Abstract
Objective:
To characterize the opioid prescribing patterns for and requirements of patients undergoing repair of spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base
Study Design:
Retrospective chart review
Setting:
Tertiary referral center
Patients:
Adults with lateral skull base sCSF leaks who underwent repairs between September 1, 2014 and December 31, 2020
Main Outcome Measure:
Mean morphine equivalents (MME) of opioids dispensed to inpatients and prescribed at discharge, additional pain-control medications dispensed, and outpatient additional opioid requests were compared between groups.
Results:
Of 78 patients included, 46 (59%) underwent repair via a transmastoid (TM), 6 (7.7%) via a middle cranial fossa (MCF), and 26 (33.3%) via a combined TM-MCF approach. Inpatients received a mean of 21.3, 31.4, and 37.6 MME per day during admission for the TM, MCF, and combined TM-MCF approaches, respectively (p=0.019, ηp2=0.101). Upon discharge, nearly all patients (n=74, 94.9%) received opioids; 27.3, 32.5, and 37.6 MME per day were prescribed after the TM, MCF, and TM-MCF approaches, respectively (p=0.015, ηp2=0.093). Five (6.4%) patients requested additional outpatient pain medication, after which 3 were prescribed 36.7 MME per day. Patients with idiopathic intracranial hypertension required significantly more inpatient MME than those without (41.5 versus 25.2, p=0.02, d=0.689), as did patients with a history of headaches (39.6 versus 23.6, p=0.042, d=0.684).
Conclusions:
Patients undergoing sCSF leak repair via the MCF or TM-MCF approaches are prescribed more opioids post-operatively than patients undergoing the TM approach. Patients with a history of headaches or idiopathic intracranial hypertension might require more opioids post-operatively.
Introduction
Over the last two decades, opioid overdose rates have tripled, and unfortunately, it is estimated that nearly half of opioid-related deaths might be associated with prescription opioids.1–3 Surgery has been identified as a major source of opioid prescriptions resulting in an estimated 13% rate of persistent opioid use.4, 5 Though more attention has been dedicated recently to curbing the postoperative opioid prescribing amounts, accurate postoperative opioid requirements are unknown, and healthcare providers are at risk of over-prescribing.
Few studies have assessed opioid needs and prescribing patterns after otologic surgery. Kirubalingam et al. found that the mean total morphine milligram equivalents (MME), which is an opioid conversion factor to standardize opioids of differing potencies, prescribed per patient following tympanoplasty without mastoidectomy was 247 compared to 283 following mastoidectomy.6 Additionally, Cooperman et al. found that on average 39.9 more total MME were prescribed per patient following mastoidectomy compared to other middle ear surgery.7 Together this evidence suggests that a mastoidectomy leads to greater opioid requirements. However, these studies did not approximate opioid usage or patient-perceived pain levels. Additionally, others have found no association between opioid prescribing patterns and otologic operative approaches (transcanal versus post-auricular).8, 9 Neurotologic procedures, such as those that require a craniotomy, have the potential to be more painful than both tympanoplasties and mastoidectomies. Boyd et al. found that patients who underwent lateral bony cranial procedures, including osseo-integrated device procedures or craniotomy hardware revisions, were prescribed significantly higher amounts of postoperative opioids compared to patients undergoing transcanal or other operative approaches.10
A temporal craniotomy is often performed as an approach to repair spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base, which are becoming increasingly more common, in parallel with the obesity epidemic and idiopathic intracranial hypertension (IIH).11 Studies propose lateral skull base sCSF leaks arise from high pressure pulsatile arachnoid granulations which lead to bony erosion, dural thinning, and eventual brain herniation through the bony defects.12 Surgical repair via a trans-mastoid (TM), middle cranial fossa (MCF), or combined (TM-MCF) is recommended to reduce the risk of meningitis.13, 14 Though historically the MCF approach was considered the gold standard, it requires temporal lobe manipulation causing more pain in the cranial nerve V ophthalmic distribution.12, 15 In contrast, the TM approach allows for shorter operative time, length of stay, and does not require significant temporal lobe manipulation or a craniotomy, all potentially resulting in less postoperative pain.11
To date, no studies have assessed opioid prescription patterns following lateral skull base sCSF leak repair for any operative approach. Given the increasing prevalence of sCSF leaks and the link between sCSF leaks, IIH, and headaches, it is important to understand both the past opioid prescribing patterns and opioid needs of patients undergoing these procedures, to direct more precise opioid prescribing practices. Therefore, this retrospective review sought primarily to assess opioid prescribing and usage patterns following operative repair of sCSF leaks for all approaches at a single tertiary care center and secondarily to determine differences in opioid needs across demographic and operative factors.
Materials and Methods
The Medical University of South Carolina Institutional Review Board waived review of this study (Pro00111774). A retrospective chart review of lateral skull base sCSF leak repairs was performed between September 1, 2014 and December 31, 2020. Patients with CSF leaks secondary to trauma, cholesteatoma, neoplasm, or history of previous lateral skull base surgery were excluded. All surgeries were performed by one of four neurotologists at a single tertiary medical center.
