Background:
Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees.
Methods:
Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure.
Results:
A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons.
Conclusions:
Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.
Study Design:
The study design is a retrospective cohort study.
Objective:
To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM).
Summary of Background Data:
Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements.
Materials and Methods:
A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA.
Results:
There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm (
P
= 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points,
P
< 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points,
P
= 0.017). Both younger age (
P
= 0.017,
β
-coefficient = −0.05) and higher preoperative mJOA (
P
< 0.001,
β
-coefficient = 0.37) predicted higher postoperative mJOA.
Conclusions:
Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.
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