Pain management following spinal surgeries: An appraisal of the available options

Effect of Adding Neural Mobilization Versus Myofascial Release to Stabilization Exercises after Lumbar Spine Fusion: A Randomized Controlled Trial

OBJECTIVES

To test the effect of adding neural mobilization (NM) versus myofascial release (MFR) to stabilization exercises (SE) on disability, pain, and lumbar range of motion (ROM) in patients with lumbar spine fusion (LSF).

DESIGN

A single blinded, parallel groups, randomized controlled trial.

SETTING

Outpatient public and governmental hospital clinics.

PARTICIPANTS

Patients (N=60) who had undergone LSF were randomly assigned into 3 equal groups.

INTERVENTION

Group I received NM plus SE, group II received MFR and SE, and group III received SE only. Each group visited the hospital 3 times a week for 4 weeks.

MAIN OUTCOME MEASURES

Oswestry disability index (ODI), visual analog scale, and back range of motion (BROM) were assessed before starting treatment, immediately after finishing treatment, and 1 month later.

RESULTS

There were statistically significant differences among the groups regarding the ODI and pain (P<.05) in favor of the study groups, but no statistically significant differences were found among groups regarding the BROM outcome (P>.05). Regarding the within-group effect, statistically significant differences were found in all outcomes after 1 month of treatment, as well as after 1 month of follow-up in each group (P<.05).

CONCLUSIONS

Patients who received NM or MFR combined with SE demonstrated better improvement, in favor of the NM group, regarding disability and pain than patients who received SE alone after LSF. No differences were found among the groups regarding lumbar ROM.

Postoperative Single-shot Epidural Fentanyl and Bupivacaine for Postoperative Analgesia After Lumbar Decompression: A Prospective, Double-blind Randomized Study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery.

METHODS

We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated.

RESULTS

Pain scores were noted to be significantly lower at all time points in the epidural group (P < 0.001). In turn, they also received less on-demand oral pain medications than those in the control group (P = 0.000). The mean time to ambulation was 0.09 days in the epidural group and 0.91 days in the decompression-alone group (P = 0.000). Criteria for hospital discharge were usually met on Day 0 in the epidural and Day 1 in the control group (P = 0.000). Within the study period, only one infection was noted in the epidural group which necessitated additional lumbar spine surgery (4.3%). No adverse events or complications related to Fentanyl use were observed.

CONCLUSIONS

A postoperative bolus of Fentanyl and Bupivacaine is effective in reducing early postoperative pain without the related complications of opiod administration.

LEVEL OF EVIDENCE

2.

Effect of Intravenous Lidocaine on Postoperative Pain in Patients Undergoing Intraspinal Tumor Resection: Study Protocol for a Prospective Randomized Controlled Trial

Purpose

Patients undergoing intraspinal tumor resection usually experience severe acute pain, delaying postoperative rehabilitation, and increasing incidence of chronic pain. Recently, an increasing number of studies have found that low-dose intravenous lidocaine infusion during and/or after surgery can reduce opioid usage and the incidence of related side effects, inhibit hyperalgesia and promote recovery. Thus far, no studies have evaluated the analgesic effect and safety of perioperative intravenous lidocaine infusion for intraspinal tumor resection, especially the long-term analgesic effects of patient-controlled analgesia (PCA) with lidocaine during the first postoperative 48 hours. This study tests the hypothesis that intra- and postoperative systemic lidocaine infusion for patients undergoing intraspinal tumor resection can relieve postoperative acute or chronic pain and reduce the opioid dosage and incidence of related side effects without other problems.

Study Design and Methods

This is a prospective, randomized, placebo-controlled, and double-blinded study. In total, 180 participants scheduled for intraspinal tumor resection will be randomly divided into lidocaine and placebo groups. The lidocaine group will be administered lidocaine intravenously during anesthesia and postoperative pain management during the first 48 postoperative hours; the placebo group will be administered normal saline at the same volume, infusion rate, and timing. The primary outcome will be the postoperative visual analog scale (VAS) score. Secondary outcomes will be postoperative cumulative sufentanil consumption, indicators of postoperative recovery, and the incidence of perioperative adverse events.