Collected data included: opioid dose and type dispensed to inpatients, opioid dose and type prescribed upon discharge, additional pain medications dispensed (e.g., acetaminophen, non-steroidal anti-inflammatory drugs, gabapentin, steroids), and outpatient requests made for additional opioid. To determine factors that could affect opioid prescribing patterns or need for pain control we collected and compared these to patient demographics, comorbidities, and operative approach. Demographic data collected included sex, race, age, body mass index (BMI) and comorbidities (hypertension, diabetes mellitus, hyperlipidemia, obstructive sleep apnea, idiopathic intracranial hypertension, history of chronic pain, and history of headaches). History of substance use disorder was not accounted for in patient demographics as the authors were not granted access to South Carolina’s Prescription Drug Monitoring Program (PDMP). The opioid dose dispensed per day was converted into morphine milligram equivalents (MME) using the Centers for Disease Control and Prevention MME conversion factors.16 For outpatient opioid prescriptions, opioid dose, frequency, duration, and number of pills prescribed were converted into the amount of MME prescribed per day. Opioid prescribing patterns and secondary opioid requests by year were also assessed. Finally, trends in opioid prescribing for each operative approach by year were analyzed.
All statistical analysis was performed using SPSS statistics version 28 (IBM Corporation, Armonk, NY). Continuous variables were assessed using the Mann-Whitney U test or Independent-samples Kruskal-Wallis test as appropriate to compare inpatient MME dispensed and outpatient MME prescribed for patients with differing demographic or operative factors. Effect sizes were assessed by Cohen’s d or partial eta squared (ηp2) as appropriate. Confidence intervals were calculated for Cohen’s d and ηp2. Statistical significance was set at p < 0.05.
Results
A total of 78 patients were included in the study. Patient characteristics are described in Table 1. The mean age at the time of surgery was 59 ± 13.2 (range: 84–24) years, forty-seven (60.3%) patients were female, and 56 (71.7%) patients were white. The average BMI was 35.2 ± 8.8 kg/m2. Notably, 24.4% (n=19) of patients had a history of headaches or migraines, 9% (n=7) had a history of chronic pain, and 14.1% (n=11) had a diagnosis of idiopathic intracranial hypertension. Forty-six (59%) patients underwent repair via the TM, 6 (7.7%) via the MCF, and 26 (33.3%) via a combined TM-MCF approach. Most patients (n=61, 78.2%) were admitted overnight post-operatively. The average length of stay was 1.3 ± 1.7 (range: 0–16) days. The average length of stay was 1.0 ± 0.6, 1.3 ± 1.9, and 1.4 ± 0.5 for the TM, MCF, and combined TM-MCF approaches, respectively (p<0.001). One patient remained in the hospital for 16 days postoperatively for management of pulmonary edema and pneumonia. This patient received surgery via the transmastoid approach, required an average of 23.8 MME per day while hospitalized, and did not receive an opioid prescription at discharge.
Table 1.
Patient Demographics
| MN ± SD or Frequency (%), N = 78 | |
| Age | 59.0 ±13.2 |
| Gender | |
| Male | 31 (39.7) |
| Female | 47 (60.3) |
| BMI a | 35.2 ± 8.8 |
| Race | |
| White | 56 (71.7) |
| AAb | 21 (26.9) |
| Asian | 1 (1.3) |
| Comorbidities | |
| HTNc | 49 (62.8) |
| DMd | 20 (25.6) |
| Hyperlipidemia | 19 (24.4) |
| OSAe | 14 (17.9) |
| IIHf | 11 (14.1) |
| History of chronic pain | 7 (9) |
| Headache/Migraine | 19 (24.4) |
| Anesthesia Duration (hours) | 4.0 ± 1.0 |
| Surgery Duration (hours) | 2.8 ±0.9 |
body mass index,
african american,
hypertension,
diabetes mellitus,
obstructive sleep apnea,
idiopathic intracranial hypertension
MME prescribed by operative approach are described in Table 2. The mean MME administered per day during hospitalization to those who underwent repair via the TM approach was 21.3 ± 17.5 compared with 31.4 ±34.2 via the MCF approach and 37.6 ± 37.1 via the combined TM-MCF approach (p = 0.019, ηp2 = 0.09 [0 – 0.22]). The mean MME administered per day for the TM approach was significantly less than approaches including craniotomies combined (21.3 ± 17.5 versus 36.4 ± 28.7; p = 0.009, d = −0.66 [−1.12 - −0.19]). Outpatient MME per day prescribed upon discharge to those receiving repair via the TM approach was also significantly less than to those who underwent repair via either the MCF or combined TM-MCF approaches (27.3 ± 17.5 versus 36.4 ±28.7; p = 0.004, d = −0.62 [−1.08 - −0.16]).
Table 2.
