Postoperative Ketorolac Administration and Pseudoarthrosis Following Multilevel Posterior Cervical Decompression and Fusion

Introduction. The effect of perioperative ketorolac use after posterior cervical decompression and fusion (PCDF) remains unclear with ongoing concern regarding NSAID-induced pseudoarthrosis. This study investigates the association between postoperative ketorolac use and pseudoarthrosis after multilevel PCDF. Methods. This retrospective cohort study analyzed adults undergoing multilevel PCDF (2002–2024) using TriNetX. Patients were grouped by postoperative ketorolac within 48 hours versus acetaminophen only. Propensity matching controlled for demographics, comorbidities, and surgical indications. Primary outcome was pseudarthrosis at four years; further secondary outcomes were assessed at 30 days, 1 year, and 4 years. Results. After matching, 1,376 patients were included in each cohort across 45 healthcare organizations. No significant differences were observed in pseudarthrosis (2.4% vs. 1.9%), reoperation (<10 instances), postoperative bleeding (0 instances), opioid prescription (13.8% vs. 13.5%), hardware complications (1.1% vs. 0.7%), pulmonary embolism (PE) (0 instances), deep vein thrombosis (DVT) (<10 instances), or surgical site infection (SSI) (<10 instances) at 30 days for the ketorolac group versus control. At 1-year no significant differences were seen in pseudarthrosis (6.3% vs. 6.3%), reoperation (1.7% vs. 2.0%), bleeding (0 instances), opioid use (35.6% vs. 34.8%), hardware issues (3.4% vs. 3.0%), PE (1.1% vs. 1.4%), DVT (1.4% vs. 2.1%), or SSI (1.1% vs. 0.8%). At 4 years, ketorolac use was linked to significantly reduced opioid prescriptions RR 0.909; 95% CI (0.834, 0.980); P =0.0123, with no significant differences in pseudarthrosis (8.1% vs. 8.4%), reoperation (3.2% vs. 2.8%), bleeding (<10), hardware issues (5.2% vs. 4.7%), PE (1.7% vs. 1.7%), DVT (1.7% vs. 1.7%), or SSI (1.6% vs. 1.7%). Conclusion. Ketorolac administration following multilevel PCDF was not associated with increased rates of pseudarthrosis or other surgical complications at four years. Ketorolac use was linked to a modest reduction in oral opioid prescriptions. Ketorolac may be a safe and effective adjunct in postoperative analgesia.