Abstract
Study Design:
Retrospective cohort study
Objective:
Our objective was to compare postoperative opioid prescriptions between male and female patients following anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).
Summary of Background Data:
Sex differences in pain are well-established in basic science and clinical medicine; however, sex differences in postoperative pain management following spine surgery are less well-studied.
Methods:
The Marketscan Commercial Claims and Encounters database was queried for adults without a history of chronic opioid use who underwent ACDF or CDA from January 2017 through June 2021. Binary logistic regression analyses of filling an opioid prescription and generalized linear model analyses of total oral morphine milligram equivalents (MMEs) prescribed were performed. “Perioperative” prescription were defined as 30 days before to 14 days after surgery; “prolonged postoperative” was defined as 91 to 180 days after surgery.
Results:
For single-level ACDF (n=9844; 51.7% female), females were more likely to fill a prolonged postoperative prescription [aOR: 1.36; 95% CI: 1.18, 1.56; p<0.001] and filled lower perioperative MMEs than males [adjusted mean difference (AMD): −15.32; 95% CI: −28.52, −2.13; p=0.02].
For multi-level ACDF (n=12,871; 52.5% female), females were more likely to fill a prolonged postoperative prescription [aOR: 1.16; 95% CI: 1.03, 1.30; p=0.02] and filled lower MMEs than males in the perioperative period [AMD: −27.47; 95% CI: −39.78, −15.17; p<0.001].
Following CDA (n=3283, 48.8% female), females were more likely to fill a prolonged postoperative opioid prescription [aOR: 1.53; 95% CI: 1.17, 2.00; p=0.002], but there was no association between sex and perioperative or prolonged postoperative MME.
Conclusions:
These findings can guide the expectations on postoperative opioid prescribing after ACDF/CDA and warrant further studies to confirm the results and optimize postoperative pain management.
Keywords: anterior cervical disectomy and fusion, cervical disc arthroplasty, postoperative pain, opioids, sex differences, marketscan, insurance database, cervical spine, spine surgery, pain medications
Introduction:
Sex differences in pain are well-established both in basic science and clinical medicine1,2. Evidence suggests that females experience a higher prevalence of different pain types including neuropathic pain, musculoskeletal pain, back pain, headaches, and osteoarthritis pain2. Surgery can result in debilitating postoperative pain which is associated with postoperative complications3. The literature regarding post-surgical pain is mixed but women appear to report higher levels of acute pain in the post-operative setting2, both for overall surgeries and for orthopedic surgeries4–6.
Anterior cervical spinal surgeries, in the form of either anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA), are commonly performed in both ambulatory and inpatient settings7,8. Opioid usage before and after ACDF has been studied in regards to various factors that influence both preoperative and postoperative opioid usage9–11.
However sex differences in ACDF have been sparingly studied, despite the frequency of this surgery, the theoretical basis for sex differences in pain outcomes following ACDF, and the clinical importance in identifying risk factors for worsening postoperative pain outcomes. One recent study looked at sex differences in medication prescribing in cervical stenosis patients pre-operatively using the Humana insurance database and found a higher opioid usage in females preoperatively11. Another recent study using a single institution database looked at machine learning tools to predict chronic opioid use after ACDF and found that male sex was predictive of prolonged opioid usage12. The literature on sex differences in postoperative opioid usage following CDA is even more limited. The aim of this retrospective observational study was to compare postoperative opioid prescriptions between male and female patients following ACDF and CDA.
Materials and Methods:
The Merative Marketscan Commercial Claims and Encounters Database and Medicare Supplemental Database were queried for ACDF and CDA procedures in inpatient or outpatient claims from January 1, 2017 through June 30, 2021. Figure 1 depicts the flow of cohort creation. Procedures were captured using Current Procedural Terminology (CPT) code 22551 for ACDF (addition of 22552 indicating multi-level) and CPT code 22856 for CDA (addition of 22858 indicating multi-level). The first ACDF or CDA per unique patient across both databases in the study period was taken. Only procedures that could be classified as single-level or multi-level were included, and patients could not have an ACDF and CDA on the same day. Additional inclusion criteria included age ≥18 years old, continuous enrollment in the database for 12 months preoperatively and 6 months postoperatively, and pharmacy enrollment for the calendar year of the index surgery. Patients were also excluded if they had other concurrent spine procedures at the index surgery or spine surgery in the past 12 months; diagnoses of cancer, intraspinal abscess, osteomyelitis, vertebral fracture with spinal cord injury, or vertebral dislocation; any kind of surgery in the 6 months after the index surgery per anesthesia CPT codes; a diagnosis of opioid use disorder in the 12 months preoperatively; or preoperative chronic opioid use (per 10+ prescriptions or 120+ days supply filled 31-365 days before surgery). Refer to the online Appendix for definitions using diagnosis and procedure codes. Patients with a geographic residence outside of the four US Census regions were also excluded. Patients with ACDF procedures were separated into single-level and multi-level samples for analysis, and all patients with CDA procedures were included in a single sample, given the smaller number of procedures.
