Lower Extremity Somatosensory Evoked Potentials Predict Functional Outcomes in Complete Traumatic Cervical Spinal Cord Injury.

BACKGROUND: Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients. METHODS: A retrospective study was conducted on prospectively collected data from 2 academic institutions. Patients 18 years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis. RESULTS: A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (P = 0.002), greater increases in ASIA motor scores at follow-up (P = 0.009), and a greater likelihood of clinically important improvement in ASIA motor score (P = 0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (P = 0.019) and clinically important improvement in ASIA motor score (P = 0.010), compared to AIS grade A or B injuries. CONCLUSIONS: The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury.

Perioperative Opioid Use in Anterior Cruciate Ligament Reconstruction Patients.

Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed outpatient orthopaedic procedures, yet there is little data about perioperative opioid prescribing practices. The purposes of this study were to quantify the perioperative opioid prescriptions filled by patients who underwent ACLR and to identify factors associated with greater postoperative opioid use. Patients who underwent ACLR at a single institution between June 2015 and May 2017 were studied using a regional prescription monitoring database to identify all preoperative and postoperative outpatient opioid prescriptions up to 2 years postoperatively. The number of morphine milligram equivalents of each opioid was calculated to determine total morphine milligram equivalents (TMEs) filled preoperatively, at discharge, and refilled postoperatively. Patients who refilled an opioid prescription postoperatively were compared with those who did not. Ninety-nine of 269 (36.8%) total patients refilled an opioid prescription postoperatively. Thirty-three patients (12.3%) required a refill after 2 weeks postoperatively, and no patients refilled after 21 months postoperatively. Fifty-seven patients (21%) received an opioid prescription in the 2 years following surgery that was unrelated to their ACL reconstruction. Increased age, higher body mass index (BMI), government insurance, current or prior tobacco use history, preoperative opioid use, and greater number of medical comorbidities were significantly associated with refilling a prescription opioid. Higher BMI and government insurance were independent predictors of refilling. Higher preoperative TMEs and surgeon were independent predictor of greater refill TMEs. In the opioid-naïve subgroup of 177 patients, only higher BMI was a predictor of refilling, and only greater comorbidities was a predictor of greater refill TMEs. The results demonstrate that preoperative opioid use was associated with postoperative opioid refills and higher refill TMEs in a dose-dependent fashion. A higher percentage of patients received an opioid prescription for reasons unrelated to the ACL reconstruction than refilled a prescription after the first 2 weeks postoperatively.

Higher preoperative expectations predict better outcomes in shoulder surgery patients.

PURPOSE: The purpose of this study is to determine if preoperative expectations (PE) are an independent predictor of greater 2-year outcomes and greater improvement from baseline in shoulder surgery patients. METHODS: Two-hundred and sixteen patients who underwent shoulder surgery at one institution were studied. Patients completed both preoperative and 2-year follow-up questionnaires including PROMIS (Patient-Reported Outcome Measurement Information System) computer-adaptive testing in six domains, American Shoulder and Elbow Surgeons (ASES) score, shoulder numeric pain scale (NPS), and the Marx Shoulder Activity Rating Scale (MARS). PE were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) expectations domain, and satisfaction was measured via the Surgical Satisfaction Questionnaire (SSQ-8). RESULTS: The mean PE score was 86.2 ± 17.8. Greater PE were associated with significantly better 2-year scores for ASES, NPS, MARS, SSQ8, and PROMIS domains of Physical Function, Fatigue, Pain Interference Fatigue and Social Satisfaction. Multivariable analyses demonstrated that greater PE were an independent predictor of both better 2-year scores and greater improvement for PROMIS SS (p < 0.001), ASES (p = 0.007), and shoulder NPS (p = 0.011). CONCLUSION: Greater PE are positively associated with numerous patient-based outcomes 2 years after surgery. With regards to pain relief, shoulder function, and social satisfaction, higher PE are also predictive of better outcome scores and more improvement. This study suggests that preoperative assessment of shoulder surgery PE is important, and that counseling patients to optimize realistic expectations may lead to superior outcomes. LEVEL OF EVIDENCE: III.

