Abstract
Background Adult spinal deformity (ASD) surgery often involves extensive spinal realignment to restore spinopelvic parameters and functional alignment. Unfortunately, patients frequently experience significant postoperative pain, often leading to prolonged opioid use. This study investigates patient- and surgery-related factors associated with opioid use and pain following ASD surgery.
Methods We conducted a retrospective review of ASD cases performed at our institution between 2016 and 2023. All patients underwent multilevel spinal fusion for correction of scoliosis and/or kyphosis.
Results Of the 264 patients, 231 (88%) required opioids postoperatively, and 22.4% remained on opioids at 12 months. Preoperative opioid use (P < 0.001), pelvic incidence (PI) <55° (P = 0.018) due to inability for pelvic retroversion, revision surgery for proximal junctional kyphosis (P = 0.006), and hardware failure (P < 0.001) were associated with prolonged opioid use. Notably, patients who underwent intradiscal osteotomy (IDO) had a shorter duration of opioid use due to more harmonious correction of their lumbar lordosis (P = 0.006). Pain scores were significantly higher in patients who underwent anterior column release (P < 0.001) and who experienced postoperative complications (proximal junctional kyphosis and hardware failure; P < 0.05). In contrast, patients treated with IDO or pedicle subtraction osteotomy reported lower pain (P < 0.05). In multivariable analysis, preoperative opioid use was the strongest independent predictor of 12-month use (OR = 3.95, P = 0.001), while PI > 55° was independently associated with decreased 12-month use (OR = 0.33, P = 0.009).
Conclusion This study highlights several key risk factors for prolonged opioid dependence and elevated postoperative pain in ASD surgery, including preoperative narcotic use, postoperative PI < 55°, revision surgery for mechanical complications, and specific osteotomy techniques. The protective effect of IDO in reducing pain and opioid duration is most likely due to more harmonious correction of lumbar lordosis and an improvement in lumbar lordosis-PI mismatch.
Clinical Relevance These findings underscore the importance of preoperative optimization, opioid-sparing pain management strategies, and enhanced recovery pathways to mitigate long-term opioid reliance and improve patient outcomes.
Level of Evidence 3.
Introduction
Adult spinal deformity (ASD) surgery involves realignment of spinal structures to correct pathological spinopelvic parameters, often resulting in significant postoperative pain requiring opioid analgesia.1,2 In 2021, there were approximately 81,000 opioid-related overdose deaths in the United States, underscoring the urgency of addressing opioid dependency risks.3 Despite the known risks of addiction and overdose, opioids remain the standard of care for managing postoperative pain in spine surgery.1,2 Alarmingly, studies suggest that up to 15% to 18% of opioid-naïve patients develop chronic opioid dependence after spine surgery, a rate that rises to 64% in patients with prior opioid use.4 Identifying predictors of long-term opioid use is therefore critical to improving patient safety and outcomes.
Numerous factors may influence opioid use following ASD surgery. Patient-specific characteristics such as central sarcopenia, surgical factors such as invasiveness, and postoperative complications, including hardware failure (HF), may all contribute to prolonged opioid dependency. HF occurs in up to 40% of ASD patients and has been linked to worsened pain and increased narcotic reliance.5 Central sarcopenia—defined by reduced psoas muscle mass—has been associated with poorer outcomes in lumbar fusion surgeries, likely due to decreased paraspinal support and blood flow, both of which may exacerbate postoperative pain.6,7 Although minimally invasive (MIS) techniques, including endoscopic approaches, are believed to reduce opioid use, their application in multilevel deformity correction remains limited.8–10
Understanding which patients are at risk for prolonged opioid use can help tailor perioperative care, improve surgical outcomes, decrease complications, and reduce healthcare costs.1,11,12 In this study, we evaluated preoperative, surgical, and postoperative factors associated with persistent opioid use and pain in a cohort of 264 patients undergoing ASD surgery at a large academic center.
Methods
Study Design
We conducted a retrospective cohort study of patients who underwent ASD correction between 2016 and 2023 at a single academic institution. A total of 264 patients were included.