Figure 1.
Flow of cohort creation
We extracted opioid prescriptions filled (Codeine, Fentanyl Transdermal, Hydrocodone, Hydromorphone, Morphine, Oxycodone, Oxymorphone, Tramadol), excluding those typically used for cough/cold (Brompheniramine, Chlorpheniramine, Pseudoephedrine, Phenylephrine, Guaifenesin)13. Outcomes were filling a perioperative (30 days before surgery to 14 days after surgery) opioid prescription (yes/no) and oral milligram morphine equivalents (MME) for all prescriptions filled in the perioperative period. Additionally, among those who filled a perioperative opioid prescription, additional outcomes included filling a prolonged postoperative (91-180 days after surgery) opioid prescription (yes/no) and MME for all prescriptions filled in the prolonged postoperative period. Prior studies have validated these time points for postoperative opioid use14–17. MMEs were trimmed at the 95th percentile because of extreme values that likely reflect administrative coding errors. The main exposure of interest was sex (male versus female). Demographic covariates of interest that were controlled for included age, geographic region of the United States in which the patient lives, and commercial versus Medicare insurance. Clinical covariates that were controlled for included the Charlson-Deyo comorbidity index18, anxiety or mood disorder, pain conditions, or non-opioid substance use disorders19. Procedure-related covariates that were controlled for included the surgery year, inpatient versus outpatient surgery status, plate instrumentation (yes/no, for ACDF only), autograft (yes/no, for ACDF only), and multi-level surgery status (yes/no, for CDA only). See definitions in the online Appendix. We also created binary indicators for perioperative non-opioid analgesic prescriptions filled (muscle relaxants, acetaminophen, nonsteroidal anti-inflammatory drugs, Cox-2 inhibitors) and opioid-naïve status (per no opioid prescriptions filled 31-365 days before surgery).
All statistical analyses were performed using SAS (version 9.4; SAS Institute, Inc. Cary, NC, USA). Characteristics of the male and female patients were compared for each procedure using chi-square tests for categorical variables and Mann-Whitney U-tests for continuous variables. Binary logistic regression analyses assessed the adjusted association between sex (male versus female) and opioid prescriptions filled; adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported. Generalized linear models assessed the association between sex (female versus male) and MMEs filled; adjusted mean differences (AMD) and 95% CIs are reported. A two-tailed α = 0.05 was used. All analyses controlled for the previously specified demographic, clinical, procedure-related, and medication covariates. Additionally, the models with the postoperative outcomes controlled for perioperative MME (in quartiles). We also completed sensitivity analyses where we repeated the models in each procedure-specific sample limited to opioid-naïve patients.
Results:
A total of 9844 patients met inclusion criteria for single-level ACDF (51.7% female), 12,5781 patients for multi-level ACDF (52.5% female), and 3283 for CDA (48.8% female). Descriptives for the ACDF procedures are summarized in Table 1, and descriptives for the CDA procedures are summarized in Table 2. The opioid-naïve subsamples included 5425 patients for single-level ACDF (50.3% female), 7169 patients for multi-level ACDF (50.3% female), and 1807 patients for CDA (46.3% female). Sex-stratified descriptives of the opioid prescriptions are summarized in Table 3.
Table 1.