Morphine Milligram Equivalents (MME) Prescribed by Operative Approach
| Inpatient opioids dispensed | Outpatient opioids prescribed | ||||||
|---|---|---|---|---|---|---|---|
| N (%) | Total MME (MN +/− SD) | p-value | Cohen’s d or ηp2 (95% confidence interval) | Total MME (MN +/− SD) | p-value | Cohen’s d or ηp2 (95% confidence interval) | |
| Approach | |||||||
| TMa | 46 (59.0) | 21.3 +/− 17.5 | 0.019 | 0.101 (0.002 – 0.226) | 27.3 +/− 14.4 | 0.015 | 0.093 (0 – 0.216) |
| MCFb | 6 (7.7) | 31.4+/− 34.2 | 32.5 +/− 8.0 | ||||
| Combined | 26 (33.3) | 37.6 +/− 27.1 | 37.4 +/−16.0 | ||||
| Craniotomy | |||||||
| No | 46 (59.0) | 21.3 +/− 17.5 | 0.009 | −0.656 (−1.117 − −0.191) | 27.3 +/− 14.4 | 0.004 | −0.619 (−1.079 − −0.156) |
| Yes | 32 (41.0) | 36.4 +/− 28.7 | 36.5 +/− 15.0 | ||||
transmastoid,
middle cranial fossa
Table 3 compares MME dispensed during admission or prescribed at discharge for patients who received other pain control medications. There was no difference in mean MME of opioids dispensed per day during hospitalization between patients who received acetaminophen, non-steroidal anti-inflammatory drugs, gabapentin, or steroids and those who did not. Patients who received steroids during hospitalization were prescribed significantly more MME of opioids at discharge (37.9 ± 18.9) as compared to those who did not (28.6 +/− 12.9, p = 0.03, d = 0.621 [0.109 – 1.12]). Notably, 85.7% (18/21) of patients who received steroids following surgery were operated on via a MCF or combined TM-MCF approach (p<0.001).
Table 3.
Morphine milligram equivalents (MME) prescribed by other pain control prescribed inpatient or post-operatively.
| Inpatient opioids dispensed | Outpatient opioids prescribed | ||||||
|---|---|---|---|---|---|---|---|
| N (%) | Total MME (MN +/− SD) | P-value | Cohen’s d or ηp2 (95% confidence interval) | Total MME (MN +/− SD) | P-value | Cohen’s d or ηp2 (95% confidence interval) | |
| Acetaminophen | |||||||
| Y | 17 (21.8) | 30.0 +/− 21.0 | 0.517 | 0.321 (−0.135 –0.773) | 34.7 +/− 20.0 | 0.474 | −0.072 (−0.523 – 0.379) |
| N | 61 (78.2) | 26.8 +/− 24.7 | 30.0 +/− 13.6 | ||||
| NSAIDs a | |||||||
| Y | 34 (43.6) | 30.3 +/− 22.1 | 0.125 | 0.202 (−0.248 – 0.650) | 31.3 +/− 12.8 | 0.558 | 0.022 (−0.426 – 0.469) |
| N | 44 (56.4) | 25.4 +/− 25.1 | 30.9 +/− 17.1 | ||||
| Gabapentin | |||||||
| Y | 10 (12.8) | 30.0 +/− 16.9 | 0.35 | 0.101 (−0.564 – 0.765) | 37.5 +/−21.5 | 0.179 | 0.478 (−0.192 – 1.146) |
| N | 68 (87.2) | 27.2+/− 24.7 | 30.1 +/− 13.7 | ||||
| Steroids given as inpatient | |||||||
| Y | 21 (26.9) | 36.6 +/− 29.6 | 0.086 | 0.526 (0.017 – 1.032) | 37.9 +/− 18.9 | 0.03 | 0.621 (0.109 – 1.129) |
| N | 57 (73.1) | 24.2 +/− 20.5 | 28.6 +/− 12.9 | ||||
| Combination with acetaminophen | |||||||
| Y | 57 (73.1) | 27.5 +/− 23.9 | 0.861 | −0.005 (−0.505 – 0.496) | 31.0 +/− 12.9 | 0.441 | −0.022 (−0.522 – 0.478) |
| N | 21 (26.9) | 27.6 +/− 24.0 | 31.3 +/−20.6 | ||||
non-steroidal anti-inflammatory drugs
Comparisons of mean opioid MME dispensed and prescribed per day by patient comorbidities are included in Table 4. Patients with a documented diagnosis of idiopathic intracranial hypertension received significantly more inpatient MME per day than those without (41.5 ±27.5 versus 25.2 ± 22.5; p = 0.02, d = 0.69 [0.04 – 1.32]). There was no significant difference in operative approach (p=0.06), or length of hospital stay (p=0.212) for patients with a history of IIH. Additionally, patients with a history of headaches or migraines received significantly more inpatient MME per day than those without (39.6 ± 31.5 versus 23.6 ± 19.6; p = 0.04, d = 0.684 [0.15 – 1.21]) and were prescribed significantly more upon discharge (36.4 ± 12.7 versus 29.3 ± 15.9; p = 0.02, d = 0.47 [−0.06 – 0.99]). Patients aged 65 years or older required significantly less MME of opioids per day as inpatients (19.3 ± 17.7) than those under the age of 65 (32.1 ± 26.1; p=0.014, d= −0.548 [−1.017 - −0.075]). Similarly, these patients were prescribed significantly less opioids at discharge (27.0 ± 16.9 versus 33.4 ± 14.2; p=0.043, d = −0.419 [−0.885 – 0.05]). There were no significant differences in MME dispensed per day during hospitalization and prescribed to outpatients amongst any other demographic variable or comorbidity.