Surgical Technique
ASD surgery was defined as a multilevel spinal fusion involving at least 5 vertebral segments, extending from the pelvis to at least L2, typically performed to correct scoliosis and/or kyphosis. Surgeries were conducted using either open or MIS techniques. MIS techniques involve small incisions with specialized instruments to correct spinal deformity. Depending on the underlying deformity and alignment goals, some patients underwent correction through anterior manipulation, including anterior column release (ACR), which involves the release of the anterior longitudinal ligament and the placement of hyperlordotic interbody cages. Others underwent posterior open approaches, such as pedicle subtraction osteotomy (PSO), a 3-column osteotomy requiring wedge-shaped resection of the vertebral body for angular correction, intradiscal osteotomy (IDO), which involves disc space release and cage insertion without vertebral resection to allow correction through interbody expansion, or Ponte osteotomy, which requires partial facetectomies to release the posterior column and facilitate correction. The choice of technique was tailored to the individual patient’s anatomy and surgical objectives. All procedures were performed by 1 of 9 neurosurgeons following standardized institutional protocols for deformity correction.
Data Collection
Data were obtained from electronic medical records and included patient demographics, prior surgeries, spinopelvic parameters, opioid use, visual analog scale (VAS) pain scores, surgical technique details, and complications. Opioid use was tracked postoperatively, with duration defined as the interval between surgery and the last documentation of opioids, and was based on a combination of prescription records and patient-reported use. Patients used a variety of opioids, including Codeine, Dilaudid, Fentanyl, Norco, Morphine, Oxycodone, Percocet, and Tramadol. Using opioids for ≥12 months postoperatively was defined as long-term opioid use. This time frame was selected after finding no standard definition for “long-term” opioid use in the reviewed literature.1,2,11,13 We also collected data relating to preoperative opioid use, which was defined as opioid use prior to surgery.
To evaluate the impact of sarcopenia, we assessed psoas muscle integrity using the Psoas-L4 Vertebral Index, measured via ImageJ software. For levels flanked by the psoas (L1–L4), we also measured the Psoas–Upper Instrumented Vertebra Index. Additionally, we graded the erector spinae muscles at L4, L5, and the upper instrumented vertebra using the Goutallier Classification System, which ranges from 0 (minimal fat) to 4 (extensive fat infiltration) based on T1- or T2-weighted magnetic resonance imaging.
Statistical Analysis
Analyses were conducted using IBM SPSS Statistics and R Studio. We used Pearson and Spearman correlations, independent t tests, Mann-Whitney U tests, and Kruskal-Wallis tests, as appropriate. ggplot2 was used for data visualization. Multivariable logistic regression analysis was conducted to identify independent predictors of long-term opioid use. Statistical significance was set at P < 0.05.
Results
Demographics
Among 264 included patients, 148 were men, and the mean age was 64.3 years. A total of 172 (65.9%) reported preoperative opioid use. Postoperatively, 231 patients (87.5%) used opioids, and 57 (22.4%) continued using them at 12 months. The mean duration of postoperative opioid use was 10.6 months. VAS data were available for 229 patients and revealed a median postoperative leg pain score of 1 and back pain score of 2. The median improvement in VAS leg pain was 2 points, while back pain improved by a median of 8 points. Average central sarcopenia values were 1.91 (L4) and 1.00 (UIV). See Table 1 and Supplemental Tables for demographic data.
Demographics, surgical characteristics, and postoperative outcomes.
Preoperative Factors
Patients with preoperative opioid use had significantly longer postoperative use (93.6% vs 76.4%, χ 2 = 16.13, P < 0.001), greater 12-month reliance (29.82% vs 11.9%, χ 2 = 9.94, P = 0.002), and prolonged opioid use duration (13.6 vs 4.9 months, t = −3.26, P = 0.001; Figures 1–3). Prior spine surgery was associated with slightly reduced postoperative leg pain (U = 5052.50, P = 0.046; Figure 4). Other demographics and preoperative features were not significantly associated with opioid use or postoperative pain.
Demographic, operative, and postoperative characteristics associated with opioid use. Postoperative opioid use was significantly associated with preoperative opioid use (A), MIS (B), HF (C), and PSO (D). MIS, minimally invasive surgery; HF, hardware failure; PSO, pedicle subtraction osteotomy.
Demographic and postoperative characteristics associated with long-term opioid use (≥12 months). Long-term postoperative opioid use was significantly associated with preoperative opioid use (A), PJK surgery (B), HF (C), and HF surgery (D). HF, hardware failure; PJK, proximal junctional kyphosis.
Length of opioid use stratified by demographic, operative, and postoperative characteristics. Length of opioid use was significantly associated with preoperative opioid use (A), IDO (B), PI>55º (C), PJK surgery (D), and HF surgery (E). HF, hardware failure; IDO, intradiscal osteotomy; PI, pelvic incidence; PJK, proximal junctional kyphosis.
Leg pain stratified by demographic, operative, and postoperative characteristics. Postoperative leg pain was significantly associated with prior back surgery (A), ACR (B), PSO (C), and IDO (D). ACR, anterior column release; IDO, intradiscal osteotomy; PSO, pedicle subtraction osteotomy; VAS, visual analog scale.