Characteristics of Anterior Cervical Discectomy and Fusion Procedures by Level and Sex
| Single-Level | Multi-Level | ||||||
|---|---|---|---|---|---|---|---|
| Female (n = 5089) | Male (n = 4755) | Female (n = 6759) | Male (n = 6112) | ||||
| Variable | Category | n (%) | n (%) | P-Value | n (%) | n (%) | P-Value |
| Age | Median, IQR | 51 (44-57) | 52 (45-59) | <0.001 | 54 (48-59) | 55 (49-60) | <0.001 |
| Geographic Region | Northeast | 652 (12.8) | 643 (13.5) | 0.12 | 910 (13.5) | 883 (14.4) | 0.03 |
| Midwest | 1121 (22.0) | 1105 (23.2) | 1393 (20.6) | 1306 (21.4) | |||
| South | 2869 (56.4) | 2566 (54.0) | 3814 (56.4) | 3293 (53.9) | |||
| West | 447 (8.8) | 441 (9.3) | 642 (9.5) | 630 (10.3) | |||
| Insurance | Commercial | 4846 (95.2) | 4462 (93.8) | 0.002 | 6319 (93.5) | 5633 (92.2) | 0.004 |
| Medicare Supplemental | 243 (4.8) | 293 (6.2) | 440 (6.5) | 479 (7.8) | |||
| Charlson-Deyo Comorbidity Index | 0 | 3509 (69.0) | 3230 (67.9) | <0.001 | 4408 (65.2) | 3919 (64.1) | 0.01 |
| 1 | 1040 (20.4) | 891 (18.7) | 1501 (22.2) | 1312 (21.5) | |||
| 2+ | 540 (10.6) | 634 (13.3) | 850 (12.6) | 881 (14.4) | |||
| Anxiety or Mood Disorder | No | 3533 (69.4) | 4023 (84.6) | <0.001 | 4555 (67.4) | 5133 (84.0) | <0.001 |
| Yes | 1556 (30.6) | 732 (15.4) | 2204 (32.6) | 979 (16.0) | |||
| Pain Conditions | No | 1706 (33.5) | 2084 (43.8) | <0.001 | 2109 (31.2) | 2520 (41.2) | <0.001 |
| Yes | 3383 (66.5) | 2671 (56.2) | 4650 (68.8) | 3592 (58.8) | |||
| Substance Use Disorders | No | 4643 (91.2) | 4266 (89.7) | 0.01 | 6156 (91.1) | 5462 (89.4) | 0.001 |
| Yes | 446 (8.8) | 489 (10.3) | 603 (8.9) | 650 (10.6) | |||
| Surgery Year | 2017 | 1305 (25.6) | 1226 (25.8) | 0.89 | 1615 (23.9) | 1493 (24.4) | 0.78 |
| 2018 | 1145 (22.5) | 1093 (23.0) | 1527 (22.6) | 1392 (22.8) | |||
| 2019 | 1181 (23.2) | 1086 (22.8) | 1568 (23.2) | 1433 (23.4) | |||
| 2020 | 950 (18.7) | 899 (18.9) | 1305 (19.3) | 1128 (18.5) | |||
| 2021 | 508 (10.0) | 451 (9.5) | 744 (11.0) | 666 (10.9) | |||
| Surgery Setting | Outpatient | 4076 (80.1) | 3842 (80.8) | 0.38 | 4192 (62.0) | 3789 (62.0) | 0.97 |
| Inpatient | 1013 (19.9) | 913 (19.2) | 2567 (38.0) | 2323 (38.0) | |||
| Plate Instrumentation | No | 723 (14.2) | 616 (13.0) | 0.07 | 2095 (31.0) | 1907 (31.2) | 0.80 |
| Yes | 4366 (85.8) | 4139 (87.0) | 4664 (69.0) | 4205 (68.8) | |||
| Autograft | No | 3045 (59.8) | 2959 (62.2) | 0.01 | 4107 (60.8) | 3709 (60.7) | 0.93 |
| Yes | 2044 (40.2) | 1796 (37.8) | 2652 (39.2) | 2403 (39.3) | |||
| Opioid-Naïve Status | No | 2360 (46.4) | 2059 (43.3) | 0.002 | 3156 (46.7) | 2546 (41.7) | <0.001 |
| Yes | 2729 (53.6) | 2696 (56.7) | 3603 (53.3) | 3566 (58.3) | |||
| Perioperative Non-Opioid Prescription | No | 1378 (27.1) | 1509 (31.7) | <0.001 | 1770 (26.2) | 1776 (29.1) | <0.001 |
| Yes | 3711 (72.9) | 3246 (68.3) | 4989 (73.8) | 4336 (70.9) | |||
P-values reflect comparisons by sex using chi-square or Mann-Whitney U-tests.
Table 2.