Table 4.
Morphine milligram equivalents (MME) dispensed during hospitalization and prescribed upon discharge by patient comorbidities and demographics
| Inpatient opioids dispensed | Outpatient opioids prescribed | |||||||
|---|---|---|---|---|---|---|---|---|
| N (%) | Total MME (MN +/− SD) | P-value | Cohen’s d or ηp2 (95% confidence interval | Total MME (MN +/− SD) | P-value | Cohen’s d or ηp2 (95% confidence interval) | ||
| Comorbidities | HTNa | 49 (62.8) | 25.7 +/− 23.9 | 0.307 | −0.261 (−0.718 – 0.198) | 31.6 +/− 13.0 | 0.687 | 0.128 (-0.329 – 0.584) |
| DMb | 20 (25.6) | 27.2 +/− 22.2 | 0.770 | −0.102 (−0.610 – 0.407) | 27 +/− 8.3 | 0.248 | −0.200(−0.709 – 0.309) | |
| OSAc | 14 (17.9) | 30.8 +/− 30.0 | 0.558 | −0.053 (−0.632 – 0.525) | 34.6 +/− 12.5 | 0.446 | 0.254 (−0.326 – 0.833) | |
| HLDd | 19 (24.4) | 25.8 +/−21.0 | 0.363 | 0.125 (−0.384 – 0.633) | 26.1 +/− 12.1 | 0.458 | −0.266(−0.775 – 0.245) | |
| Headache | 19 (24.4) | 39.6 +/− 31.5 | 0.042 | 0.684 (0.154 – 1.210) | 36.4 +/− 12.7 | 0.024 | 0.468 (−0.056 – 0.989) | |
| IIHe documented | Y | 11 (14.1) | 41.5 +/− 27.5 | 0.023 | 0.689 (0.040 1.321) | 34.3 +/− 13.7 | 0.396 | 0.245 (−0.395 – 0.883) |
| N | 67 (85.9) | 25.2 +/− 22.5 | 30.5 +/− 15.5 | |||||
| Chronic pain | Y | 7 (9) | 37.0 +/− 26.8 | 0.319 | 0.432 (−0.349 – 1.21) | 40.71 +/− 10.5 | 0.023 | 0.696 (−0.09 – 1.478) |
| N | 71 (91) | 26.6 +/− 23.4 | 30.1 +/− 15.4 | |||||
| Demographic Variable | ||||||||
| Sex | Male | 31 (39.7) | 24.2 +/− 22.1 | 0.322 | −0.228 (−0.682 – 0.228) | 31.9 +/− 14.8 | 0.966 | 0.094 (−0.360 – 0.547) |
| Female | 47 (60.3) | 29.7 +/− 24.8 | 30.5 +/− 15.6 | |||||
| Race | White | 56 (71.8) | 29.4 +/− 26.7 | 0.657 | 0.020 (0 – 0.099) | 31.9 +/− 14.7 | 0.369 | 0.007 (0 – 0.062) |
| AAf | 21 (26.9) | 23.3 +/− 13.5 | 28.9 +/− 17.1 | |||||
| Hispanic | 1 (1.3) | 10 +/− 0 | 30 +/− 0 | |||||
| Asian | 0 (0) | 0 | 0 | |||||
| BMI g | 18.5–24.9 | 5 (6.4) | 44.8 +/− 44.1 | 0.85 | 0.068 (0 – 0.141) | 31 +/− 8 | 0.824 | 0.056 (0 – 0.121) |
| 25–29.9 | 23 (29.5) | 25.3 +/− 17.7 | 29.6 +/− 12.2 | |||||
| 30–34.9 | 14 (17.9) | 18.8 +/− 12.8 | 32.1 +/− 20.4 | |||||
| 35–39.9 | 11 (14.1) | 28.9 +/− 28.6 | 26.4 +/− 12.1 | |||||
| 40–49.9 | 20 (25.6) | 29.2 +/− 18.3 | 31.6 +/−14.3 | |||||
| >50 | 5 (6.4) | 35.3 +/− 36.7 | 43 +/− 20.4 | |||||
hypertension,
diabetes mellitus,
obstructive sleep apnea,
hyperlipidemia,
idiopathic intracranial hypertension,
african american,
body mass index
Five patients, three of whom underwent repair via the TM approach, requested additional opioid prescriptions after surgery. These patients received significantly more MME per day during hospitalization than patients who did not request additional medication (55 ± 33.3 MME versus 25.6 ± 21.9; p = 0.072, d = 1.24 [0.31 – 2.17]) but were prescribed similar amounts upon discharge (30 ± 15.5 versus 31.1 ± 15.3; p = 0.53, d = −0.1 [−1.01 – 0.8]). Of these patients, none had a history of chronic pain and one (20%) had a history of headaches. Three of the five patients received additional opioid prescriptions, and additional prescriptions averaged 36.7 ± 15.5 MME per day. Four patients who underwent repair via the TM approach received no discharge opioids. None of these patients requested secondary opioid prescriptions.