Discussion

This study investigates the effect of continuous intravenous lidocaine infusion on postoperative sufentanil consumption and VAS scores. The findings will provide a new strategy of anesthesia and analgesia management for intraspinal tumor resection.

Cold Therapy and the Effect on Pain and Physiological Parameters in Patients Recovering from Spine Surgery: A Randomized Prospective Study

BACKGROUND

This study aimed to determine the effect of cold therapy (CT) on pain and physiological parameters after spine surgery.

MATERIALS AND METHODS

This study was a prospective, randomized controlled trial. Study participants were randomly assigned to either a control group or a CT group. The outcome measured was pain intensity rated by a numeric rating scale. Psychological outcome measures were considered secondary.

RESULTS

Thirty-eight patients in each group completed the study. No statistically significant difference was found between the pain scores of patients in the CT and those in the control group during the 24-h period following surgery (group: F = 0.01, p = 0.922). However, it was found that the pain scores of patients in the CT group were significantly lower than those in the control group during the 48-h period (group: F = 10.59, p = 0.002).

CONCLUSION

CT reduced pain scores during the 48-h period following spine surgery. Our findings support the use of CT as an adjuvant therapy in pain management.

Regional Anesthesia in Neuroanesthesia Practice

Regional anesthesia has been an undervalued entity in neuroanesthetic practice. However, in the past few years, owing to the development of more advanced techniques, drugs and the prolific use of ultrasound guidance, the unrecognised potential of these modalities have been highlighted. These techniques confer the advantages of reduced requirements for local anesthetics, improved hemodynamic stability in the intraoperative period, better pain score postoperatively and reduced analgesic requirements in the postoperative period. Reduced analgesic requirement translates into lesser side effects associated with analgesic use. Furthermore, the transition from the traditional blind landmark-based techniques to the ultrasound guidance has increased the reliability and the safety profile. In this review, we highlight the commonly practised blocks in the neuroanesthesiologist's armamentarium and describe their characteristics, along with their individual particularities.

Analgesic efficacy of intravenous nefopam after spine surgery: a randomized, double-blind, placebo-controlled trial

Background: The incidence of moderate to severe pain is high among patients undergoing spinal surgery. Nefopam can be used as an adjuvant analgesic postoperatively after spine surgery. The study aimed to assess the analgesic efficacy and side effects of nefopam on 24-hour postoperative morphine consumption after spine surgery. Methods: The study is a randomized, double-blinded, placebo-controlled trial. A total of 96 patients were randomized into 4 treatment groups, 24 each. In group 1, patients received normal saline before surgical incision and before the end of surgery. In group 2, patients received 30 mg nefopam before surgical incision and normal saline before the end of surgery. In group 3, patients received normal saline before surgical incision and 30 mg of nefopam before the end of surgery. In group 4, patients received 30 mg of nefopam in both timings. Patient-controlled analgesia morphine was used for the postoperative period. Outcomes were to determine 24-hour morphine consumption and incidence of side effects.  Results: Of 96 patients enrolled, 21 in placebo-placebo, 22 in nefopam-placebo, 22 in placebo-nefopam and 21 in nefopam-nefopam groups completed the study.  Analysis of the Kruskal-Wallis test on the intention-to-treat basis shows no significant difference in 24-hour postoperative morphine consumption between four groups, which were 18 [IQR 13.5-29], 20 [IQR 11-28.3], 17 [IQR 11.5-28.5], 13 [IQR 8.5-18.5] mg., respectively (p = 0.223). Incidence of side effects, including tachycardia, sedation, sweating and nausea/ vomiting, did not differ. Conclusions: Adding perioperative nefopam to opioid analgesic does not improve analgesic efficacy in patients who underwent spine surgery. Registration: Thai Clinical Trials Registry ID TCTR20171115001; registered on 15 November 2017.