Sarcopenia-related findings included higher Goutallier grades in the left multifidus at L5/S1 among postoperative opioid users (χ 2 = 7.99, P = 0.046). Increased fat infiltration in the right erector spinae at L4/L5 correlated with higher postoperative back pain (H = 9.73, P = 0.045) and smaller VAS improvements (H = 13.97, P = 0.007). Similar associations were seen in the right multifidus and erector spinae at L5/S1. Data on postoperative and 12-month opioid use are summarized in Tables 2 and 3 and Figures 1–3. Data on postoperative leg and back pain can be found in Table 4 and Figures 4–6.
Postoperative and long-term opioid use.
Length of opioid use.
Postoperative back pain and change in back pain.
Back pain stratified by operative and postoperative characteristics. Postoperative back pain was significantly associated with IDO (A), ACR (B), and PJK surgery (C). ACR, anterior column release; IDO, intradiscal osteotomy; PJK, proximal junctional kyphosis; VAS, visual analog scale.
Change in back pain stratified by operative characteristics. Change in back pain was significantly associated with PSO (A), IDO (B), and ACR (C). ACR, anterior column release; IDO, intradiscal osteotomy; PSO, pedicle subtraction osteotomy; VAS, visual analog scale.
Surgical Factors
IDO was associated with reduced duration of opioid use (4.1 vs 12.0 months, t = 4.05, P = 0.022), and PSO was linked to greater postoperative opioid use (97.6% vs 85.4%, χ 2 = 4.77, P = 0.029), most likely due to more harmonious spinopelvic correction in the IDO group. Both IDO and PSO patients reported greater back pain improvement. IDO patients had significantly lower median postoperative back (U = 1858.0, P = 0.006) and leg VAS scores (U = 1806.5, P = 0.003) and greater changes in back pain (U = 1644.0, P < 0.001). PSO was associated with greater change in back pain (U = 2581.0, P = 0.043) and lower leg pain (U = 2547.5, P = 0.030). ACR was associated with higher postoperative back pain (U = 2441.5, P < 0.001) and less VAS improvement. Interestingly, MIS patients were more likely to be discharged with opioids (97.7% vs 85.5%, χ 2 = 5.05, P = 0.025). Data on postoperative and 12-month opioid use are summarized in Tables 2 and 3 and Figures 1–3. Data on postoperative leg and back pain can be found in Table 4 and Figures 4–6.
Postoperative Factors
Long-term opioid use was more common in patients without HF (28.9% vs 15.5%, χ 2 = 4.99, P = 0.026), those requiring surgery for HF (46.2% vs 21.5%, χ 2 = 7.78, P = 0.005), and those undergoing proximal junctional kyphosis (PJK) surgery (45.5% vs 22.2%, χ 2 = 5.24, P = 0.021; Figure 2). Opioid use duration was longer in patients with pelvic incidence (PI) <55° (13.5 vs 8.3 months, t = 2.04, P = 0.042), PJK surgery (21.4 vs 9.9 months, t = −2.47, P = 0.014), and HF surgery (22.6 vs 9.4 months, t = −3.20, P = 0.002; Figure 3). Additionally, patients who required surgery for PJK had greater back pain (U = 1488.5, P = 0.030). Data on postoperative and 12-month opioid use are summarized in Tables 2 and 3 and Figures 1–3. Data on postoperative leg and back pain can be found in Tables 4 and 5 and Figures 4–6.
Postoperative leg pain and change in leg pain.
Multivariable Regression Analysis of Factors Associated With 12-Month Opioid Use
A binary logistic regression analysis was performed to identify factors independently associated with 12-month opioid use. Variables included in the model were age at surgery, male sex, PSO, IDO, ACR, sarcopenia, history of illicit drug use, preoperative opioid use, MIS, PI > 55%, PJK or HF (and their respective reoperations), and surgical complications.
The multivariate model was statistically significant (χ 2 = 36.89, df = 15, P = 0.001), demonstrated good fit (Hosmer-Lemeshow P = 0.642), and explained 28.7% of the variance in prolonged opioid use (Nagelkerke R 2 = 0.287). Notably, preoperative opioid use remained the strongest independent predictor (OR = 3.95, 95% CI 1.73–9.01, P = 0.001), and PI > 55° was independently predictive of opioid use at 12 months postoperative (OR = 0.33, 95% CI 0.14–0.76, P = 0.009). Patients with postoperative PJK also trended toward prolonged opioid use (P = 0.052). Results are detailed in Table 6.