Opioid prescribing patterns by year are reported in Table 5, and operative approaches utilized during the years of the study are indicated in Table 6. The highest mean MME dispensed to inpatients per day was in 2016 (50.3 ± 37.6), and of note 77.8% of repairs in this year were via the MCF or combined TM-MCF approach. The lowest mean MME dispensed to inpatients per day was in 2019 (13.3 ± 10) and 25% of patients underwent repair via the MCF or combined TM-MCF approach in this year. The highest mean MME prescribed per day upon discharge was in 2017 (33.4 ± 11.6) and the lowest was in 2019 (17.5 ± 10.9).There was no significant difference in inpatient MME dispensed per day based on the surgeon operating (p=0.05, ηp2=0.082 [0–0.19]). However, there was a significant difference in outpatient opioid prescriptions based on operating surgeon (p=0.001, ηp2=0.174 [0.0026–0.3]). The surgeon who prescribed the lowest amount of MME to inpatients performed 100% of surgeries conducted in 2019. There was a significant difference in the distribution of surgeons operating each year (p<0.001, ηp2=0.272 [0.094–0.401]).
Table 5.
Inpatient and outpatient opioid MME prescribed by year.
| Year (N) | 2014 (7) | 2015 (7) | 2016 (9) | 2017 (14) | 2018 (12) | 2019 (4) | 2020 (25) | p-value | ηp2 (95% confidence interval) | |
|---|---|---|---|---|---|---|---|---|---|---|
| Inpatient | MME per day; MN +/− STD DEV | 22.4 +/− 17.0 | 25.1 +/− 15.3 | 50.3 +/− 37.6 | 27.0 +/− 16.3 | 24.8 +/− 30.2 | 13.3 +/− 10.0 | 25.2 +/− 17.2 | 0.109 | 0.133 (0 – 0.220) |
| MME. Per day; median; range | 24; 52.2 | 23.8; 49 | 24; 99.5 | 24.1; 62.1 | 14.3; 106.1 | 14.2; 25 | 19.8; 65.2 | |||
| Outpatient | MME per day; MN +/− STD DEV | 30 +/− 19.3 | 22.9 +/− 10.3 | 32.8 +/− 9.5 | 33.4 +/− 11.6 | 27.9 +/− 12.2 | 17.5 +/− 10.9 | 35.4 +/− 18.1 | 0.238 | 0.104 (0 – 0.181) |
| MME per day; median; range | 30; 70 | 30; 30 | 30; 25 | 30; 40 | 20; 40 | 20; 30 | 30; 90 | |||
| No outpatient prescription; N (%) | 1 (14.3) | 1 (14.3) | 0 (0) | 0 (0) | 0 (0) | 1 (25) | 1 (4) | |||
| Secondary requests; N (%) | 0 (0) | 0 (0) | 2 (22.2) | 1 (7.1) | 0 (0) | 0 (0) | 2 (8) |
Table 6.
Operative approach by year; N (%)
| Year | TM | MCF and combined |
|---|---|---|
| 2014 | 7 (100) | 0 (0) |
| 2015 | 7 (100) | 0 (0) |
| 2016 | 2 (22.2) | 7 (77.8) |
| 2017 | 4 (28.6) | 10 (71.4) |
| 2018 | 7 (58.3) | 5 (41.7) |
| 2019 | 3 (75) | 1 (25) |
| 2020 | 16 (64) | 9 (36) |
trans-mastoid approach,
middle cranial fossa
Discussion
This study is the first to assess post-operative opioid prescriptions following surgical repair of lateral skull base sCSF leaks. Significantly fewer MME were dispensed during hospitalization and prescribed upon discharge to patients undergoing the TM compared to the MCF and combined TM-MCF approaches, suggesting that the middle fossa craniotomy induces more pain. This finding is consistent with current literature reporting that following craniotomies, up to 84% of patients experience moderate to severe pain, and 67% and 24% of patients undergoing a temporal craniotomy endorse moderate and severe pain, respectively.17 In fact, it has been suggested that following craniotomies, patients be prescribed 10 MME every six hours for moderate pain upon discharge.18 In line with this recommendation, patients in this study were prescribed a mean of 9.1 MME every six hours.