Analgesic efficacy of intravenous nefopam after spine surgery: a randomized, double-blind, placebo-controlled trial

Background: The incidence of moderate to severe pain is high among patients undergoing spinal surgery. Nefopam can be used as an adjuvant analgesic postoperatively after spine surgery. The study aimed to assess the analgesic efficacy and side effects of nefopam on 24-hour postoperative morphine consumption after spine surgery. Methods: The study is a randomized, double-blinded, placebo-controlled trial. A total of 96 patients were randomized into 4 treatment groups, 24 each. In group 1, patients received normal saline before surgical incision and before the end of surgery. In group 2, patients received 30 mg nefopam before surgical incision and normal saline before the end of surgery. In group 3, patients received normal saline before surgical incision and 30 mg of nefopam before the end of surgery. In group 4, patients received 30 mg of nefopam in both timings. Patient-controlled analgesia morphine was used for the postoperative period. Outcomes were to determine 24-hour morphine consumption and incidence of side effects.  Results: Of 96 patients enrolled, 21 in placebo-placebo, 22 in nefopam-placebo, 22 in placebo-nefopam and 21 in nefopam-nefopam groups completed the study. Analysis of the Kruskal-Wallis test shows no significant difference in 24-hour postoperative morphine consumption between four groups, which were 18 [IQR 13.5-29], 20 [IQR 11-28.3], 17 [IQR 11.5-28.5], 13 [IQR 8.5-18.5] mg., respectively (p = 0.223).  Incidence of side effects, including tachycardia, sedation, sweating and nausea/ vomiting, did not differ. Conclusions: Adding perioperative nefopam to opioid analgesic does not improve analgesic efficacy in patients who underwent spine surgery. Registration: Thai Clinical Trials Registry ID TCTR20171115001; registered on 15 November 2017.

Current Trends in Pediatric Spine Deformity Surgery: Multimodal Pain Management and Rapid Recovery

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose of this article is to perform a review of the literature assessing the efficacy of opioid alternatives, multimodal pain regimens, and rapid recovery in pediatric spine surgery.

METHODS

A literature search utilizing PubMed database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease postoperative pain and expedite recovery after posterior spinal fusion in adolescent idiopathic scoliosis patients have been provided based on results of studies with the highest level of evidence.

RESULTS

Refining perioperative pain management to lessen opioid consumption with multimodal regimens may be useful to decrease recovery time, pain, and complications. Nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, neuraxial blockades, and local anesthesia alone offer benefits for postoperative pain management, but their combination in multimodal regimens and rapid recovery pathways may contribute to faster recovery time, improved pain levels, and lower reduction in total opioid consumption.

CONCLUSION

A rapid recovery pathway using the multimodal approach for pediatric scoliosis correction may offer superior postoperative pain management and faster recovery than traditional opioid only pain protocols.

Multimodal Analgesia (MMA) Versus Patient-Controlled Analgesia (PCA) for One or Two-Level Posterior Lumbar Fusion Surgery

A multimodal analgesic method was known to avoid the high-dose requirements and dose-dependent adverse events of opioids, and to achieve synergistic effects. The purpose of this study was to compare the efficacy of our multimodal analgesia (MMA) regimen with that of the patient-controlled analgesia (PCA) method for acute postoperative pain management. Patients who underwent one or two-level posterior lumbar fusion (PLF) followed by either MMA or PCA administration at our hospital were compared for pain score, additional opioid and non-opioid consumption, side effects, length of hospital stay, cost of pain control, and patient satisfaction. From 2016 through 2017, a total 146 of patients were screened. After propensity score matching, 66 remained in the PCA and 34 in the MMA group. Compared with the PCA group, the MMA group had a shorter length of hospital stay (median (interquartile range): 7 days (5-8) vs. 8 (7-11); P = 0.001) and lower cost of pain control (70.6 ± 0.9 USD vs. 173.4 ± 3.3, P < 0.001). Baseline data, clinical characteristics, pain score, additional non-opioid consumption, side effects, and patient subjective satisfaction score were similar between the two groups. The MMA seems to be a good alternative to the PCA after one or two-level PLF.

Using Electronic Health Record Activity to Represent Interdisciplinary Care Teams and Examining their Contribution to Hospital Length of Stay

Modeling variance in patient outcomes using medical claims and other forms of aggregated administrative data may ignore significant contributions associated with providers who are not recorded in billing transactions. We examined the association between interdisciplinary provider factors and length of stay (LOS) for 1,099 lumbar spine surgery patients. Interdisciplinary provider "dose" (number of providers/case), "workload" (care of other patients), and "activity" factors were defined and generated. Hierarchical Regression models were used to test the impact of these provider factors controlling for the effect of socio-demographic and clinical factors. Interdisciplinary provider factors explained 12% of additional variance in LOS. EHR-based interdisciplinary care team representations hold promise in contributing to our understanding of health care delivery and quality. Keywords: interdisciplinary care, nursing documentation, workload, length of stay, electronic health records (EHR).