Multivariable analysis of factors associated with 12-month opioid use.
Discussion
At our institution, we identified several preoperative, intraoperative, and postoperative factors that significantly increase the risk of long-term opioid use and persistent pain following ASD surgery. Key predictors of prolonged opioid use included prior opioid exposure, central sarcopenia, PSO, PJK, and HF. In contrast, interbody device-only constructs appeared protective, associated with an average of 8 months less opioid use—potentially due to reduced postoperative leg and back pain.
Stratifying patients into high- and low-risk groups for prolonged opioid use is essential to addressing the ongoing opioid epidemic, particularly as narcotics remain a mainstay in managing postoperative spine pain. Our findings—11.90% of opioid-naïve patients and 29.82% of prior opioid users continuing opioid use at 1 year—are slightly below previously reported rates, where chronic use has ranged from 18% to 30% in opioid-naïve patients and up to 50% in prior users.1,2,4,11,14–16 Controlling for potential confounders in a multivariable logistic regression model revealed that only preoperative opioid use and PI > 55° are independently associated with opioid use at 12 months, and postoperative PJK trended toward significance (P = 0.052). Preoperative use conferred a nearly 4-fold increased odds of continued narcotics at 1 year postoperative (OR = 3.95, P = 0.001), while PI > 55° was protective against long-term opioid use. Given the multifactorial nature of opioid dependence, these findings provide better insight into factors that may increase the risk of long-term opioid use.
Baseline Patient Characteristics
Although a history of illicit substance use was not associated with any measure of pain or opioid use, prior opioid exposure was a strong predictor of prolonged postoperative narcotic dependence. Patients with prior opioid use required narcotics for 9 months longer (t = −3.26, P < 0.001) and were significantly more likely to need opioids at 12 months postoperatively (29.82% vs 11.90%, P = 0.002). Preoperative opioid use remained a significant predictor of 12-month opioid use in multivariable analyses (OR = 3.95, P = 0.001). Importantly, these patients did not report higher postoperative pain scores, suggesting their ongoing use may be driven more by dependence than inadequate pain control. These findings are consistent with previous studies identifying preoperative opioid exposure as a strong risk factor for continued use.1,2,4,11,14–17 Cook et al stratified preoperative opioid users based on the number of prescriptions filled within the 6 months preceding surgery, classifying them as sporadic or chronic users, and found that chronic users were more likely than sporadic ones to use opioids 1 year after surgery.4 Variations in the nature, amount, and duration of preoperative opioid use may account for the differences in reported rates of postoperative opioid use across different patient cohorts. For purposes of a more complete analysis, future studies may benefit from parsing the independent effect of each of these parameters on postoperative opioid use following ASD surgery.
Sarcopenia was also significantly associated with pain and opioid use. Patients with chronic postoperative opioid use had higher Goutallier grades in the left multifidus at L5/S1 (P = 0.046), reflecting greater baseline muscle atrophy. Prior studies have similarly linked reduced paraspinal muscle mass to increased postoperative pain and disability.6,18–20 A proposed mechanism is that loss of paraspinal muscle mass reduces spinal support and stability, exacerbating postoperative pain and increasing the need for narcotic analgesia.21
Surgical Characteristics
Surgical technique also influenced opioid requirements. Compared with MIS, patients who underwent open surgery reported less postoperative narcotic use (P = 0.025), mainly due to a better spinopelvic correction. This mirrors findings from Shalita et al, who found no reduction in opioid prescription rates with MIS for ASD.22 Despite MIS’s benefits in minimizing soft tissue trauma, its limitations in deformity correction and spinal alignment may explain its lack of superiority regarding long-term pain outcomes.23–25 Moreover, some studies report no significant difference in postoperative pain or narcotic use between MIS and open surgery at 12 months.26–28
Among surgical correction techniques, IDO was associated with a significantly reduced duration of opioid use (P = 0.022), while PSO was associated with increased narcotic needs (P = 0.029), likely because of a more harmonious correction of lumbar lordosis in the IDO group.29 IDO and PSO both corresponded with lower postoperative pain scores, whereas ACR was associated with higher pain levels in both the back and legs (P < 0.050). While no prior study has directly investigated the influence of different osteotomy techniques on postoperative opioid use, a few have found an association between osteotomy type and postoperative pain.29,30 Ghandhari et al, described improved pain outcomes in patients receiving PSO, while Carballo Cuello et al found that patients who underwent IDO had significantly lower back pain at 3 months than patients who underwent PSO.29,30 IDO’s benefits may derive from its preservation of vertebral bodies and pedicles, which limits destabilization and reduces invasiveness, as well as from its association with early mobility and more harmonious restoration of lumbar lordosis.31 Conversely, ACR disrupts the anterior longitudinal ligament and disc space, and PSO requires extensive bone resection—both increasing instability and postoperative pain compared with IDO.32–34 With limited current literature on IDO, our findings suggest that further comparative studies are warranted.