In this study, mean MME prescribed during hospitalization and after discharge following the TM approach was similar to post-mastoidectomy prescribing practices in the literature. 6, 19, 20 Following mastoidectomies, Qian et al. reported patients were prescribed a mean of 26.3 MME per day and took a mean of 20.9 MME per day post-operatively.19 This suggests that patients might not require the amount prescribed. In addition to risks of over-prescribing opioids, like overdose and abuse, it has been found that following mastoidectomies, opioid prescriptions of greater MME per day are associated with additional opioid requests, and as prescriptions lasted longer, with recurrent opioid use.20 It is therefore important to prescribe the lowest amount of MME to patients while still controlling pain. Though three of the five patients in this study who requested additional opioids had undergone a TM approach, four patients who underwent a TM approach were not prescribed any opioids upon discharge. This suggests that there is a range of postoperative pain levels and opioid requirements after the TM approach that is difficult to account for given the multitude of potential variables and lack of data on opioid use.
Migraines, on the other hand, have been linked to greater postoperative pain and increased postoperative opioid requirements and prescriptions.21–24 Our data also confirms that patients with a history of headache require and are prescribed significantly more MME per day during hospitalization and upon discharge. Unfortunately, headache is also linked to opioid abuse. Patel et al. found that 2.3% of patients hospitalized for headaches had previously abused opioids, and opioid abusers with headaches have a higher prevalence of prolonged hospitalization, severe loss of function, and disability.25 These findings warrant careful opioid prescribing practices for patients with a history of headache and consideration of beneficial alternative or supplementary options like subcutaneous sumatriptan.26
IIH occurs due to impaired absorption of CSF most commonly in obese, middle-aged females and often presents with positional headache.27, 28 De Simone et al. found that 84% of those with IIH experience headaches, which are classified as a migraine headache in 68% and reported as daily pain in 51% of patients.29 Headache in IIH is thought to arise from nociceptive firing at congested dural sinuses resulting in trigemino-vascular activation and calcitonin gene-related peptide (CGRP) release.29 Following ventriculoperitoneal shunt placement, patients with IIH experience improvement in headaches without increased postoperative pain levels. This indicates that these patients should not receive increased MME of opioids per day postoperatively.30 However, because CSF leakage allows release of intracranial pressure (ICP), repair might increase pressure leading to headaches, perhaps explaining the higher MME requirements of and dispensing to patients with IIH in this study than those without IIH.27 31
Post-operative opioid use can be affected by demographic variables, such as age, sex, race, and BMI, as well. In this study, patients aged 65 years and older were dispensed significantly fewer MME of opioids during hospitalization and prescribed significantly fewer MME of opioids at discharge than those less than 65 years of age. Previous studies have demonstrated an association between lower opioid prescriptions and advanced age,32 which is perhaps related to a perceived increased risk of falls and overdose in the setting of polypharmacy in the elderly population.33, 34. Though Ren et al. identified an association between higher BMI and the need for additional opioid prescriptions, the current study found no differences in opioid prescriptions between BMI groups.35 Although African American race has been associated with lower opioid prescriptions but higher rates of opioid refill requests,36, 37 the current study found no association. Likewise, no differences in inpatient MME dispensed or outpatient MME prescribed at discharge were noted for patients who received other pain control medications, such as NSAIDs, acetaminophen, or gabapentin. However, it is worth noting that the 2022 CDC guidelines suggest the use of NSAIDs when possible, and several studies have demonstrated their potential in reducing post-operative opioid use. This approach should be used for first-line pain control after ambulatory otologic procedures, including mastoidectomies.5, 38 NSAIDs and acetaminophen are always recommended but not routinely prescribed after otologic surgery at this institution, therefore it was impossible to assess their effects on postoperative opioid needs upon discharge.
There are several limitations to this study. The retrospective nature deems it subject to inherent selection bias and errors in data collection. Because this study was conducted at a single institution and included a small sample size, the generalizability of the results is limited. Additionally, lateral skull base sCSF leak repair was performed by four neurotologists, introducing possible bias due to individual surgeon preferences for MCF, TM, or combined TM-MCF approaches and differing surgical techniques. Individual preferences could account for the variation in prescribing practices from year to year. A multi-center study would improve the generalizability of results. Additionally, there was no ability to survey patients to determine the MME of opioids consumed or to quantify patient pain levels following surgery. Our analysis was limited to opioid MME dispensed to inpatients per day and discharge opioid prescriptions. While these data approximate inpatient opioid needs, they do not capture outpatient opioid needs or use; given that very few patients requested additional opioids, it is possible that the prescribing practices reported here represent an overestimation of opioid needs. Indeed, a recent study found that around 50% of opioids remain unused following surgery.39 A prospective or quality improvement study to assess patient pain control under the current prescribing practices would better inform the need to make any changes. Several studies have demonstrated that prospective analysis of prescribing practices and implementation of quality improvement measures reduces postoperative opioid prescriptions while maintaining adequate pain control.40, 41
Conclusion
Patients with lateral skull base sCSF leaks who undergo repair via a MCF or combined TM-MCF approach require more postoperative pain medication than those who undergo repair via a TM approach as inpatients. Additionally, patients with a history of headaches and IIH might require more postoperative opioids than those without. Patient race, sex, and BMI do not appear to impact immediate postoperative opioid need and discharge prescribing following lateral skull base sCSF leak repair. While nearly all patients only required one opioid prescription at discharge, indicating sufficient prescribing practices in this study, post-operative opioid need remains unknown. Surgeons should aim to prescribe the lowest amount of opioid possible following lateral skull base sCSF leak repair. This might include 30 MME per day for those undergoing the TM approach and slightly more for those undergoing the MCF or combined TM-MCF approach. Future studies should assess post-operative pain levels and outpatient opioid use following repair of lateral skull base sCSF leaks in order to develop more precise postoperative opioid prescribing recommendations.