The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion

OBJECTIVE

Assess preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores and differences between preoperative and postoperative PROMIS-PF scores for patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

After Institutional Review Board approval, a prospectively maintained surgical registry was retrospectively reviewed for elective spine surgeries of nontraumatic, degenerative pathology between 2015-2018. Inclusion criteria were primary or revision, single-level ACDF procedures. Multilevel procedures and patients without preoperative surveys were excluded. A preoperative PROMIS score cutoff of 35 divided patients into PROMIS-PF score categories (e.g. , ≥ 35.0, < 35.0). Categorical and continuous variables were evaluated with chi-square tests and t-tests. Linear regression analyzed PROMIS-PF score improvement.

RESULTS

Eighty-six patients were selected, the high and low PROMIS-PF subgroups only differed in mean age (49.1 vs. 41.3, p = 0.002). Significant differences in PROMIS-PF scores were observed among high and low preoperative PROMIS-PF score subgroups at 6 weeks (p = 0.006), 12 weeks (p = 0.006), and 6 months (p = 0.014). Mean differences between preoperative and postoperative PROMIS-PF scores were significantly different between the high and low PROMIS-PF subgroups at 6 weeks (p = 0.041) and 1 year (p = 0.038). A significant negative association was observed between preoperative PROMIS scores and magnitude of improvement at the 6-week postoperative time point (slope = -0.6291, p < 0.001).

CONCLUSION

Patients with low preoperative PROMIS-PF scores demonstrated greater improvements at 6 weeks and 1 year. Clinicians should consider patients with low preoperative PROMIS-PF scores to be in the unique position to potentially experience larger postoperative improvement magnitudes than patients with higher preoperative PROMIS-PF scores.

Perioperative duloxetine as part of a multimodal analgesia regime reduces postoperative pain in lumbar canal stenosis surgery: a randomized, triple blind, and placebo-controlled trial

Background

Duloxetine is an antidepressant that is also useful in chronic neuropathic and central origin pain. In this study, the role of duloxetine in decreasing acute postoperative pain after lumbar canal stenosis surgery is explored.

Methods

In this single center, triple blinded, and placebo-controlled trial, 96 patients were randomized for statistical analysis. The intervention group received oral duloxetine 30 mg once a day (OD) for 2 days before surgery, 60 mg OD from the day of surgery to the postoperative second day and 30 mg OD for the next 2 days (a total duration of 7 days). A placebo capsule was given in the other group for a similar time and schedule. The same standard perioperative analgesia protocols were followed in both groups.

Results

Total morphine consumption up to 24 hours was significantly decreased in the duloxetine group (P < 0.01). The time to the first analgesia requirement was similar in both groups but the time to the second and third dose of rescue analgesia increased significantly in the duloxetine group. The time to ambulation was decreased significantly (P < 0.01) in the duloxetine group as compared to the placebo group. Pain scores remained similar during most of the time interval. No significant difference was observed in the complication rate and patient satisfaction score recorded.

Conclusions

Duloxetine reduces postoperative pain after lumbar canal stenosis surgery with no increase in adverse effects.