Characteristics of Cervical Disc Arthroplasty Procedures by Level and Sex
| Female (n = 1602) | Male (n = 1681) | |||
|---|---|---|---|---|
| Variable | Category | n (%) | n (%) | P-Value |
| Age | Median, IQR | 46 (39-52) | 47 (40-54) | |
| Geographic Region | Northeast | 183 (11.4) | 182 (10.8) | 0.08 |
| Midwest | 381 (23.8) | 370 (22.0) | ||
| South | 703 (43.9) | 715 (42.5) | ||
| West | 335 (20.9) | 414 (24.6) | ||
| Insurance | Commercial | 1591 (99.3) | 1660 (98.8) | 0.10 |
| Medicare Supplemental | 11 (0.7) | 21 (1.2) | ||
| Charlson-Deyo Comorbidity Index | 0 | 1240 (77.4) | 1340 (79.7) | 0.03 |
| 1 | 274 (17.1) | 234 (13.9) | ||
| 2+ | 88 (5.5) | 107 (6.4) | ||
| Anxiety or Mood Disorder | No | 1135 (70.8) | 1398 (83.2) | <0.001 |
| Yes | 467 (29.2) | 283 (16.8) | ||
| Pain Conditions | No | 566 (35.3) | 732 (43.5) | <0.001 |
| Yes | 1036 (64.7) | 949 (56.5) | ||
| Substance Use Disorders | No | 1491 (93.1) | 1572 (93.5) | 0.61 |
| Yes | 111 (6.9) | 109 (6.5) | ||
| Surgery Year | 2017 | 341 (21.3) | 324 (19.3) | 0.32 |
| 2018 | 358 (22.3) | 406 (24.2) | ||
| 2019 | 390 (24.3) | 404 (24.0) | ||
| 2020 | 331 (20.7) | 331 (19.7) | ||
| 2021 | 182 (11.4) | 216 (12.8) | ||
| Surgery Setting | Outpatient | 1385 (86.5) | 1492 (88.8) | 0.05 |
| Inpatient | 217 (13.5) | 189 (11.2) | ||
| Multi-Level | No | 1057 (66.0) | 1063 (63.2) | 0.10 |
| Yes | 545 (34.0) | 618 (36.8) | ||
| Opioid-Naïve Status | No | 765 (47.8) | 711 (42.3) | 0.002 |
| Yes | 837 (52.2) | 970 (57.7) | ||
| Perioperative Non-Opioid Prescription | No | 340 (21.2) | 407 (24.2) | 0.04 |
| Yes | 1262 (78.8) | 1274 (75.8) |
P-values reflect comparisons by sex using chi-square or Mann-Whitney U-tests.
Table 3.
Sex-Stratified Opioid Prescriptions
| Single-Level ACDF | Multi-Level ACDF | CDA | ||||
|---|---|---|---|---|---|---|
| Female | Male | Female | Male | Female | Male | |
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | |
| Perioperative Opioid Prescription | 4373 (85.9) | 3990 (83.9) | 5717 (84.6) | 5172 (84.6) | 1388 (86.6) | 1436 (85.4) |
| Prolonged Postoperative Opioid Prescription | 621 (14.2) | 412 (10.3) | 832 (14.5) | 603 (11.7) | 159 (11.5) | 109 (7.6) |
| Median (IQR) | Median (IQR) | Median (IQR) | Median (IQR) | Median (IQR) | Median (IQR) | |
| Perioperative MME | 420 (250-630) | 400 (225-653) | 420 (280-675) | 440 (280-675) | 385 (225-530) | 364 (225-600) |
| Prolonged Postoperative MME | 280 (135-600) | 300 (140-720) | 300 (135-630) | 300 (150-750) | 225 (135-600) | 245 (120-675) |
ACDF= anterior cervical discectomy and fusion; CDA= cervical disc arthroplasty; CI= confidence interval, MME= morphine milligram equivalent
For single-level ACDF, there was no association between sex and filling a perioperative prescription [aOR: 1.07; 95% CI: 0.95, 1.20; p=0.29], but females were more likely to fill a prolonged postoperative prescription [aOR: 1.36; 95% CI: 1.18, 1.56; p<0.001]. Females filled lower perioperative MMEs than males [AMD: −15.32; 95% CI: −28.52, −2.13; p=0.02] but not prolonged postoperative MMEs [AMD: −22.50; 95% CI: −76.79, 31.79; p=0.42].
