifically the submuscular technique) consumed more opioids.

SUBMITTER: Hozack BA

PROVIDER: S-EPMC6346364 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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Publications

Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery.

Hozack Bryan A BA Abboudi Jack J Gallant Gregory G Jones Christopher M CM Kirkpatrick William W Liss Frederic E FE Rivlin Michael M Takei T Robert TR Wang Mark L ML Silverman Matthew M Foltz Carol C Ilyas Asif M AM

Hand (New York, N.Y.) 20180929 1

<h4>Background</h4>Managing postoperative pain is important for patients and surgeons. However, there is concern over opioid dependency. Cubital tunnel decompression is among the most common upper extremity surgeries. Our study aimed to analyze opioid use after cubital tunnel decompression to guide postoperative opioid prescribing.<h4>Methods</h4>We prospectively collected opioid consumption for 16 consecutive months (February 2016 to June 2017) for cubital tunnel decompression patients. Data on ...[more]

PMID: 30269520

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Project description:BACKGROUND:In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition. METHODS:Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression. RESULTS:In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider. CONCLUSIONS:Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.

Project description:ImportanceCubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications.ObjectiveTo evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure.Data sourcesPubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies.Study selectionExperimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier.Data extraction and synthesisData were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact.Main outcomes and measuresThe primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence.ResultsA total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates.Conclusions and relevanceIn this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.

Project description:Cubital tunnel syndrome (CuTS) is the 2nd most common compressive neuropathy. To improve both diagnosis and the selection of patients for surgery, there is a pressing need to develop a reliable and objective test of ulnar nerve 'health'. Diffusion tensor imaging (DTI) characterises tissue microstructure and may identify differences in the normal ulnar from those affected by CuTS. The aim of this study was to compare the DTI metrics from the ulnar nerves of healthy (asymptomatic) adults and patients with CuTS awaiting surgery. DTI was acquired at 3.0 T using single-shot echo-planar imaging (55 axial slices, 3 mm thick, 1.5 mm2 in-plane) with 30 diffusion sensitising gradient directions, a b-value of 800 s/mm2 and 4 signal averages. The sequence was repeated with the phase-encoding direction reversed. Data were combined and corrected using the FMRIB Software Library (FSL) and reconstructed using generalized q-sampling imaging in DSI Studio. Throughout the length of the ulnar nerve, the fractional anisotropy (FA), quantitative anisotropy (QA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) were extracted, then compared using mixed-effects linear regression. Thirteen healthy controls (8 males, 5 females) and 8 patients with CuTS (6 males, 2 females) completed the study. Throughout the length of the ulnar nerve, diffusion was more isotropic in patients with CuTS. Overall, patients with CuTS had a 6% lower FA than controls, with the largest difference observed proximal to the cubital tunnel (mean difference 0.087 [95% CI 0.035, 0.141]). Patients with CuTS also had a higher RD than controls, with the largest disparity observed within the forearm (mean difference 0.252 × 10-4 mm2/s [95% CI 0.085 × 10-4, 0.419 × 10-4]). There were no significant differences between patients and controls in QA, MD or AD. Throughout the length of the ulnar nerve, the fractional anisotropy and radial diffusivity in patients with CuTS are different to healthy controls. These findings suggest that DTI may provide an objective assessment of the ulnar nerve and potentially, improve the management of CuTS.

Project description:ImportanceThere is growing evidence that opioids are overprescribed following surgery. Improving prescribing requires understanding factors associated with opioid consumption.ObjectiveTo describe opioid prescribing and consumption for a variety of surgical procedures and determine factors associated with opioid consumption after surgery.Design, setting, and participantsA retrospective, population-based analysis of the quantity of opioids prescribed and patient-reported opioid consumption across 33 health systems in Michigan, using a sample of adults 18 years and older undergoing surgery. Patients were included if they were prescribed an opioid after surgery. Surgical procedures took place between January 1, 2017, and September 30, 2017, and were included if they were performed in at least 25 patients.ExposuresOpioid prescription size in the initial postoperative prescription.Main outcomes and measuresPatient-reported opioid consumption in oral morphine equivalents. Linear regression analysis was used to calculate risk-adjusted opioid consumption with robust standard errors.ResultsIn this study, 2392 patients (mean age, 55 years; 1353 women [57%]) underwent 1 of 12 surgical procedures. Overall, the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption (median, 30 pills; IQR, 27-45 pills of hydrocodone/acetaminophen, 5/325 mg, vs 9 pills; IQR, 1-25 pills; P < .001). The quantity of opioid prescribed had the strongest association with patient-reported opioid consumption, with patients using 0.53 more pills (95% CI, 0.40-0.65; P < .001) for every additional pill prescribed. Patient-reported pain in the week after surgery was also significantly associated with consumption but not as strongly as prescription size. Compared with patients reporting no pain, patients used a mean (SD) 9 (1) more pills if they reported moderate pain and 16 (2) more pills if they reported severe pain (P < .001). Other significant risk factors included history of tobacco use, American Society of Anesthesiologists class, age, procedure type, and inpatient surgery status. After adjusting for these risk factors, patients in the lowest quintile of opioid prescribing had significantly lower mean (SD) opioid consumption compared with those in the highest quintile (5 [2] pills vs 37 [3] pills; P < .001).Conclusions and relevanceThe quantity of opioid prescribed is associated with higher patient-reported opioid consumption. Using patient-reported opioid consumption to develop better prescribing practices is an important step in combating the opioid epidemic.

Dataset Information

Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery.

Background

Methods

Results

Conclusions

Publications

Prospective Evaluation of Opioid Consumption Following Cubital Tunnel Decompression Surgery.

Similar Datasets

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