Funding:
NIH T32 DC0014435 Training Grant
Footnotes
Conflicts of Interest: none.
Meeting information: Triological Society 2023 Combined Sections Meeting, Coronado, CA January 26–28, 2023.
References
- 1.Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010–2015. MMWR Morb Mortal Wkly Rep. Dec 30 2016;65(50–51):1445–1452. [DOI] [PubMed] [Google Scholar]
- 2.Thiels CA, Anderson SS, Ubl DS, et al. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. Oct 2017;266(4):564–573. [DOI] [PubMed] [Google Scholar]
- 3.Sethi RKV, Miller AL, Bartholomew RA, et al. Opioid prescription patterns and use among patients undergoing endoscopic sinus surgery. Laryngoscope. May 2019;129(5):1046–1052. [DOI] [PubMed] [Google Scholar]
- 4.Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. Jun 21 2017;152(6):e170504. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. Nov 4 2022;71(3):1–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kirubalingam K, Nguyen P, Klar G, Dion JM, Campbell RJ, Beyea JA. Opioid Prescriptions Following Otologic Surgery: A Population-Based Study. Otolaryngol Head Neck Surg. Sep 28 2021:1945998211045364. [DOI] [PubMed] [Google Scholar]
- 7.Cooperman SP, Jin MC, Qian ZJ, Alyono JC. National Trends in Opioid Prescriptions Following Outpatient Otologic Surgery, 2005–2017. Otolaryngol Head Neck Surg. Apr 2021;164(4):841–849. [DOI] [PubMed] [Google Scholar]
- 8.Casazza GC, Gurgel RK, McCrary HC, et al. Are Opioids Necessary in Middle Ear Surgery? Comparing the Transcanal and Postauricular Approach. Otol Neurotol. Jul 1 2021;42(6):851–857. [DOI] [PubMed] [Google Scholar]
- 9.Ngombu S, Hooks A, Rock AN, et al. Comparison of Opioid Prescription Patterns and Consumption Following Otologic Surgery. Otol Neurotol. Feb 2020;41(2):229–234. [DOI] [PubMed] [Google Scholar]
- 10.Boyd C, Shew M, Penn J, et al. Postoperative Opioid Use and Pain Management Following Otologic and Neurotologic Surgery. Ann Otol Rhinol Laryngol. Feb 2020;129(2):175–180. [DOI] [PubMed] [Google Scholar]
- 11.McNulty B, Schutt CA, Bojrab D, Babu S. Middle Cranial Fossa Encephalocele and Cerebrospinal Fluid Leakage: Etiology, Approach, Outcomes. J Neurol Surg B Skull Base. Jun 2020;81(3):268–274. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Scullen T, Freeman Z, Mathkour M, et al. Middle Fossa Encephaloceles Treated via the Transmastoid Approach: A Case Series and Review of the Literature. Oper Neurosurg (Hagerstown). Oct 13 2021;21(5):332–342. [DOI] [PubMed] [Google Scholar]
- 13.Son HJ, Karkas A, Buchanan P, et al. Spontaneous cerebrospinal fluid effusion of the temporal bone: repair, audiological outcomes, and obesity. Laryngoscope. May 2014;124(5):1204–1208. [DOI] [PubMed] [Google Scholar]
- 14.Rao N, Redleaf M. Spontaneous middle cranial fossa cerebrospinal fluid otorrhea in adults. Laryngoscope. Feb 2016;126(2):464–468. [DOI] [PubMed] [Google Scholar]
- 15.Fontaine D, Almairac F, Santucci S, et al. Dural and pial pain-sensitive structures in humans: new inputs from awake craniotomies. Brain. Apr 1 2018;141(4):1040–1048. [DOI] [PubMed] [Google Scholar]
- 16.Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. Mar 18 2016;65(1):1–49. [DOI] [PubMed] [Google Scholar]
- 17.Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M. Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth. Jul 2007;54(7):544–548. [DOI] [PubMed] [Google Scholar]
- 18.Santos CMT, Pereira CU, Chaves PHS, Torres P, Oliveira D, Rabelo NN. Options to manage postcraniotomy acute pain in neurosurgery: no protocol available. Br J Neurosurg. Feb 2021;35(1):84–91. [DOI] [PubMed] [Google Scholar]
- 19.Qian ZJ, Alyono JC, Woods OD, Ali N, Blevins NH. A Prospective Evaluation of Postoperative Opioid Use in Otologic Surgery. Otol Neurotol. Oct 2019;40(9):1194–1198. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Mahairas AD, Neff R, Craker N, McNulty BN, Shinn JB, Bush ML. Trends in Opioid Usage Following Tympanoplasty and Mastoidectomy. Otol Neurotol. Sep 2020;41(8):e1035–e1040. [DOI] [PubMed] [Google Scholar]
- 21.Potter T, Soni P, Krywyj M, et al. Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery. Laryngoscope. Mar 30 2022. [DOI] [PubMed] [Google Scholar]
