Inpatient Opioid Use After Rapid Recovery Protocol for Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Abstract

Background

Rapid recovery pathways reduce opioid use after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), but inpatient opioid consumption patterns and associated factors within these pathways remain incompletely defined.

Methods

We retrospectively reviewed 160 patients with AIS who underwent PSF at a single tertiary children’s hospital managed with a rapid recovery protocol. Outcomes included total inpatient opioid use (oral morphine equivalents [OME]/kg), PCA pushes/hour, and PRN opioid requests per postoperative day (POD). We evaluated associations between patient/surgical factors and inpatient opioid metrics, and between inpatient opioid metrics and post-discharge outcomes (opioid refills and pain at follow-up) using univariate analyses and regression modeling.

Results

Mean inpatient opioid consumption was 2.8 OME/kg (2.1 OME/kg PCA; 0.8 OME/kg PRN). Patients averaged 0.9 PCA pushes/hour and 2.5 PRN requests/POD. Higher total OME/kg was associated with age ≥15 years (P = .048), preoperative pain (P = .49), and ≥12 levels fused (P = .02). Higher PCA use was associated with preoperative pain (P = .009) and ≥12 levels fused (P = .008), while increased PRN requests were associated with age ≥15 years (P = .03) and operative time ≥6 h (P = .04). All three inpatient opioid use metrics were associated with post-discharge opioid refill; PRN requests/POD were associated with pain at 6 weeks, and total OME/kg and PCA pushes/hour were associated with pain at 6 months (all P < .05 for these associations).

Conclusions

In a rapid recovery pathway, older age, preoperative pain, greater number of levels fused, and longer operative time were associated with increased inpatient opioid use after PSF for AIS. These factors may help anticipate analgesic needs and guide perioperative counseling and pain management.

Keywords

adolescent idiopathic scoliosis posterior spinal fusion opioid consumption rapid recovery pathway patient factors pain management Level IV Case Series

Introduction

Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder in children, with studies estimating an incidence ranging from 0.5% to 5.2%.^1,2 Treatment for AIS is dependent on magnitude of deformity, with general recommendations of observation alone for Cobb angle <25°, bracing for Cobb angle between 25 and 45°, and posterior spinal fusion (PSF) surgery for Cobb angle >45°. Recently, changes in pain management after PSF have emerged, with increased focus on the implementation of rapid recovery pathways and enhanced recovery after surgery (ERAS) pathways. First proposed by Kehlet in 1997, ERAS pathways employ evidence-based guidelines and multimodal care to facilitate early recovery in patients undergoing major surgery.³

While the initial focus of ERAS pathways was on colorectal surgery, ERAS protocols have since been shown to improve outcomes in many surgical domains including general, thoracic, gynecologic, urologic, orthopedic, and emergency surgeries.^4,5 In the setting of PSF for AIS, ERAS and rapid recovery pathways have been associated with shorter length of stay and lower opioid use compared with traditional pathways.^6-12 Reported effects on post-operative pain are mixed, with some studies showing improved pain control^7,9-15 and other showing no differeance.^6,8,16 Beyond pain and opioid exposure, these pathways have been linked to earlier mobilization and physical therapy clearance, shorter urinary catheter duration, less opioid related pruritus, and earlier return to school.^10,13,15,16 Readmission rates have generally been similar between pathways, with some studies showing no significant differences.^10,14

Although published studies have evaluated opioid use within ERAS and rapid recovery pathways for AIS PSF, our study adds to this growing literature by further characterizing inpatient opioid consumption patterns and associated patient and surgical factors to help guide ongoing refinement of ERAS protocols.

At our institution, a rapid recovery pathway was adopted in 2017 for patients with AIS undergoing PSF.¹⁷ The objectives of this study were to describe inpatient opioid use patterns within this protocol, identify patient and surgical factors associated with higher inpatient opioid requirements, and evaluate the association between inpatient opioid use and early post-discharge outcomes, including opioid refill and pain at follow-up. We hypothesized that meaningful variability in inpatient opioid use would persist within this protocol and that higher inpatient opioid use would be associated with greater post-discharge analgesic needs and worse pain outcomes.

Materials and Methods

Study Population and Setting

This study was approved by the institutional review board. This retrospective case series was conducted among patients with AIS undergoing PSF who were surgically managed by two fellowship-trained surgeons at a tertiary children’s hospital from February 2017 to December 2021. All patients had a preoperative diagnosis of adolescent idiopathic scoliosis. Patients aged 10-20 years were included. Patients were excluded if they had congenital disorders, comorbidities reliant upon analgesia for treatment, intellectual or behavioral disorders, a history of cancer, or unusual hospital courses such as returns to the operating room or rapid response events.