Perioperative opioid use and Press Ganey patient satisfaction scores after anterior cruciate ligament reconstruction.

BACKGROUND: Satisfaction measures such as Press Ganey (PG) scores are increasingly used to determine reimbursement. PURPOSE: To investigate the relationship between PG satisfaction scores and perioperative opioid use in patients undergoing anterior cruciate ligament reconstruction (ACLR). METHODS: Patients undergoing ACLR were retrospectively identified. Perioperative opioid prescription data were collected using the electronic medical record. RESULTS: Positive correlations existed between immediate preoperative total morphine equivalents (TMEs) and PG scores. There was a negative correlation between "Pain Control" and preoperative TMEs. CONCLUSION: PG scores were correlated with preoperative and intraoperative opioid administration but not postoperative opioid administration.

Predictors of met expectations two years after knee surgery.

INTRODUCTION: The purpose of this study is to determine which patient factors predict two-year postoperative met expectations in a cohort of patients undergoing knee surgery. Additionally, this study aims to measure the association between met expectations and postoperative outcomes. METHODS: 319 patients undergoing knee surgery at one institution were studied. Patients completed patient-reported outcome questionnaires prior to surgery and again two years postoperatively. Preoperative Expectations and postoperative Met Expectations were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) Expectations domain. RESULTS: The mean Met Expectations score was significantly lower than the preoperative Expectations Score. Worse two-year Met Expectations were associated with older age, higher BMI, greater comorbidities, more previous surgeries, black race, unemployment, lower income, government insurance, Worker's Compensation, smoking, and no injury prior to surgery. Greater Met Expectations were correlated with better scores on all two-year outcome measures as well as greater improvement on most outcome measures. Race, insurance status, function, mental health, and knee pain were found to be independent predictors of Met Expectations. CONCLUSION: This study identified multiple patient factors and outcome measures that were associated with Met Expectations two years after knee surgery.

Preoperative expectations and early postoperative met expectations of extremity orthopaedic surgery.

BACKGROUND: Preoperative patient expectations and met expectations are likely associated with the outcome of treatment. However, there is a lack of data regarding the preoperative expectations and early postoperative met expectations of patients undergoing extremity orthopaedic surgery. The purpose of this study was to identify the predictors of early postoperative met expectations in a cohort of patients undergoing extremity orthopaedic surgery and to assess the relationship between patient expectations and patient-reported outcome (PRO) measures. We hypothesized that patients with higher preoperative expectation scores and higher postoperative met expectation scores would have better early postoperative outcomes. METHODS: Four hundred thirty-five patients age seventeen and older who underwent extremity orthopaedic surgery at one institution were prospectively enrolled in this study. Each patient completed a preoperative questionnaire that included an assessment of demographics, pain, function, general health, treatment expectations, activity level, and Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive testing. Expectations were evaluated using the Expectations Domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. Patients completed a follow-up questionnaire two weeks after surgery that also assessed MODEMS met expectations and satisfaction (Surgical Satisfaction Questionnaire (SSQ-8)). RESULTS: The mean preoperative expectation score was 86.95 ± 16.59, and the mean postoperative met expectation score was 55.02 ± 27.63 (0-100 scale with 100 representing the highest level of expectations). Greater met expectations were significantly associated with white race (p = 0.025), college degree (p = 0.011), and higher income (p = 0.002). Greater met expectations were also significantly associated with greater postoperative physical function, social satisfaction, activity level, and subjective improvement, as well as lower pain interference, joint pain, body pain, fatigue, anxiety, and depression (p < 0.01 for each). Multivariable analysis results found that less postoperative joint pain and greater postoperative social satisfaction, improvement, and physical function were all significant independent predictors of greater met expectations at two weeks postoperative (p < 0.01 for each). CONCLUSION: Greater preoperative expectations are associated with better activity and less pain two weeks after surgery. Met expectations of extremity orthopaedic surgery were associated with postoperative physical function, social satisfaction, activity, pain, anxiety, depression, and subjective improvement. These results may have implications for preoperative counseling and risk factor modification.