Opioid Use in Opioid Naive Patients After Minimally Invasive Spine Surgery

Abstract

Study Design

Prospective cohort study.

Objectives

To evaluate postoperative opioid use in opioid-naive patients undergoing lumbar or cervical spine surgery and assess the impact of surgical approach (open vs minimally invasive) and number of operative levels on opioid consumption.

Methods

A prospective cohort of 217 opioid-naive patients undergoing outpatient spine surgery from August 2023 to December 2024 was analyzed. Patients were stratified by surgical approach (open, tubular, endoscopic) and by single-vs multilevel procedures. Opioid usage was measured in total morphine milligram equivalents (MME) based on patient-reported pill counts at 2 weeks and follow-up interviews at 3 months.

Results

Patients undergoing single-level procedures used significantly fewer opioids than those undergoing multilevel procedures (75.1 ± 97.0 MME vs 167.3 ± 239.6 MME; P = .0068). Among lumbar surgeries, endoscopic procedures had the lowest average opioid use (48.6 ± 57.8 MME), significantly less than open procedures (164.7 ± 223.7 MME; P = .0021). Overall, 17.5% of patients required no postoperative opioids, with the highest rate seen in the single-level endoscopic group (36.3%).

Conclusion

Minimally invasive spine surgery techniques, particularly endoscopic and tubular approaches, were associated with reduced postoperative opioid use and fewer refill requests compared to open procedures within this heterogeneous cohort of lumbar and cervical procedures. Multilevel surgeries were associated with higher opioid consumption. These findings support the development of tailored opioid prescribing protocols for opioid-naive patients, potentially reducing overprescription and improving pain management. Patient education on non-opioid analgesia and standardized prescribing guidelines may further reduce opioid reliance after spine surgery.

Keywords

opioid-naive lumbar discectomy lumbar laminectomy endoscopic minimally invasive ACDF TDR

Introduction

The opioid epidemic remains a significant public health crisis in the United States, with prescription opioids continuing to contribute substantially to opioid-related morbidity and mortality. In 2021, prescription opioids were involved in over 17,000 overdose deaths, underscoring the urgent need for more responsible prescribing practices.¹ Among medical specialties, orthopedic surgeons consistently rank among the highest prescribers of opioids, particularly for opioid-naive patients undergoing surgery.²

Spine surgery presents a unique challenge in this context, as it is frequently associated with severe postoperative pain and a longstanding reliance on opioid-based analgesia. Effective pain control is essential for optimal postoperative recovery, yet pain management after spinal procedures remains suboptimal in many cases. Inadequate analgesia can delay mobilization, prolong hospitalization, and contribute to opioid misuse and dependency.³ Notably, Stratton et al (2020) reported that nearly 10% of opioid-naive patients who underwent thoracic or lumbar decompression or decompression and fusion spine surgery were using daily opioids at their 1-year follow-up, a concerning indicator of long-term opioid dependence.⁴

Despite increasing awareness of these risks, there is currently no widely adopted, standardized opioid-prescribing protocol in spine surgery. However, standardized approaches in other surgical specialties have demonstrated success in reducing opioid consumption while maintaining effective pain control. In orthopedic trauma surgery, opioid-sparing pathways have significantly decreased postoperative opioid use without compromising pain outcomes.⁵ Likewise, total joint arthroplasty programs utilizing multimodal analgesia, including acetaminophen, NSAIDs, gabapentinoids, and regional anesthesia, have improved pain management while minimizing opioid exposure.^6,7 Tailored guidelines in general, plastic, and hand surgery have also been shown to reduce prescribing variability and limit the risk of persistent opioid use.^8,9 These models provide a promising framework for developing similar protocols in spine surgery.

Another promising strategy to reduce opioid requirements is minimizing the invasiveness of the surgical procedure. Traditional open lumbar surgeries are associated with greater postoperative pain due to larger incisions, extensive muscle dissection, and increased soft tissue trauma, often necessitating higher doses of opioids for adequate pain control.¹⁰ In response, minimally invasive techniques such as tubular retractor-based and biportal endoscopic approaches have been developed to reduce tissue disruption, enhance recovery, and potentially decrease opioid requirements while achieving comparable clinical outcomes.