For multi-level ACDF, there were no sex-related statistically significant differences in filling a perioperative prescription [aOR: 0.92; 95% CI: 0.83, 1.02; p=0.10], but females were more likely to fill a prolonged postoperative prescription [aOR: 1.16; 95% CI: 1.03, 1.30; p=0.02]. However, females filled lower MMEs than males in the perioperative period [AMD: −27.47; 95% CI: −39.78, −15.17; p<0.001], and a not statistically significantly lower MME in the prolonged postoperative period [AMD: −43.05; 95% CI: −87.64, 1.54; p=0.06].
After CDA, there was no association between sex and filling a perioperative prescription [aOR: 1.00; 95% CI: 0.81, 1.24; p=0.98], but females were more likely to fill a prolonged postoperative opioid prescription [aOR: 1.53; 95% CI: 1.17, 2.00; p=0.002]. There was no significant difference in MMEs filled in either the perioperative [AMD: −3.01; 95% CI: −25.99, 19.97; p=0.80] or prolonged postoperative periods [AMD: −36.25; 95% CI: −119.80, 47.31; p=0.40].
When examining only opioid-naïve patients in sensitivity analyses, the patterns of findings were different (Appendix Table A2). For single-level ACDF, there were no sex-specific differences in number of prescriptions filled, however there were significantly lower MMEs filled by females than males in the prolonged postoperative period. After multi-level ACDF, female versus male sex was associated with decreased odds of filling a perioperative opioid prescription with no association with prolonged postoperative opioid prescription, and females only filled significantly lower MMEs in the perioperative period. After CDA, there were no significant differences in opioid prescriptions filled between sexes.
Discussion:
In this retrospective study of ACDF and CDA patients in a large national insurance database, there was no association between sex and the likelihood of filling a perioperative opioid prescription across the three procedure types. However, female patients were more likely to fill a prolonged postoperative opioid prescription. Additionally, females filled fewer MMEs in the perioperative period following single-level ACDF, and in both the perioperative and prolonged postoperative period following multi-level ACDF. The findings appear to contradict one another; however, they suggest a possible way to optimize postoperative opioid prescriptions for anterior cervical surgery based on patient sex. Female patients could potentially be better served with a longer duration but lower dosage opioids than male patients.
These findings are in partial accordance with a prior study suggesting that females were more likely than males to experience high opioid use after 1- and 2- level anterior cervical surgery20. However, the study by Lovecchio et al. only followed the first 6 weeks after surgery with a small number of 48 patients at 3 locations. Our study with a longer follow-up period and larger sample size finds that females are more likely to fill opioid prescriptions even 3-6 months after anterior cervical spine surgery.
There is substantial evidence to suggest a biological difference in pain perception between males and females. Preclinical animal models have found that females experience more allodynia and chronic pain behaviors in models replicating a number of conditions including cancer pain and complex regional pain syndrome21. Sex differences exist in chemical transmissions of pain, as well as in opioid receptor responses to analgesia21. This biological basis for differences in pain perception based on sex has been borne out clinically in female predominance of a number of pain conditions2,21. Given the findings of our study, it appears that post-surgical pain after ACDF or CDA may also be more prominent in females compared to males, at least in regards to number of postoperative opioid prescriptions filled.
In a separate subgroup analysis of only opioid-naïve patients, most of the differences between sexes found in the primary analyses were no longer statistically significant. This could be partially explained by the lower sample sizes and diminished power of exclusively opioid-naïve patients. However, there were also some significant findings that differed from the primary analyses, including a decreased odds of filling a perioperative opioid prescription for female versus male patients undergoing multi-level ACDF and higher prolonged postoperative MMEs in females undergoing CDA. These combined findings could also point to some sex-related differences in patients with preoperative opioid use that contributes to the differences seen between sexes in the perioperative and prolonged postoperative opioid use in the overall sample. Across all surgeries, females were less likely to be opioid-naïve, which reflects the biological and translational research finding of the female prevalence in many chronic pain conditions2,21. These results suggest the need for follow-up research that further disentangles the role of sex, preoperative opioid use, and chronic pain conditions.
ACDF and CDA are associated with less postoperative pain than many other spinal surgeries, especially posterior approaches. Lovecchio et al. recorded an overall low MME taken following anterior cervical surgeries20. A recent randomized trial also found that an opioid free postoperative pain management pathway was effective following ACDF and CDA22. Evaluating sex differences in opioid prescriptions following other spinal surgeries is thus an interesting future research question that could yield different results, and further help improve postoperative pain medication prescriptions following spinal surgeries.
