Abstract
The 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. To determine the association between SCS and long-term opioid therapy (LOT) for PLS. In 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. SCS. The 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. 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. These findings suggest that under real-life conditions, SCS was associated with small, clinically questionable associations with opioid discontinuation and not starting opioids in the context of PLS.
Highlights
Low back pain (LBP) is the leading cause of disability worldwide, with point and 1-month prevalence rates of 12% and 23%, respectively.[1,2] Each year in the US, approximately 900 000 patients undergo spine surgery, with the incidence of failed back surgery syndrome, called postlaminectomy syndrome (PLS), being around 19% for laminectomy and 46% for fusion.[3,4,5]The treatment of PLS is challenging
In opioid-naive patients, spinal cord stimulation (SCS) was associated with a small decreased likelihood of patients subsequently receiving long-term opioid therapy (LOT) (7.6% vs 7.0%; difference, −0.6% [95% CI, −1.0% to −0.2%]; P = .003)
SCS was associated with an increased likelihood of not being on opioids in both opioid-naive and LOT patients
Summary
Low back pain (LBP) is the leading cause of disability worldwide, with point and 1-month prevalence rates of 12% and 23%, respectively.[1,2] Each year in the US, approximately 900 000 patients undergo spine surgery, with the incidence of failed back surgery syndrome, called postlaminectomy syndrome (PLS), being around 19% for laminectomy and 46% for fusion.[3,4,5]The treatment of PLS is challenging. The use of spinal cord stimulation (SCS) to treat PLS, the most common indication, has surged dramatically with the advent of new technologies that purport to better alleviate axial pain.[6] The global SCS market size is expected to reach $2.8 billion by 2025, with an anticipated growth rate of 8.3% per year.[7,8] Despite high reported success rates in the literature, the quality of studies is low, with industry-sponsored trials reporting better outcomes than non-industry-sponsored studies.[6] This discrepancy may be due to methodological flaws and bias, short follow-up periods, and lack of objective outcome measures
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