The main objective of this study is to provide data that can inform the development of a standardized, evidence-based framework for opioid prescribing following spine surgery. Furthermore, we hypothesize that (1) multilevel procedures are associated with increased postoperative opioid consumption compared to single-level surgeries, and (2) minimally invasive approaches, specifically tubular and biportal endoscopic techniques, are associated with lower postoperative opioid requirements compared to traditional open procedures for lumbar procedures.

Methods

The institutional review board affiliated with the researchers’ institution approved this study. Data collection was performed from August 1, 2023, until December 31, 2024. Electronic medical records were queried for patient medical history, demographics, procedures, medications, and detailed notes. All patients undergoing outpatient spine surgery (1-3 level laminectomy and/or discectomy, 1-2 level anterior cervical discectomy and fusion (ACDF), and 1-2 level cervical total disc replacement (TDR)) were included. The patients in the laminectomy and discectomy groups were further stratified by approach, including open, tubular, and endoscopic approaches (Figure 1).

Figure 1.

Flow graph of inclusion and exclusion criteria.

The pool was filtered to opioid naive patients through review of the patient’s medication history, but most importantly, confirmed using the statewide prescription database, preoperative urine drug screen, and through patient interviews at the time of surgery. Opioid naive was defined as no exposure to opioids within 3 months of surgery.¹¹

Patients received a single preoperative dose of celecoxib 100 mg and gabapentin 300 mg in the preoperative holding area just before surgery. Patients were given the following opioids after surgery: hydrocodone 5 mg, tramadol 50 mg, and oxycodone 5 mg. The patients were asked to bring their medication bottles to their 2-week postoperative follow-up. Type of opioid prescribed and medication utilization were recorded in total morphine milligram equivalents (MME). Additionally, patients were contacted through phone calls made by the physician’s office at 3 months, and any additional opioid use was recorded. If patients required refills, this was also recorded. MMEs were calculated based on the prescribed dosing and the amount of the prescription that was used (Table 1). Other recorded data points were gender, age, Charlson comorbidity index, diabetes mellitus, smoking, alcohol use, and BMI. The location of surgery was also recorded, which included a tertiary hospital or an ambulatory surgical center setting.

Table 1.

Opioids Conversion to MME

Medication	Conversion to MME
Hydrocodone 5 mg	Number of pills * 1 MME
Oxycodone 5 mg	Number of pills * 1.5 MME
Tramadol 50 mg	Number of pills * 0.1 MME

Statistical Analysis

Continuous variables were presented as medians and interquartile ranges, while categorical variables are displayed as frequencies and percentages. To determine whether there was a statistically significant difference in mean MME used between single and multilevel surgeries a two-sample t-test was utilized. In order to analyze whether the amount of MME changed based on the number of levels a Two-Way ANOVA with an interaction effect was performed. Lastly, a one-way ANOVA was done to determine whether there was a statistically significant difference between MME means of different procedure types. Post hoc testing was done using bonferroni corrections to account for multiple testing. All testing was two sided with an alpha of 0.05. Statistical analysis was done using SAS v 9.4.

Results

In total, 322 patients underwent up to three-level lumbar decompressive surgery or up to two-level anterior-based cervical surgery. Of these, 217 patients were included. 101 patients were excluded for non-opioid naivety. Four patients were excluded due to the following reasons: one patient presented to the emergency department acutely after surgery due to medical complications, two patients underwent revision surgery soon after the index surgery (one for a recurrent disc herniation 21 days after surgery and one for a hematoma washout 11 days after surgery), and one patient had a significant psychiatric history that resulted in hospitalization.

All included patients received a standardized multimodal preoperative analgesic regimen consisting of celecoxib, gabapentin, and oxycodone, along with intraoperative local anesthetic at the incision site.

Of the included patients, 31.8% were female (Table 2). The average age was 54.6 (+/−15.6), and 71.9% of patients were white. The average BMI was 29.3 (+/− 5.9). 170 patients underwent surgery at an ambulatory surgery center, and 47 patients at a tertiary hospital (Table 6).

Table 2.

Patient demographic characteristics including average MME for all patients.