EVALUATION OF PAIN SYNDROME AND EFFICIENCY OF PAIN MANAGEMENT IN LUMBAR SPINE SURGERY

Multimodal analgesia for lumbar spine surgery is still a controversial problem, because of possible fusion problems, significant neuropathic component of pain, and influence of anesthesia type. Aim of the study was to assess the efficacy of pain management after lumbar spine surgery considering characteristics of pain, type of anesthesia and analgesic regimen. Material and methods. 254 ASA I-II patients with degenerative lumbar spine disease were enrolled into prospective study. Patients were operated either under spinal anesthesia (SA) or total intravenous anesthesia (TIVA). In postoperative period patients got either standard pain management (SPM – paracetamol±morphine) or multimodal analgesia (MMA – paracetamol+parecoxib+pregabalin±morphine). Results. We revealed neuropathic pain in 53.9 % of patients, who were elected for lumbar spine surgery. VAS pain score in patients with neuropathic pain was higher, than in patients with nociceptive pain. Total intravenous anesthesia was associated with greater opioid consumption during the first postoperative day. Multimodal analgesia based on paracetamol, parecoxib and pregabalin allowed to decrease requirements for opioids, postoperative nausea and dizziness. Pregabalin used for evening premedication had equipotential anxiolytic effect as phenazepam without postoperative cognitive disturbances. Conclusions. Multimodal analgesia is opioid-sparing technique that allows to decrease complications. Spinal anesthesia is associated to a decreased opioid consumption in the 1st postoperative day.

Evaluation of ultrasound-guided lateral thoracolumbar interfascial plane block for postoperative analgesia in lumbar spine fusion surgery: a prospective, randomized, and controlled clinical trial

Objective

Ultrasound-guided lateral thoracolumbar interfascial plane block (US-TLIP block) is a novel regional technique for anesthesia or analgesia. However, there has been no prospective, randomized and controlled clinical trial investigating the perioperative analgesic effect of US-TLIP block on lumbar spinal fusion surgery. The aim of this study was to investigate the analgesic effect of bilateral single-shot US-TLIP in patients undergoing lumbar spinal fusion surgery.

Methods

A prospective and randomized comparative clinical study was conducted. A total of 60 patients (ASA classes: I–II), aged 21–74 years who were scheduled for lumbar spinal fusion surgery were randomized and divided into the TLIP group (Group T, n = 30) and control group (Group C, n = 30). The patients in Group T received preoperative bilateral single-shot US-TLIP with 30 ml of 0.375% ropivacaine at the third lumbar spine (L3) vertebral level, and the patients in Group C received an injection of 30 ml 0.9% saline through same technique. All patients received patient-controlled analgesia (PCA) after their operation. The frequency of PCA compressions and rescue analgesic administrations were recorded. Opioids (sufentanil and remifentanil), anesthetic consumption, the number of postoperative days spent in a hospital bed, overall hospital stay time and postoperative complications were recorded. The Visual Analogue Scale (VAS) and Bruggemann Comfort Scale (BCS) scores for pain and comfort assessment were recorded at 1, 12, 24, 36, and 48 hours postoperatively.

Results

Opioids and anesthetic consumption in the perioperative period decreased significantly in the TLIP group compared to the control group (P < 0.05). The VAS and BCS scores in the TLIP group were lower at 12, 24, and 36 hours postoperatively (P < 0.05). US-TLIP block has been shown to shorten postoperative hospital stays (P < 0.05). There was no significant difference in postoperative complications between the two groups.

Conclusion

Our study findings show that bilateral US-TLIP block exhibits significant analgesia and safety in patients undergoing lumbar spinal fusion surgery.

Multimodal analgesia in pain management after spine surgery

Multimodal analgesia (MMA) is the simultaneous use of multiple analgesic medications that work in a synergistic manner to provide pain control. In recent years, spine surgery has seen the growth of multimodal perioperative protocols for managing pain. Postoperative pain following spinal procedures is a common complaint, with persistent pain even after the immediate convalescent period leading to negative impacts on health. A multidisciplinary approach is essential in reducing postoperative morbidity and complication rates. This review demonstrates the efficacy in the combined use of opioid-alternative medications such as NSAIDs, gabapentinoids, local anesthetics, acetaminophen, and other neuromodulatory pharmacologic agents. Continued research will be essential in the optimization of the MMA protocol for treating patients who undergo spine procedures.

