Association of Spinal Cord Stimulator Implantation With Persistent Opioid Use in Patients With Postlaminectomy Syndrome

Abstract

IMPORTANCEThe results of studies evaluating spinal cord stimulation (SCS) for postlaminectomy syndrome (PLS) have yielded mixed results. This has led to an increased emphasis on objective outcome measures such as opioid prescribing.OBJECTIVE To determine the association between SCS and long-term opioid therapy (LOT) for PLS. DESIGN, SETTING, AND PARTICIPANTSIn this cohort study, adults with PLS were identified using the TriNetx Diamond Network and separated based on whether they underwent SCS. Patients were stratified according to baseline opioid use (opioid-naive or receiving LOT) and subsequent opioid therapy over the 12-month period ranging from 3 to 15 months post-SCS implantation or post-PLS index date. Statistical analysis was performed from June to December 2021. EXPOSURE SCS. MAIN OUTCOMES AND MEASURESThe main outcome was cessation of opioid use among patients receiving LOT or abstinence from opioids among opioid-naive patients. Opioid-naive patients were defined as those receiving at most 2 opioid prescriptions per year, and patients on LOT were those receiving at least 6 opioid prescriptions per year. RESULTS Among 552 937 eligible patients treated between December 2015 and May 2021, 26 179 with PLS received an SCS implant. The median (IQR) patient age was 60 (51-69) years; 305 802 patients (55.3%) were female. Among those reporting racial identify (37.0% [204 758 patients]), 9.3% (18 971 patients) were African American, 0.3% (648 patients) were Asian, and 90.4% (185 139 patients) were White. Compared with those who did not receive an SCS, individuals who received an SCS were more likely to be using opioids preimplantation (mean [SD] prescriptions: 4.3 [8.5] vs 4.1 [9.3]; P < .001) but less likely to be using opioids after SCS implantation (mean [SD] prescriptions: 3.8 [8.2] vs 4.0 [9.4]; P = .006). In the 12-month study period, similar proportions in the SCS and no-SCS groups receiving baseline LOT remained on LOT (70.3% [n = 74 585] vs 69.2% [n = 3882],respectively; P = .10). In opioid-naive patients, SCS was associated with a small decreased likelihood of patients subsequently receiving LOT (7.6% vs 7.0%; difference, −0.6% [95% CI, −1.0% to −0.2%]; P = .003). In multivariable analysis, SCS was associated with an increased likelihood of not being on opioids in both opioid-naive (adjusted odds ratio [OR], 0.90 [95% CI, 0.85-0.96]; P < .001) and LOT patients (adjusted OR, 0.93 [95% CI, 0.88-0.99]; P = .02). White patients were significantly more likely to be diagnosed with PLS (ie, underwent surgery) (90.4% vs 85.2%; difference, 5.2% [95% CI, 5.1%-5.4%]; P < .001) and receive an SCS (93.7% vs 90.3%; difference, 3.4% [95% CI, 2.9% to 4.0%]; P < .001) than patients of other racial identities. (continued) Key Points Question What is the association between spinal cord stimulation and long-term opioid use in patients with postlaminectomy syndrome? Findings In this large cohort study involving 552 937 patients treated between 2015 and 2021, spinal cord stimulation was associated with a statistically signific...

Long-term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared With Conventional Medical Therapy for Chronic Pain

“…A prior meta-analysis of 5 clinical trials, 4 of which were industry funded, found a minor reduction in opioid use after SCSs compared with CMM . In contrast, a recent independent study with 1-year follow-up of patients postlaminectomy found small, clinically questionable opioid discontinuation associated with SCSs . We extend these findings to 2 years and several additional endpoints among a broader population receiving SCS for multiple indications.…”

“…27 In contrast, a recent independent study with 1-year follow-up of patients postlaminectomy found small, clinically questionable opioid discontinuation associated with SCSs. 28 We extend these findings to 2 years and several additional endpoints among a broader population receiving SCS for multiple indications. SCSs may also be associated with harm in some patients.…”

Persistent Use of Prescription Opioids Before and After Lumbar Spine Surgery

“…The widespread and increasing use of spinal cord stimulation for persistent pain following lumbar spine surgery does not appear to result in clinically meaningful cessation of opioids or improvement in pain or disability. [42][43][44]…”

“…Although these results were among a different subpopulation of surgical patients, we strongly encourage clinical trials where patients with, or at risk of opioid abuse are provided interventions aiming at cessation or tapering opioid use. The widespread and increasing use of spinal cord stimulation for persistent pain following lumbar spine surgery does not appear to result in clinically meaningful cessation of opioids or improvement in pain or disability 42–44 …”

Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients

“…However, the literature is conflicting regarding whether these devices reduce opioid use 30,[50][51][52][53] , especially to a clinically significant degree 30 . Hwang et al found that 20% of patients had a decreased daily opioid dose a year after SCS implantation compared with preoperative doses while 40% saw no change.…”