CDA in particular is a relatively new surgery that is increasing in popularity23. An understanding of the postoperative pain medication needs of these patients is critical, and less well-understood than ACDF patients. Prabhu et al. published a case series detailing the efficacy of their multimodal pain regimen on outpatient CDA patients, and found that on postoperative day 0 the average MME utilized was 17.424. This is slightly less than the average MME of 20 on POD1 found in a study of both ACDF and CDA by Lovecchio et al20. It is possible that CDA patients require a lower dose of postoperative opioids than ACDF patients. A recent study by Jain et al. found that 74.4% of patients undergoing one- or two-level CDA had continued postoperative pain, thus suggesting that postoperative pain control following CDA remains an area with space for improvement23. Some argue that axial neck pain is not well-treated by CDA compared to ACDF, however there are studies showing that axial neck pain can improve following CDA24,25. In our study we did not separate out single-level CDA from multi-level given the overall lower frequency of arthroplasty compared to ACDF. There could be differences in postoperative pain prescriptions between single- and multi-level CDA, similar to ACDF, that we did not capture. Future studies are needed to clarify the postoperative opioid needs of CDA patients, particularly if any differences exist based on number of levels. We also excluded hybrid ACDF/CDA surgeries from our analysis.
Overprescription of postoperative opioids is a current nationwide concern, and it has been shown that around 6% of patients undergoing surgical procedures will continue to use postoperative opioids in the chronic (90-180 day) period16,26. ACDF and CDA are minimally-invasive and relatively less painful spine surgeries, thus limiting excess postoperative opioid use should be a goal following these procedures. Spine surgeons should be cognizant of the fact that female patients tend to be more likely to fill a prolonged postoperative opioid prescription, but males fill higher MMEs postoperatively, and surgeons can use this information to help tailor postoperative opioid prescriptions to their individual patients.
This is a retrospective study of a large national insurance database and is subject to the limitations associated with all studies of this nature. Our sample was limited to commercially-insured and Medicare patients, and thus may not accurately reflect Medicaid or uninsured patients. The database is only able to track filled prescriptions, not prescriptions written or actual amount or frequency of medications taken. We also do not have information on in-hospital opioid administration, which could influence perioperative prescriptions. Lack of information on pain intensity also limits interpretation of the clinical appropriateness of any observed sex-related differences. Different definitions of chronic pre- and postoperative opioid use have been used and validated in the spine surgery literature27,28. Using different definitions in this study could result in different results. Clinical data available in the database is limited, and thus many clinical factors that could affect postoperative pain may not be adequately controlled for. The setting of ambulatory spine surgery (ambulatory surgery center versus hospital outpatient) has been shown to result in different postoperative opioid prescriptions following ACDF15. Despite controlling for inpatient versus outpatient surgery in this analysis, it is possible that surgical setting could affect perioperative and prolonged postoperative prescriptions in a way that was not caught or adequately controlled, and our study results are not generalizable to cases performed in an ambulatory surgery center.
Conclusions:
In this study evaluating sex differences in opioid prescriptions filled after ACDF and CDA, female patients were more likely to fill an opioid prescription 91-180 days postoperatively across all procedure types. Additionally, female patients undergoing single-level ACDF used lower perioperative MMEs than males, and females undergoing multi-level ACDF filled lower MMEs in the perioperative and prolonged postoperative periods. These findings can guide postoperative opioid prescribing after ACDF/CDA and warrant further studies to confirm the results and optimize postoperative pain management.
Supplementary Material
Key Points:
Female patients were more likely to fill a prolonged postoperative (91-180 days) opioid prescription following single-level ACDF, multi-level ACDF, and CDA
Female patients filled lower perioperative MME than male patients following single-level ACDF
Female patients filled lower perioperative and prolonged postoperative MME than male patients following multi-level ACDF
There were otherwise no significant sex differences in filling postoperative opioid prescriptions
Funding:
This work was supported in part through the computational resources and staff expertise provided by Scientific Computing and Data at the Icahn School of Medicine at Mount Sinai and supported by the Clinical and Translational Science Awards (CTSA) grant UL1TR004419 from the National Center for Advancing Translational Sciences.
Footnotes
IRB approval: This work was determined exempt from local institutional review board approval
Previous Presentations: Portions of this manuscript have been presented at the 2025 Spine Summit in Tampa, FL
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