- 22.Nahman-Averbuch H, Shefi T, Schneider VJ 2nd, et al. Quantitative sensory testing in patients with migraine: a systematic review and meta-analysis. Pain. Jul 2018;159(7):1202–1223. [DOI] [PubMed] [Google Scholar]
- 23.Gill AS, Virani FR, Hwang JC, et al. Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery. Otolaryngol Head Neck Surg. Apr 2021;164(4):889–894. [DOI] [PubMed] [Google Scholar]
- 24.Lavoie-Gagne O, Nwachukwu BU, Allen AA, Leroux T, Lu Y, Forsythe B. Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery. JBJS Rev. Jun 2020;8(6):e0154. [DOI] [PubMed] [Google Scholar]
- 25.Patel UK, Malik P, Shah D, et al. The Opioid Epidemic and Primary Headache Disorders: A Nationwide Population-Based Study. Cureus. Aug 14 2020;12(8):e9743. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Patel KS, Laiwalla AN, DiCesare JAT, Garrett MC, Wang AC. Subcutaneous sumatriptan: association with decreases in postoperative pain and opioid use after elective cranial surgery. J Neurosurg. Jan 3 2020:1–9. [DOI] [PubMed] [Google Scholar]
- 27.Tam EK, Gilbert AL. Spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension. Curr Opin Ophthalmol. Nov 2019;30(6):467–471. [DOI] [PubMed] [Google Scholar]
- 28.Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE. Spontaneous cerebrospinal fluid leaks: a variant of benign intracranial hypertension. Ann Otol Rhinol Laryngol. Jul 2006;115(7):495–500. [DOI] [PubMed] [Google Scholar]
- 29.De Simone R, Sansone M, Bonavita V. Headache in idiopathic intracranial hypertension. A CGRP-dependent head pain? Neurol Sci. Dec 2020;41(Suppl 2):417–421. [DOI] [PubMed] [Google Scholar]
- 30.Mukherjee N, Bhatti MT. Update on the surgical management of idiopathic intracranial hypertension. Curr Neurol Neurosci Rep. Mar 2014;14(3):438. [DOI] [PubMed] [Google Scholar]
- 31.Mollan SP, Davies B, Silver NC, et al. Idiopathic intracranial hypertension: consensus guidelines on management. J Neurol Neurosurg Psychiatry. Oct 2018;89(10):1088–1100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Goyal A, Payne S, Sangaralingham LR, et al. Variations in Postoperative Opioid Prescription Practices and Impact on Refill Prescriptions Following Lumbar Spine Surgery. World Neurosurg. Sep 2021;153:e112–e130. [DOI] [PubMed] [Google Scholar]
- 33.Bloomer A, Wally M, Bailey G, et al. Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients. Geriatr Orthop Surg Rehabil. 2022;13:21514593221125616. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.By the American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. Apr 2019;67(4):674–694. [DOI] [PubMed] [Google Scholar]
- 35.Ren Y, Mehranpour P, Moshtaghi O, Schwartz MS, Friedman RA. Opioid Prescribing Patterns After Skull Base Surgery for Vestibular Schwannoma. Otol Neurotol. Jan 1 2022;43(1):e116–e121. [DOI] [PubMed] [Google Scholar]
- 36.Chavez LJ, Cooper JN, Deans KJ, et al. Evaluation of racial disparities in postoperative opioid prescription filling after common pediatric surgical procedures. J Pediatr Surg. Dec 2020;55(12):2575–2583. [DOI] [PubMed] [Google Scholar]
- 37.Lu PW, Fields AC, Andriotti T, et al. Opioid Prescriptions After Hemorrhoidectomy. Dis Colon Rectum. Aug 2020;63(8):1118–1126. [DOI] [PubMed] [Google Scholar]
- 38.Mavrommatis MA, Fan CJ, Villavisanis DF, et al. Opioids Are Infrequently Required following Ambulatory Otologic Surgery. Otol Neurotol. Oct 1 2021;42(9):1360–1365. [DOI] [PubMed] [Google Scholar]
- 39.Robinson KA, Thiels CA, Stokes S, et al. Comparing Clinician Consensus Recommendations to Patient-reported Opioid Use Across Multiple Hospital Systems. Ann Surg. Feb 1 2022;275(2):e361–e365. [DOI] [PubMed] [Google Scholar]
- 40.Thuener JE, Clancy K, Scher M, et al. Impact of perioperative pain management protocol on opioid prescribing patterns. Laryngoscope. May 2020;130(5):1180–1185. [DOI] [PubMed] [Google Scholar]
- 41.Asmaro K, Fadel HA, Haider SA, et al. Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs. Neurosurgery. Jun 15 2021;89(1):70–76. [DOI] [PubMed] [Google Scholar]