ABSTRACT
BACKGROUND: Transmission of severe acute respiratory syndrome coronavirus 2 can occur during aerosol generating procedures. Several steps in spinal fusion may aerosolize blood but little data exists to quantify the risk this may confer upon surgeons. Aerosolized particles containing infectious coronavirus are typically 0.5-8.0 µm. AIM: To measure the generation of aerosols during spinal fusion using a handheld optical particle sizer (OPS). METHODS: We quantified airborne particle counts during five posterior spinal instrumentation and fusions (9/22/2020-10/15/2020) using an OPS near the surgical field. Data were analyzed by 3 particle size groups: 0.3-0.5 µm/m3, 1.0-5.0 µm/m3, and 10.0 µm/m3. We used hierarchical logistic regression to model the odds of a spike in aerosolized particle counts based on the step in progress. A spike was defined as a > 3 standard deviation increase from average baseline levels. RESULTS: Upon univariate analysis, bovie (P < 0.0001), high speed pneumatic burring (P = 0.009), and ultrasonic bone scalpel (P = 0.002) were associated with increased 0.3-0.5 µm/m3 particle counts relative to baseline. Bovie (P < 0.0001) and burring (P < 0.0001) were also associated with increased 1-5 µm/m3 and 10 µm/m3 particle counts. Pedicle drilling was not associated with increased particle counts in any of the size ranges measured. Our logistic regression model demonstrated that bovie (OR = 10.2, P < 0.001), burring (OR = 10.9, P < 0.001), and bone scalpel (OR = 5.9, P < 0.001) had higher odds of a spike in 0.3-0.5 µm/m3 particle counts. Bovie (OR = 2.6, P < 0.001), burring (OR = 5.8, P < 0.001), and bone scalpel (OR = 4.3, P = 0.005) had higher odds of a spike in 1-5 µm/m3 particle counts. Bovie (OR = 0.3, P < 0.001) and drilling (OR = 0.2, P = 0.011) had significantly lower odds of a spike in 10 µm/m3 particle counts relative to baseline. CONCLUSION: Several steps in spinal fusion are associated with increased airborne particle counts in the aerosol size range. Further research is warranted to determine if such particles have the potential to contain infectious viruses. Previous research has shown that electrocautery smoke may be an inhalation hazard for surgeons but here we show that usage of the bone scalpel and high-speed burr also have the potential to aerosolize blood.
ABSTRACT
BACKGROUND CONTEXT Preoperative opioid use in spine patients is associated with adverse patient-reported outcomes, higher rates of perioperative complications, increased postoperative opioid dependence, and greater surgical costs. PURPOSE The purpose of this study is to determine whether a structured preoperative opioid tapering regimen can successfully reduce postoperative opioid use and improve outcomes in spinal fusion surgery. STUDY DESIGN/SETTING Single center RCT. PATIENT SAMPLE To date, 12 patients enrolled (5 control, 7 taper). OUTCOME MEASURES Milligram morphine equivalent (MME) opioid use;back and leg numeric pain rating scale (NPRS);PROMIS (depression, anxiety, fatigue, sleep, satisfaction, physical function, pain interference, pain behavior);other medication use;intra- and perioperative outcomes;complications;subjective opiate withdrawal scale (SOWS). METHODS Patients undergoing thoracolumbar, lumbar, or lumbosacral spinal fusion surgery and taking opioids daily for 4 weeks prior to the preoperative planning visit were eligible for inclusion (buprenorphine and long-acting formulations excluded). Consenting patients were randomized to undergo a 4-week tapering program (reduction of 10% per week for a total of 40% prior to surgery) or to the control group. Patients were guided through the tapering process via weekly phone calls. Control patients also received weekly phone calls with the same outcomes administered, with the exception of the SOWS. All patients were followed postoperatively with weekly phone calls for 6 weeks, and via their 3- and 6-month postoperative visits. A preliminary analysis of the data to date was performed through data visualization and univariate statistics (a=0.5, SAS v9.4). RESULTS Initially, this study was powered conservatively for 78 patients. The COVID pandemic resulted in significant study disruptions and enrollment challenges. Patients, many of whom are seeking surgery for poorly controlled pain, were wary of tapering their opiate use, with the top reasons for study refusal including: (1) pain not well controlled, unwilling to risk randomization, (2) pain well controlled, unwilling to risk randomization, (3) Insufficient time, (4) no response after initial contact, and (5) unresponsive to any contact. For the 12 patients enrolled to date [50% female, median age 68 (range 49–74)]. The breakdown of opioids taken was: hydrocodone/acetaminophen 5 (41%), oxycodone/acetaminophen 3 (25%), tramadol 3 (25%), and oxycodone 1 (8%). All but 2 (16%) of patients used additional pain medications, most commonly acetaminophen (50%) and gabapentin (42%). The median number of levels fused in both groups was 5 (range control: 2-5, range experimental: 2-11). There were no obvious differences in baseline demographics, surgical approach, or analgesia. Total in-hospital MME was a median of 365 (IQR 143-395) for the control group and 295 (IQR: 189-322) for the taper group (p = 0.625). Three (60%) of the control group and 1 (15%) of the taper group required a pain consult (p = 0.222). None of the control group and 4 (57%) of the taper group had perioperative complications (p = 0.081). Control and taper patients had similar baseline NPRS pain;however, the taper group had lower back pain during the taper period (median back pain 1.5 to 6 points lower;p <0.05 for taper weeks 1 & 3;p <0.10 for taper weeks 2 and 4). Postoperative pain did not differ between groups. Visually, trends in leg pain were similar, but the variability was larger. No differences were evident in the PROMIS CATs between groups. During the taper period, none of the tapering patients experienced more than mild withdrawal symptoms. CONCLUSIONS Patients are hesitant to participate in preoperative opiate tapering, and the COVID epidemic further exacerbated these anxieties. In those patients who did taper, there is some evidence towards reduced preoperative pain and potentially lower in-hospital MMEs. To date, no differences are evident in postoperative PROMs. Enrollment of additional patients is ongoing, as is the analysis of pre- and postoperative MMEs. FDA DEVICE/DRUG STATUS This does not discuss or include any applicable devices or drugs.