Variable	Value
N	217
Age	54.62 ± 15.62
Body Mass Index(BMI)	29.3 ± 5.9
Morphine milligram Equivalents(MME)	104.4 (IQR 15-130)
Gender, female	69 (31.8%)
Race
American Indian	1 (0.5%)
Asian	9 (4.1%)
Black	17 (7.8%)
Hispanic	6 (2.8%)
White	156 (71.9%)
Not reported	27 (12.4%)

Overall, the mean opioid intake for single-level procedures was 75.1 MME (+/− 97.0), with an interquartile range (IQR) from 10-100 MME (Table 3). The mean opioid intake for multilevel procedures was 167.3 MME (+/− 239.6), with an IQR of 23.8-205 MME. There was a statistically significant difference in MME intake between single and multilevel procedures (P = .0068). Differences between MME in ACDF and endoscopic lumbar laminectomy/discectomy did reach statistical significance (P = .0021). The IQR for open lumbar surgery was 25-240 MME, while the IQR for cervical procedures was 30-187.5 MME.

In total, 30 patients out of 217 (13.8%) requested refills (Table 4). The single-level endoscopic laminectomy/discectomy group and the multilevel tubular group had the least number of refills requested at 2 of 91 (2.2%) and 0 of 6 (0%), respectively. The multilevel ACDF and multilevel open lumbar groups had the highest proportion of refill requests at 8 of 24 (33.3%) and 6 of 17 (40.0%), respectively.

Table 3.

All-Single Level vs All-Multilevel

All-single level vs All-Multilevel
Level	N	Minimum	Lower quartile	Median	Upper quartile	Maximum	Mean	Standard deviation
1	161	0.0	10.0	40.0	100.0	575.0	75.1	97.0
2+	56	0.0	23.8	75.0	205.0	1092.5	167.3	239.6

Difference between MME intake for single and multilevel procedures, P = .0068.

38 patients out of 217 (17.5%) required no postoperative opioids. These patients were managed with the same standardized multimodal analgesic protocol described above. Patients in the single-level endoscopic lumbar group had the greatest number of opioid-free patients, with 33 of 91 (36.3%). The single-level ACDF group had the second greatest, with 2 of 9 (22.2%) not requiring opioids. The multilevel TDR and multilevel tubular groups had 0 patients who were opioid-free postoperatively. The open multilevel group had one opioid-free patient after surgery.

Within the lumbar discectomy and/or laminectomy group, the average amount of MME taken by the endoscopic group was the least at 48.6 (+/−57.8) with an IQR of 0-87.5 MME, while tubular patients used an average of 92.5 (+/−121.4) MME, with an IQR of 18-95 MME (Table 5). This comparison was not statistically significant (P = 0.7068).

Table 4.

No Narcotics and Refill Requests

Category	Level	# Patients No narcotics (%total in category)	# Patients requesting refills (%total in category)
Laminectomy/Discectomy	Single	33 (24.4%)	6 (4.4%)
Laminectomy/Discectomy	Multi	1 (4.0%)	6 (24.0%)
ACDF	Single	2 (22.2%)	1 (11.1%)
ACDF	Multi	1 (4.0%)	8 (33.3%)
TDR	Single	1 (5.9%)	2 (11.8%)
TDR	Multi	0 (0.0%)	1 (14.3%)
Approach
Endoscopic	Single	33 (36.3%)	2 (2.2%)
Endoscopic	Multi	0 (0.0%)	0 (0.0%)
Tubular	Single	4 (9.0%)	3 (9.1%)
Tubular	Multi	0 (0.0%)	0 (0.0%)
Open	Single	1 (12.5%)	1 (12.5%)
Open	Multi	1 (6.67%)	6 (40.0%)

The open lumbar surgery group had statistically higher MME use than the endoscopic group at 164.54 (+/− 164.7) MME (P = 0.0021) (Table 5). MME use for open lumbar approaches compared to tubular did not reach a statistically significant difference (P = .2946). Across all surgical approaches (cervical, endoscopic lumbar, open lumbar, and tubular lumbar), the distribution of MME reached statistical significance (P = .0001). These comparisons reflect opioid consumption within the context of uniform multimodal perioperative management.