Antidepressants in Spine Surgery: A Systematic Review to Determine Benefits and Risks

Antidepressant drugs can be advantageous in treating psychiatric and non-psychiatric illnesses, including spinal disorders. However, spine surgeons remain unfamiliar with the advantages and disadvantages of the use of antidepressant drugs as a part of the medical management of diseases of the spine. Our review article describes a systematic method using the PubMed/Medline database with a specific set of keywords to identify such benefits and drawbacks based on 17 original relevant articles published between January 2000 and February 2018; this provides the community of spine surgeons with available cumulative evidence contained within two tables illustrating both observational (10 studies; three cross-sectional, three case-control, and four cohort studies) and interventional (seven randomized clinical trials) studies. While tricyclic antidepressants (e.g., amitriptyline) and duloxetine can be effective in the treatment of neuropathic pain caused by root compression, venlafaxine may be more appropriate for patients with spinal cord injury presenting with depression and/or nociceptive pain. Despite the potential associated consequences of a prolonged hospital stay, higher cost, and controversial reports regarding the lowering of bone mineral density in the elderly, antidepressants may improve patient satisfaction and quality of life following surgery, and reduce postoperative pain and risk of delirium. The preoperative treatment of preexisting psychiatric diseases, such as anxiety and depression, can improve outcomes for patients with spinal cord injury-related disabilities; however, a preoperative platelet function assay is advocated prior to major spine surgical procedures to protect against significant intraoperative blood loss, as serotonergic antidepressants (e.g., selective serotonin reuptake inhibitors) and bupropion can increase the likelihood of bleeding intraoperatively due to drug-induced platelet dysfunction. This comprehensive review of this evolving topic can assist spine surgeons in better understanding the benefits and risks of antidepressant drugs to optimize outcomes and avoid potential hazards in a spine surgical setting.

Intravenous Acetaminophen Does Not Reduce Inpatient Opioid Prescription or Opioid-Related Adverse Events Among Patients Undergoing Spine Surgery

BACKGROUND

Having entered the US market relatively recently, the perioperative role of intravenous acetaminophen (ivAPAP) remains to be established for several surgeries. Using national data, we therefore assessed current utilization and whether it reduces inpatient opioid prescription and opioid-related side effects in a procedure with relatively high opioid utilization.

METHODS

Patients undergoing a lumbar/lumbosacral spinal fusion (n = 117,269; 2011-2014) were retrospectively identified in a nationwide database and categorized by the amount and timing of ivAPAP administration (1 or >1 dose on postoperative day [POD] 0, 1, or 1+). Multivariable models measured associations between ivAPAP utilization categories and opioid prescription and perioperative complications; odds ratios (or % change) and 95% confidence intervals are reported.

RESULTS

Overall, ivAPAP was used in 18.9% (n = 22,208) of cases of which 1 dose on POD 0 was the most common (73.6%; n = 16,335). After covariate adjustment, use of ivAPAP on POD 0 and 1 was associated with minimal changes in opioid prescription, length and cost of hospitalization particularly favoring >1 ivAPAP dose with a modestly (-5.2%, confidence interval, -7.2% to -3.1%; P < .0001) decreased length of stay. Use of ivAPAP did not coincide with a consistent pattern of significantly reduced odds for complications. In comparison, the most commonly used nonopioid analgesic, pregabalin/gabapentin, did demonstrate reduced opioid prescription combined with lower complication risk.

CONCLUSIONS

We could not show that perioperative ivAPAP reduces inpatient opioid prescription with subsequent reduced odds for adverse outcomes. It remains to be determined if and under what circumstances ivAPAP has a meaningful clinical role in everyday practice.

Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion

BACKGROUND

Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery.

OBJECTIVE

To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol.

METHODS

A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution.

RESULTS

A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P &gt; .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P &lt; .001) and 24 to 72 hr postoperatively (4.7 vs 3.4, P &lt; .001), PRE vs POST, respectively. Maximum pain scores and time to achieving appropriate pain control also significantly improved during these same intervals (all P &lt; .05). A concomitant decrease in opioid consumption during the first 72 hr was seen (110 vs 71 morphine milligram equivalents, P = .02). There was an observed reduction in opioid-related adverse events per patient (1.31 vs 0.83, P &lt; .001) and hospital length of stay (4.6 vs 3.9 days, P = .03) after implementation of the protocol.

CONCLUSION

Implementation of an evidence-based, multimodal analgesia protocol improved postoperative outcomes, including pain scores, opioid consumption, and length of hospital stay, after posterior lumbar spinal fusion.

Are dorsal ramus nerve blocks the solution to postoperative lumbar spine surgery pain?