Scoliosis Rapid Recovery Pathway

In 2017, our hospital adopted a postoperative protocol for patients with AIS undergoing PSF was similar to protocols that have been described in the literature.^{10,13,14,16,18} In this protocol, patients use intravenous (IV) patient-controlled analgesia (PCA) for primary pain control from arrival in the pediatric intensive care unit after surgery to postoperative day (POD) 1 or 2, depending on patient progress. Patients are typically placed on a demand-driven PCA with a lockout period of 10 min. However, if patients are in significant pain, they may be placed on a basal or continuous rate of medication or given boluses for relief. After discontinuation of PCA, patients are prescribed an IV or oral opioid, usually oxycodone, ordered pro re nata (PRN) until discharge. For pain specifically related to muscle spasms, patients receive an IV or oral benzodiazepine, usually diazepam, PRN. For around-the- clock relief, patients receive scheduled IV ketorolac (followed by scheduled oral ibuprofen), as well as scheduled IV and oral acetaminophen throughout their hospitalization. The patient’s clinical status determines whether a medication is given IV or oral. Upon discharge, patients are typically prescribed ibuprofen, acetaminophen, and short courses of oxycodone and diazepam. If additional medications are needed, the patient/family are told to call the physician’s office, or they can address these needs at the 2-week follow-up visit. Details of our hospital-specific protocol are provided in Supplemental Table 1.

Measures of Opioid Consumption

We measured inpatient opioid consumption during the index hospitalization, including (1) total inpatient opioid use expressed as oral morphine equivalents (OME) per kilogram (kg) of body weight (OME/kg); (2) PCA utilization measured as PCA pushes per hour of PCA use; and (3) PRN opioid use measured as the number of PRN opioid doses requested per postoperative day (POD). We also evaluated the association between inpatient opioid use metrics and post-discharge outcomes, including opioid prescription refills and pain scores at the 6-week and 6-month follow-up visits. Outpatient pain was assessed using Scoliosis Research Society (SRS) patient-reported outcome surveys.¹⁹

Statistical Analysis

Univariate analyses (Student’s t-tests, Wilcoxon rank-sum tests, and chi-squared tests) examined associations between covariates and inpatient opioid use metrics. Associations between inpatient opioid use metrics and post-discharge outcomes (opioid refill and pain at follow-up) were evaluated using logistic regression, with results reported as odds ratios (ORs) with 95% confidence intervals. All analyses were performed using Stata (Version 17.0, StataCorp, College Station, TX).

Results

A total of 160 patients were included. Mean age was 15.1 years (SD 2.2); 113 (70.6%) were female and 47 (29.4%) were male. Median BMI was 22.0 (IQR 19.7–24.7). The number of surgeries performed each year was as follows: 24 (15.0%) surgeries in 2017, 32 (20.0%) surgeries in 2018, 36 (22.5%) surgeries in 2019, 33 (20.6%) surgeries in 2020, and 35 (21.9%) surgeries in 2021. 46 (28.8%) patients were ASA class I, 109 (68.1%) were ASA class II, and 5 (3.1%) were ASA class III. Median major curve was 55° (IQR 53–63), median number of levels fused was 12 (IQR 10–13), and median number of Ponte osteotomies was 3 (IQR 2–4). The mean operative time was 367.5 min (SD 74.9), and median estimated blood loss was 500 cc (IQR 425–750). Forty-one patients (25.6%) required blood transfusion intraoperatively and/or postoperatively. The median length of stay was 4.3 days (IQR 3.5–4.5).

Mean inpatient opioid consumption was 2.8 OME/kg (2.1 OME/kg from PCA; 0.8 OME/kg from PRN opioids). Patients averaged 0.9 PCA pushes per hour of PCA use and 2.5 PRN opioid requests per postoperative day (POD). In terms of inpatient multimodal pain management, 154 (96.3%) patients received acetaminophen, 156 (97.5%) received NSAIDs, and 140 (87.5%) received a benzodiazepine.

In univariate analyses (Table 1), age ≥15 years (P = .048), preoperative pain (P = .049), and number of vertebral levels fused ≥12 (P = .02) were associated with higher total OME/kg consumed. Preoperative pain (P = .009) and ≥12 levels fused (P = .008) were associated with higher PCA pushes per hour. Age ≥15 years (P = .03) and surgery length ≥6 h (P = .04) were associated with higher PRN opioid requests per POD.