There was a significant difference in MME intake between patients who had surgery at an ambulatory surgical center and a tertiary hospital (P = .0287)(Table 6). The mean MME for patients treated at ambulatory surgical centers was greater than that of patients treated at the tertiary hospital, at 109.6(+/−167.9) and 72.9(+/−78.9), respectively, with a P-value of .0287. The IQR for the ambulatory surgical centers was 15-132.5 MME, while the IQR for the tertiary hospital was 15-106.3 MME.

Table 5.

Surgical Approach

Approach	N	Lower quartile	Median	Upper quartile	Maximum	Mean	Standard deviation
Cervical	64	30.0	88.8	187.5	1092.5	147.8	196.4
Endoscopic	91	0.0	22.5	87.5	225.0	48.6	57.8
Open	27	25.0	60.0	240.0	775.0	164.5	164.7
Tubular	39	18.0	50.0	95.0	562.5	92.5	121.4

Cervical vs Endo: P-value = .0003.

Cervical vs Open: P-value = 1.0.

Cervical vs Tubular: P-value = .3786.

Endoscopic vs Open: P-value = .0021.

Endoscopic vs Tubular: P-value = .7068.

Open vs Tubular: P-value = .2946.

Table 6.

Ambulatory Surgical Center vs Tertiary Hospital

Setting	N	Minimum	Lower quartile	Median	Upper quartile	Maximum	Mean	Standard deviation
Ambulatory center	170	0.0	15.0	50.0	132.5	1092.5	109.6	167.9
Tertiary hospital	47	0.0	15.0	50.0	106.3	300.0	72.9	78.9

Difference between MME intake between an ambulatory surgical center and a tertiary hospital, P = .0287.

Discussion

We prospectively collected and analyzed opioid usage in 217 patients who underwent up to three-level lumbar decompressive surgery or up to two-level anterior cervical surgery. Importantly, this cohort included a heterogeneous mix of pathologies and procedures, including lumbar discectomy, lumbar laminectomy, anterior cervical discectomy and fusion (ACDF), and cervical total disc replacement (TDR), each of which carries distinct postoperative pain profiles and expected analgesic requirements. Our analysis demonstrates that endoscopic and tubular approaches required less postoperative opioid use for pain management compared to open lumbar approaches. Patients treated through open approaches requested the greatest number of medication refills, while endoscopic and tubular procedures requested fewer, reaching a statistical difference between the endoscopic and open groups. This indicates that less invasive approaches may be associated with reduced post-operative opioid use. Patients treated through multilevel procedures utilized more opioids for postoperative pain management compared to single-level procedures; however, the difference was not statistically significant. We offer interpretations of our study as a template to be utilized by other surgeons who prescribe opioids for postoperative pain management.

Refill requests among our multilevel ACDF patient cohort (33.3%) were slightly higher compared to those reported by Massie et al, who found that 26.5% of their any-level ACDF patients requested refills. Although our study suggests that opioid-naive patients undergoing ACDF likely will need opioids for postoperative pain control, other cohorts find that over a quarter of their patients did not require any postoperative opioids. In our cohort, 9.1% of patients undergoing ACDF at any level required no postoperative opioids, whereas a separate study from Lovecchio et al reported that 27.1% of patients undergoing 1-2 level ACDF were discharged without opioid use. This raises the question of whether additional preoperative education is needed during surgical consultations to better manage patient expectations regarding pain and opioid use after surgery. If patients are informed that many others successfully manage their pain without opioids, they may be more likely to consider non-opioid alternatives for analgesia. These comparisons should be interpreted cautiously, as differences in procedure type and preoperative protocols may account for variability in refill rates and opioid avoidance.