Background

Open lumbar spine surgery typically results in significant post-operative pain. Most pain protocols promote a multimodal approach aiming to reduce opiate requirements. This case-matched, prospective clinical study aims to establish the efficacy of dorsal ramus nerve root (DRN) blocks for post-operative analgesia.

Methods

We conducted a case-control observational, single centre, prospective study of 15 consecutive patients who had DRN block for a single-level lumbar discectomy or one/two-level lumbar spinal decompression, from Jan 2018 to Jun 2018. These were case matched with a field infiltration group. We analyse for differences in mean and maximum rest pain scores, opiate requirement, mobilisation status and length of stay (LoS).

Results

No differences were seen in pain scores in the first 24 hours post-operation for DRN block vs. field infiltration groups (2.8 vs. 2.7, P=0.90). No reduction in the morphine sulphate equivalents dosage requirement was seen in the DRN group (43.1±46.4 vs. 37.6±33.5, P=0.26). Similar proportions of patients mobilised early (P=1.0) and the mean LoS was 1.7 vs. 1.8 days (P=0.81).

Conclusions

Dorsal ramus nerve block is not superior to local anaesthetic field infiltration of surgical wound in minor one or two level lumbar spinal decompression surgery in terms of alleviating pain, reducing opiate requirements, or facilitating earlier mobilisation and discharge.

Comparative Evaluation of Pregabalin and Clonidine as Preemptive Analgesics for the Attenuation of Postoperative Pain Following Thoracolumbar Spine Surgery

STUDY DESIGN

Prospective, randomized, double blind, placebo-controlled study.

PURPOSE

To compare clonidine and pregabalin with placebo for the attenuation of postoperative pain after thoracolumbar spinal surgery and instrumentation.

OVERVIEW OF LITERATURE

Spine surgery is associated with moderate to severe postoperative pain that needs to be controlled to improve patient's outcome. Alpha 2 agonists (e.g., clonidine) and gabapentenoids (e.g., pregabalin) are successfully used as part of a multimodal analgesic regimen.

METHODS

Total 75 patients were enrolled and randomly allocated into three groups. Group P received pregabalin (150 mg), group C received clonidine (150 mcg), and group N received placebo 90 minutes preoperatively. A standard anesthesia protocol comprising fentanyl, thiopentone, vecuronium, nitrous oxide, and oxygen in isoflurane was used for all patients. Postoperative recovery profile, pain, time for first analgesic, 24-hour analgesic requirement, sedation, and hemodynamic parameters were noted.

RESULTS

Recovery profile was similar in all three groups; however, the patients in group P and C were more sedated (p<0.05). Group N patients had a higher Visual Analog Scale (VAS) score (p<0.05) and the time for first analgesic was also lower (p=0.02). Postoperative (24-hour) analgesic requirement was maximum in group N, followed by that in group C and group P. The VAS score was highest in the control group; however, after 12 hours, it was similar in all groups.

CONCLUSIONS

Postoperative pain and analgesic requirement is significantly attenuated by preoperative administration of a single dose of clonidine (150 mcg) or pregabalin (150 mg); pregabalin was more effective. Thus, their use offers a reasonable strategy for pain management in patients undergoing spine surgery.

Multimodal Analgesia for Perioperative Management of Patients presenting for Spinal Surgery

Multimodal, non-opioid based analgesia has become the cornerstone of ERAS protocols for effective analgesia after spinal surgery. Opioid side effects, dependence and legislation restricting long term opioid use has led to a resurgence in interest in opioid sparing techniques. The increasing array of multimodal opioid sparing analgesics available for spinal surgery targeting novel receptors, transmitters, and altering epigenetics can help provide an optimal perioperative experience with less opioid side effects and long-term dependence. Epigenetic mechanisms of pain may enhance or suppress gene expression, without altering the genome itself. Such mechanisms are complex, dynamic and responsive to environment. Alterations that occur can affect the pathophysiology of pain management at a DNA level, modifying perceived pain relief. In this review, we provide a brief overview of epigenetics of pain, systemic local anesthetics and neuraxial techniques that continue to remain useful for spinal surgery, neuropathic agents, as well as other common and less common target receptors for a truly multimodal approach to perioperative pain management.