Table 1.

Association Between Preoperative Factors and Pain Medication Usage Postoperatively

	Total OME/kg consumed		PCA pushes per hour of use		Opioid PRNs requested per POD
	Median (IQR)	P-value	Median (IQR)	P-value	Median (IQR)	P-value
Age		.048		.24		.03
<15 years	2.11 (1.43, 3.76)		0.76 (0.51, 1.14)		1.95 (0.98, 3.46)
≥15 years	2.73 (1.84, 4.03)		0.90 (0.51, 1.42)		2.93 (1.73, 3.46)
Gender		.67		.40		.29
Male	2.52 (1.76, 3.74)		0.92 (0.51, 1.24)		2.95 (1.29, 3.87)
Female	2.53 (1.48, 3.85)		0.77 (0.51, 1.21)		2.42 (1.21, 3.37)
Primary payer		.35		.23		.40
Private	2.13 (1.42, 3.82)		0.72 (0.44, 1.15)		2.51 (1.59, 3.46)
Public	2.59 (1.77, 3.88)		0.85 (0.59, 1.24)		2.48 (1.02, 3.50)
BMI		.42		.96		.14
Underweight	2.67 (1.92, 4.79)		0.71 (0.51, 1.92)		0.92 (0.52, 3.74)
Normal	2.54 (1.48, 3.99)		0.78 (0.49, 1.26)		2.65 (1.28, 3.46)
Overweight	2.82 (1.90, 3.79)		0.86 (0.57, 1.19)		1.89 (1.20, 3.13)
Obese	2.10 (1.27, 2.76)		0.74 (0.51, 1.23)		2.59 (1.82, 4.66)
Preop pain		.049		.009		.12
Yes	2.94 (1.94, 4.12)		1.08 (0.67, 1.52)		3.11 (1.69, 3.83)
No	2.19 (1.47, 3.72)		0.75 (0.47, 1.17)		2.48 (1.13, 3.33)
ASA score		.98		.70		.33
I	2.40 (1.76, 3.41)		0.77 (0.54, 1.11)		2.51 (1.20, 3.30)
II	2.55 (1.44, 3.85)		0.81 (0.49, 1.27)		2.42 (1.26, 3.42)
III	2.25 (1.63, 3.47)		1.14 (0.43, 1.80)		3.86 (2.82, 4.51)
# Levels fused		.02		.008		.08
<12	2.08 (1.45, 3.58)		0.73 (0.43, 1.11)		2.20 (1.04, 3.20)
≥12	2.78 (1.87, 4.17)		0.92 (0.65, 1.42)		2.63 (1.69, 3.64)
Surgery length		.61		.86		.04
<6 h	2.41 (1.56, 3.67)		0.79 (0.55, 1.22)		2.31 (1.20, 3.13)
≥6 h	2.53 (1.54, 3.85)		0.77 (0.47, 1.24)		2.67 (1.32, 3.88)
Est. Blood loss		.24		.17		.06
<600 cc	2.26 (1.41, 3.95)		0.75 (0.48, 1.20)		2.40 (0.98, 3.20)
≥600 cc	2.80 (1.79, 3.79)		0.91 (0.61, 1.24)		2.52 (1.73, 3.88)

Abbreviations: OME, oral morphine equivalents; PCA, patient-controlled analgesia; PRN, pro re nata; POD, postoperative day; IQR, interquartile range; BMI, body mass index; Preop, preoperative; ASA, American society of anesthesiologists.

Note: Bold indicates statistically significant p values (< 0.05).

In post-discharge analyses (Table 2), higher total OME/kg (OR 1.33, 95% CI 1.08–1.64), PCA pushes per hour (OR 2.11, 95% CI 1.10–4.05), and PRN requests per POD (OR 1.49, 95% CI 1.16–1.92) were each associated with increased odds of opioid refill. Pain outcomes differed by time point: PRN requests per POD were associated with pain at 6 weeks (OR 1.37, 95% CI 1.05–1.79), whereas total OME/kg (OR 1.66, 95% CI 1.19–2.32) and PCA pushes per hour (OR 3.82, 95% CI 1.60–9.13) were associated with pain at 6 months.

Table 2.