In the state of Michigan, a statewide collaborative has been established to improved patient care. There have been recent steps toward establishing a postoperative opioid prescribing protocol for spine surgery, notably from the Michigan Spine Surgery Improvement Collaborative (MSSIC). Following a study conducted by Lim et al in 2022, guidelines were created establishing a goal of prescribing less than or equal to 225 MME in total for 1-2 level lumbar discectomy, 1-2 level anterior cervical discectomy and fusion, and anterior cervical corpectomy and fusion for opioid naïve patients. Opioid naive patients were defined as those who were not taking opioids 30 days or more leading up to their surgery.¹² While helpful, these guidelines apply only to 1 to 2 level lumbar discectomy, 1 to 2 level anterior cervical discectomy and fusion, and 1 to 2 level anterior cervical corpectomy and fusion. These recommendations are the total amount, and a concern of postoperative narcotic prescription is that there is no standardization so 225 MME may also be over prescribing narcotics. One study reported that, following 1- to 2-level ACDF, patients were typically prescribed an average of 12 opioid tablets, in the form of oxycodone 5 mg.¹³ Our study provides further information by providing data on the average amount of opioids used in lumbar laminectomy, lumbar discectomy, anterior cervical discectomy and fusion, and cervical total disc replacement. It also includes stratification of approach type for laminectomy and discectomy, covering open, tubular, and endoscopic approaches. This contributes to the possible refinement of the opioid-prescribing guidelines for opioid-naive patients so a minimum amount could be prescribed without compromising the need to call the surgeon’s office for refills in the majority of cases.

One study demonstrated that spine surgery patients were prescribed the highest quantity of MME postoperatively compared to trauma and adult reconstruction patients.¹⁴ Spine patients also had the highest mean VAS (Visual Analog Scale) pain scores. This study suggests decreasing opioid use by utilizing multimodal analgesia, such as a combination of nonopioids and anesthesia during surgery, to minimize opioid use perioperatively.¹⁵ This approach is further supported by a study from Bae et al, which demonstrates that a multimodal perioperative pain regimen combining NSAIDs, gabapentinoids, and paracetamol effectively reduces postoperative opioid consumption. Additionally, regional anesthesia techniques such as erector spinae plane (ESP) and thoracolumbar interfascial plane (TLIP) blocks are increasingly employed to manage perioperative and postoperative pain.¹⁶ Another study demonstrated that there was no statistically significant difference between the number of refill requests before and after implementation of opioid prescribing guidelines; however, opioid consumption decreased overall after the guidelines were implemented.¹⁷ Physicians may better manage patient expectations regarding post-operative opioid requirements by using the averages of patients who have undergone the same surgery. Patient education could potentially decrease their expectant postoperative opioid requirement. Compared to established literature that found 18.1% of patients requested refills of any opioid medication, our findings demonstrated a lower percentage at only 13.8% of patients requesting refills.¹⁸ In contrast to the studies mentioned previously, all patients in this cohort underwent multimodal anesthesia. Regional blocks were not used but nonspecific muscle block with local anesthetic was used at the incision site only. All had preoperative gabapentin 300 mg and celecoxib 100 mg. While our findings demonstrate an association between the endoscopic approach to lumbar decompression and reduced postoperative opioid consumption, this relationship should be interpreted in the context of concurrent multimodal analgesia. The routine administration of non-opioid agents, including celecoxib and gabapentin, represents a potential confounding factor that may independently contribute to decreased opioid requirements. Notably, patients categorized as not using opioids postoperatively may still have achieved adequate pain control through these non-opioid analgesics, underscoring the importance of considering multimodal pain management when attributing reductions in opioid use to surgical approach alone. Furthermore, variability in individual pain perception, surgical indication, and extent of tissue dissection may also contribute to observed differences, limiting the ability to isolate surgical approach as an independent determinant of opioid consumption.

Newer minimally invasive surgery (MIS) techniques have emerged over the last several years, such as unilateral bi-portal endoscopy (UBE). When compared to open and tubular approaches, UBE is theorized to be less traumatic to the surrounding soft tissue. In 2024, Tong et al reported that opioid use after single-level UBE was significantly lower in the immediate postoperative period when compared to the single-level tubular approach.¹⁹ This suggests that the less invasive methods of UBE could result in less postoperative pain compared to the tubular approach. Our findings were similar to their results, as there was significantly lower post-operative opioid consumption after endoscopic lumbar surgeries compared to open. Physicians may use this information to guide their treatment plan for patients when considering the risks and benefits of different surgical approaches.