Postoperative Outcomes
Spinopelvic alignment also played a role in postoperative opioid use. Patients with PI ≤ 55° had a significantly longer duration of opioid use by approximately 5 months (P = 0.042), mainly due to low pelvic tilt compensation. This association persisted in multivariable analyses; patients with PI > 55° had 67° lower odds of continued opioid use at 12 months compared with patients with PI ≥ 55° (OR = 0.33, P = 0.009). While a higher PI is typically associated with more severe deformity, the findings suggest that patients with higher PI may receive more aggressive sagittal correction, leading to better alignment, pain relief, and reduced opioid needs.35–38 To date, no study has directly investigated the effect of preoperative spinopelvic parameters on postoperative pain and opioid use.
Postoperative complications, such as PJK and HF, were strongly associated with increased pain and narcotic use (P < 0.05), consistent with existing literature.1,39–41 Interestingly, although patients with HF used more opioids overall, they were less likely to be using them at 12 months (P = 0.026). This may reflect successful conservative management in many HF cases, with prolonged use observed mainly in those requiring reoperation.42,43 While not reaching statistical significance in multivariable analyses (OR = 3.47, P = 0.052), patients with PJK trended toward a 3 times greater risk of continued need for narcotics 1 year postoperatively. Overall, our findings underscore the multifactorial nature of postoperative opioid use following ASD surgery. By recognizing and addressing modifiable risk factors—including preoperative opioid exposure, sarcopenia, surgical invasiveness, and postoperative complications—surgeons can better tailor perioperative care and reduce long-term narcotic dependence.
Limitations
Several limitations of our study warrant discussion. Despite our relatively large sample size, there is inherent bias given the single-center, retrospective design, limiting generalizability. Also, our findings rely primarily on univariate analyses, and future studies should perform rigorous multivariate analyses to further reveal risk factors for prolonged opioid use and pain after ASD surgery. Additionally, patients included in this study underwent ASD over 7 years. This large period may have created a population with heterogeneous treatments and technologies, limiting the ability to compare these patients over time. Also, surgical techniques in ASD surgery are often selected based on individual patient anatomy and severity of deformity. As such, differences in outcomes between techniques like ACR, PSO, and IDO may partly reflect underlying patient characteristics, introducing selection bias due to differences in surgical invasiveness and patient characteristics. While our subgroup comparisons provide useful insights, future studies with more standardized surgical indications or matched cohorts could help further clarify the relationship between surgical approach and postoperative opioid use. Finally, even though we carefully sorted through follow-up notes and prescriptions for data on opioid use, there were insufficient data on the strength and frequency of opioid use. Future prospective analyses collecting various data points such as opioid types, dosage, administration methods, and morphine milliequivalent conversions would greatly aid in progressing this research further and improving postoperative pain management for patients.
Conclusion
While the addictive and dangerous side effects of opioids are well established, there are few studies examining factors associated with opioid dependence following ASD surgery. In this study, we demonstrated that preoperative opioid use and central sarcopenia may increase the risk of postoperative opioid dependence. Intraoperative factors such as surgical invasiveness, type of osteotomy, and whether ACR was performed can also predict postoperative opioid use. These findings offer opportunities for surgeons to optimize surgical planning and postoperative pain management. We recommend greater use of preoperative and intraoperative screening for these risk factors to decrease the postoperative opioid reliance and associated morbidity and addiction. The retrospective nature of this study and the lack of patient stratification based on the type, amount, and duration of preoperative opioid use prevent us from making specific causal claims regarding the impact of preoperative factors on opioid reliance after ASD surgery. Prospective studies with further analysis of clinical outcomes based on more specifically defined risk factors are needed to establish such associations.
Supplementary material
Supplemental Tables.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Data Availability The data are available upon reasonable request from the authors.
Ethical Approval & Informed Consent This study was conducted in accordance with the principles of the Declaration of Helsinki. Institutional review board approval was obtained prior to the initiation of the study. Patient data were anonymized to ensure confidentiality, and no identifiable information was included in this retrospective analysis. All data were collected and stored in compliance with institutional and regulatory guidelines to maintain the privacy and security of patient information.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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