The Association Between Inpatient Opioid Use and Post-discharge Pain Metrics

	Opioid refill post-discharge	Pain at 6 weeks follow-up	Pain at 6 months follow-up
	OR (95% CI)	OR (95% CI)	OR (95% CI)
Total OME per kg	1.33 (1.08, 1.64)	1.24 (0.99, 1.55)	1.66 (1.19, 2.32)
PCA pushes per hour	2.11 (1.10, 4.05)	1.44 (0.72, 2.92)	3.82 (1.60, 9.13)
Opioid PRNs per POD	1.49 (1.16, 1.92)	1.37 (1.05, 1.79)	1.12 (0.80, 1.57)

Abbreviations: OR, odds ratio; CI, confidence interval; OME, oral morphine equivalents; PCA, patient-controlled analgesia; PRN, pro re nata; POD, postoperative day.

Note: Bold indicates statistically significant associations (95% confidence intervals excluding the null value of 1.0).

Discussion

Rapid recovery pathway for adolescent idiopathic scoliosis posterior spinal fusion have been increasingly adopted to standardize perioperative care and reduce opioid exposure, yet meaningful variability in opioid requirements persists even within these protocols. In this retrospective case series of AIS patients managed with a standardized rapid recovery pathway, we found that older age, preoperative pain, a greater number of levels fused, and longer operative time were associated with increased inpatient opioid use. Overall inpatient opioid consumption averaged 2.8 oral morphine equivalents per kilogram, with the majority derived from PCA use during the first postoperative days. Importantly, higher inpatient opioid use metrics were associated with increased odds of post-discharge opioid refill, and higher PRN requests and PCA utilization were associated with worse pain outcomes at follow-up. Collectively, these findings suggest that within rapid recovery pathways, a subset of patients demonstrates consistently higher opioid requirements and downstream analgesic needs, which may help inform perioperative counseling and targeted optimization of multimodal pain management.

Predicting which patients will require more opioid medications post-PSF remains important for optimizing pain control. Our study found that age, preoperative pain, and the number of vertebral levels fused correlated with increased total inpatient opioid use. Specifically, preoperative pain and number of vertebral levels fused were associated with increased PCA use, while age and surgery length were associated with increased PRN opioid use.

Older patients demonstrated increased opioid usage in this rapid recovery pathway, possibly because they better understand the role of opioids thus request more medication. This aligns with studies showing that older pediatric and adolescent patients utilize more opioids postoperatively, although one study found that younger age is associated with increased morphine consumption.^20-23 Notably, these studies were not in the setting of a rapid recovery pathway, highlighting our study’s importance.

Increased preoperative pain also correlated with increased postoperative opioid use, consistent with prior findings in patients with AIS undergoing PSF.²² This may be due to increased postoperative pain, as it has been shown that preoperative pain is associated with increased postoperative pain and analgesic use.²⁴ Bailey et al. describe three distinct pain trajectories following surgery for patients with AIS undergoing PSF, and identified greater baseline pain and anxiety as predictors for belonging to the persistent pain trajectory.²⁵ Unlike fixed preoperative characteristics such as age, preoperative pain is a potentially intervenable predictor of postoperative opioid use, which should be a focus of future interventions.

We also show that the number of levels fusions and surgery length are associated with increased opioid use. Previous studies have shown that increased surgery time is correlated with increased pediatric opioid use.²³ PSF has been shown to correlate with more pediatric opioid usage as compared to other procedures including arthroscopy, pectus excavatum repair, tonsillectomy, and hip reconstruction.²⁰ The extensive surgical excision and tissue trauma in PSF likely contribute to increased pain and need for opioids.²⁶

Another finding of this study is that higher inpatient opioid use is associated with increased outpatient opioid requests and pain. This finding, along with the aforementioned patient characteristics, helps identify patients with AIS undergoing PSF who may need more postoperative opioids vs those who may not. Ultimately the goal is to optimize pain control while limiting the well-established negative consequences of excess opioid consumption—including short-term effects such as nausea, vomiting, constipation, and sedation and long-term risks such as tolerance, dependence, and hyperalgesia.^27,28 Recent investigations have demonstrated that both adult and pediatric patients undergoing orthopedic surgery are prescribed more opioids than necessary.^29-32 Predicting which patients may benefit most from postoperative opioids may help decrease overprescription and consequent risk of chronic opioid use and opioid abuse.