Several patients in this study reported not taking any prescribed opioids, instead only using nonopioid analgesia. 38 of 217 (17.5%) used only nonopioid analgesia for postoperative pain. One study that implemented an opioid-minimization protocol before elective minimally invasive spine surgery resulted in 47% of patients not using any opioids by their 1-month follow-up.²⁰ Our findings, along with the existing literature, lend evidence that nonopioid analgesia is a viable option for postoperative pain management in some cases.

Limitations

The limitations of this study include the derivation from a single surgeon’s database, collected from one hospital and one surgery center within a single geographic region. Given that studies have suggested opioid usage varies by region in the U.S., with higher usage reported in the South, these findings may not be generalizable to other populations (Gupta et al). Pain tolerance and expectations may also differ between patients in this region compared to those in other parts of the world. Additionally, differences between the two surgical centers mean that patients may have been managed by different anesthesia teams, potentially influencing the dose of opioids required intraoperatively. Patients treated at ambulatory surgical centers may have reported higher opioid use compared to those treated at tertiary centers. This could be because patients who stayed overnight at tertiary centers did not include in-hospital opioid consumption in their reported use, and by the time they were discharged, they were further out from surgery and potentially required fewer opioids. It is also important to note that this reflects a single surgeon’s prescribing protocol and may be influenced by varying postoperative expectations set by different surgeons during the preoperative period. The study also includes a mix of surgical techniques, with the senior surgeon performing mainly endoscopic procedures for 1-3-level procedures. However, some patients undergoing open or tubular procedures may have been selected based on body habitus or medical comorbidities, which could have led to increased opioid usage. The senior surgeon favors more minimally invasive techniques like endoscopic and tubular approaches for higher BMI patients. Importantly, this cohort includes a heterogeneous mix of pathologies and procedures, including lumbar discectomy, lumbar laminectomy, ACDF, and cervical TDR, each associated with distinct pain generators, tissue dissection requirements, and postoperative recovery trajectories. As a result, pooled analyses across these procedure types should be interpreted as exploratory. Differences in opioid consumption may reflect underlying procedural complexity, surgical indication, or spinal region rather than surgical approach alone. Additionally, postoperative MME data demonstrated substantial variability, with large standard deviations and wide interquartile ranges, suggesting a skewed distribution with potential outliers. Parametric statistical tests were used for group comparisons; however, the non-normal distribution of opioid consumption may limit the robustness of these analyses. Although sample sizes were sufficient for primary comparisons, results should be interpreted with caution given the potential violation of normality assumptions. Future studies may benefit from nonparametric analyses or transformation of skewed data to confirm these findings. Several subgroup analyses, including direct comparisons between cervical open vs cervical tubular, cervical open vs endoscopic, cervical tubular vs endoscopic, and open vs tubular approaches, were limited by small sample sizes and were therefore underpowered to detect meaningful differences. Consequently, nonsignificant findings in these comparisons should not be interpreted as evidence of no difference between techniques. Therefore, nonsignificant findings in these subgroup comparisons should not be interpreted as evidence of equivalence between techniques but rather as inconclusive due to limited statistical power. Future studies with larger cohorts are needed to adequately assess potential differences in opioid utilization across these surgical approaches. Despite these limitations, a notable strength is the inclusion of objective measures such as precise pill counts and preoperative assessments. Additionally, having a single surgeon minimizes variability in surgical technique, providing consistency in the operative approach.

Conclusion

Effective pain management following spine surgery remains a significant clinical challenge due to the severity of postoperative pain and the traditional dependence on opioid-based regimens. This study evaluated opioid consumption across various surgical approaches, within a heterogeneous cohort of lumbar and cervical procedures. Our findings suggest that the minimally invasive methods of endoscopic and tubular approaches were associated with lower postoperative opioid consumption compared to open techniques. Differences in opioid utilization may reflect procedural complexity, pathology, or patient-specific factors rather than surgical approach alone.

Footnotes

ORCID iDs

Dylan Moran

Daniel Park

Ethical Considerations

This study received ethical approval from the Corewell Health IRB (approval #2023-1999) on February 9, 2024. This is an IRB-approved retrospective study, all patient information was de-identified and patient consent was not required. Patient data will not be shared with third parties.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.*

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