Perioperative opioid prescribing concerns in anterior cervical surgery

Opioid prescriptions are increasingly used to treat cervical pain. This violates most opioid prescribing guidelines and is associated with worse clinical outcomes, prolonged post-operative opioid use, and dependence. This study aims to analyse the impact of preoperative opioid prescribing on perioperative and long-term opioid use following anterior cervical surgery.

A retrospective cohort study of consecutive patients undergoing 1-2 level anterior cervical discectomy and fusion (ACDF), cervical disc replacement (CDR), or hybrid procedures by a single surgeon in Melbourne, Australia (Oct 2020-Feb 2024). SafeScript data was used to quantify opioid prescribing. Outcomes included postoperative opioid use, morphine milligram equivalents (MME), complications, and patient-reported outcome measures (PROMs).

Sixty-one patients were identified, 28 opioid-sensitised (OS) and 33 opioid-naïve (ON). Patient demographics and complications between groups were similar. More OS patients required opioids at 6 weeks (3.0% vs. 25.0%, P=0.01) and 6 months postoperatively (0.0% vs. 29.0%, P=0.001), but not at 1 year (6.1% vs. 17.9%, P=0.15). Patients prescribed preoperative opioids for <1-month have an increased risk of opioid use at 6 weeks [odds ratio (OR) =12.2, 95% confidence interval (CI): 1.4-104.7, P=0.02] and 1-3 months postoperatively (OR =14.4, 95% CI: 1.7-122.4, P=0.02). Opioid prescribing 3-6 months preoperatively was associated with postoperative use at 6 weeks (OR =11.3, P=0.003), 3 months (OR =30.7, P<0.001), 6 months (OR =23.0, P<0.001) and 12 months (OR =8.6, P=0.01) postoperatively. Six-month postoperative MME was higher amongst OS patients (2,265 vs. 577 mg, P=0.04) and correlated with MME prescribed 1-month (r=0.553, P<0.001) and 3-month preoperatively (r=0.691, P<0.001). Preoperative Neck Disability Index (NDI), visual analogue scale (VAS)-neck and VAS-arm were similar between groups, but OS patients had a lower EuroQol-5 Dimensions-3 Level (EQ-5D-3L) index (0.56 vs. 0.68, P=0.03). Postoperative NDI, VAS-neck, VAS-arm and EQ-5D-3L index were similar at 6 weeks, 6 months and 12 months.

OS patients undergoing anterior cervical surgery are more likely to chronically use opioids postoperatively compared to ON patients. Duration of preoperative opioid use significantly predicts prolonged postoperative use, with no corresponding improvement in PROMs.