One of the pillars of rapid recovery and ERAS pathways is the use of multimodal pain control. In addition to considering the patient factors that we describe in this paper, we want to emphasize the importance of implementing multimodal pain strategies. Pain is multifactorial and influenced by a complex interaction of genetic, physiologic, psychologic, and sociological factors.²⁴ Many multimodal strategies have been shown to be beneficial following pediatric spinal surgery.³³ Such modalities include NSAIDs, which were shown to reduce the need for postoperative opioids³⁴; acetaminophen, which has been shown to decrease postoperative pain and opioid consumption^35-37; gabapentin, which resulted in early postoperative decrease in pain and opioid use³⁸; epidural analgesia, which was shown to be comparable to morphine-based PCA³⁹; intrathecal morphine, which has been shown to be a safe and effective strategy to control pain⁴⁰; and local anesthesia, which decreased the need for morphine infusion.⁴¹ At our institution we have implemented paravertebral blocks for patients with AIS undergoing PSF in an effort to further reduce opioid use. Additionally, preoperative patient education on multimodal pain management is associated with decreased opioid use for patients with AIS undergoing PSF and should be integrated into rapid recovery pathways.⁴² These modalities should be considered, along with the patient’s psychosocial context, when administering postoperative opioids, especially in patients at higher risk for postoperative pain and opioid use as identified in this study and the literature.

These findings have practical implications for pathway implementation. Although many perioperative milestones within rapid recovery protocols are largely protocol driven, readily available preoperative factors such as age and baseline pain status may help identify patients more likely to require higher inpatient opioid exposure even within a standardized pathway. Clinically, these variables could be used to trigger targeted adjuncts such as enhanced preoperative counseling and expectation setting, early acute pain service involvement, and intensified multimodal analgesia planning, while preserving consistent core pathway elements for all patients.^24,39 Framing perioperative outcomes as measures of pathway fidelity also clarifies that the intent is not to suggest host dependence of these milestones, but rather to direct supportive resources within an otherwise standardized protocol. Future prospective studies should evaluate whether such risk stratified pathway augmentation reduces opioid exposure without compromising pain control or recovery milestones.

This study has several limitations. It is retrospective and demonstrates correlation between patient factors and opioid consumption, but claims about causation cannot be made. Additionally, this study was conducted at a single institution, which may reduce generalizability. Future multicenter studies should investigate factors that influence pediatric inpatient opioid consumption in a diverse array of settings. Because of an electronic medical record transition at our institution, comparable pre-2017 data were unavailable, precluding inclusion of a historical control group and limiting our ability to compare outcomes before and after rapid recovery implementation. Furthermore, this study investigates short-term opioid consumption, focusing on inpatient and outpatient usage up to 6-months postoperatively, warranting future long-term investigations. We also believe that mental health plays a critical role in perioperative pain management and is another important factor to investigate in the future. Finally, this study did not extensively investigate the impact of inpatient opioid use on postoperative outcomes, and future studies should investigate outcomes such as long-term pain, function, and other quality-of-life metrics.

In a rapid recovery pathway, older age, preoperative pain, a greater number of levels fused, and longer operative time were associated with increased inpatient opioid use after PSF for AIS. Higher inpatient opioid use was associated with greater likelihood of post-discharge opioid refill and higher pain scores at follow-up. These factors may help anticipate analgesic needs and guide perioperative counseling and pain management.

Supplemental Material

Supplemental material—Inpatient Opioid Use After Rapid Recovery Protocol for Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis

Supplemental material for Inpatient Opioid Use After Rapid Recovery Protocol for Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis by Kathryn R. Segal, Emily D. Ferreri, Mohamed Said, Zachariah Samuel, Edina Gjonbalaj, Leila Mehraban Alvandi, Jacob F. Schulz, Eric D. Fornari, and Jaime A. Gomez in Montefiore Einstein Journal of Musculoskeletal Medicine and Surgery

Footnotes

ORCID iD

Mohamed Said

Ethical Considerations

This study was reviewed and approved by the Institutional Review Board (IRB) of the Albert Einstein College of Medicine (East Campus IRB, Jack and Pearl Resnick Campus, Bronx, NY), under IRB protocol number 2016-6029, reference number 125847. Approval was granted on May 12, 2025, with an expiration date of May 11, 2026.

Consent to Participate

A waiver of informed consent was granted by the Institutional Review Board due to the retrospective nature of the study.

Author Contributions

All persons who meet authorship criteria are listed as authors, and no others meeting these criteria have been omitted.

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 not publicly available due to institutional restrictions but are available from the corresponding author on reasonable request.*

Anonymity Statement

All identifying information related to the authors, institutions, and ethics committees is included only on the title page and will be removed from the blinded manuscript to preserve reviewer anonymity.

Supplemental Material

Supplemental material for this article is available online.

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