Preemptive analgesia after lumbar spine surgery by pregabalin and celecoxib: a prospective study

Objective

To evaluate the preemptive analgesic effect of combination pregabalin with celecoxib for lumbar spine surgery.

Methods

A prospective, randomized study was conducted among 60 lumbar spine surgery patients and divided into two groups. Postoperative pain relief was achieved with intravenous patient-controlled analgesia with morphine. The preemptive analgesia group received oral pregabalin (150 mg) and celecoxib (200 mg) 2 hrs before surgery, and the control group received a placebo. Pain was assessed by visual analogue scale (VAS). Side effects and morphine consumption were monitored until 48 hrs after surgery.

Results

VAS score at rest and during movement was statistically significantly lower in the preemptive analgesia group at most time points (p<0.05). Morphine consumption was significantly lower in the preemptive analgesia group compared with control group in the 24 first hours (29.03±4.38 mg vs 24.43±4.94) and 48 hrs (52.23±9.57 mg vs 44.20±10.21 mg), p<0.05. Hemodynamics, respiratory rate, and SpO₂ were similar for both groups. The sedation score was only statistically significant at H8 time point. The incidence of nausea/vomiting in the preemptive group did not statistically differ from the control group.

Conclusion

Preoperative administration of pregabalin combined with celecoxib had a good preemptive analgesia effect and reduced intravenous morphine consumption after lumbar spine surgery. Side effects were mild and transient.

Comparison of Effects of Hemostatic Gelatin Sponge Impregnated with Ropivacaine versus Normal Saline Applied on the Transverse Process of the Operated Vertebrae on Postoperative Pain in Patients Undergoing Spinal Instrumentation Surgery: A Randomized Clinical Trial

BACKGROUND

Protocols for effective postoperative pain control in patients undergoing spinal surgery are not standardized. In our study, we compared the effects of hemostatic absorbable gelatin sponge impregnated with ropivacaine versus normal saline when applied to the transverse process of the operated vertebrae on the postoperative pain following instrumentation spine surgery.

METHODS

A prospective double-blind randomized study was conducted on 30 patients undergoing spine surgery. At the end of surgery, the hemostatic gelatin sponge was applied by the surgeon on the transverse process of the operated vertebra containing either ropivacaine 0.5% or normal saline NaCl 0.9. Pain was assessed using the visual analog scale (VAS) every 4 hours for 48 hours postoperatively in the 2 groups (ropivacaine vs. normal saline). The total amount of postoperative opioid use was also recorded.

RESULTS

The VAS score was significantly lower in patients receiving hemostatic gelatin sponge impregnated with local anesthetics as compared with patients receiving gelatin sponge impregnated with normal saline 48 hours postoperatively; the mean total dose of meperidine given in the first 48 hours postoperatively was significantly lower (53.5 ± 51.0 mg) in patients receiving gelatin sponge impregnated with local anesthetics as compared with patients receiving hemostatic gelatin sponge impregnated with normal saline (140.5 ± 102 mg).

CONCLUSIONS

Use of intraoperative hemostatic gelatin sponge impregnated with ropivacaine applied on the transverse process of the operated vertebrae intraoperatively resulted in decreasing the postoperative pain in patients undergoing lumbar instrumentation surgery as manifested by the decrease in the VAS score and the total dose of opioids.

Can Liposomal Bupivacaine Be Safely Utilized in Elective Spine Surgery?

STUDY DESIGN

Single-blinded prospective randomized control trial.

OBJECTIVES

To compare the incidence of adverse events (AEs) and hospital length of stay between patients who received liposomal bupivacaine (LB) versus a single saline injection, following posterior lumbar decompression and fusion surgery for degenerative spondylosis.

METHODS

From 2015 to 2016, 59 patients undergoing posterior lumbar decompression and fusion surgery were prospectively enrolled and randomized to receive either 60 mL injection of 266 mg LB or 60 mL of 0.9% sterile saline, intraoperatively. Outcome measures included the incidence of postoperative AEs and hospital length of stay.

RESULTS

The most common AEs in the treatment group were nausea (39.3%), emesis (18.1%), and hypotension (18.1%). Nausea (23%), constipation (19.2%), and urinary retention (15.3%) were most common in the control group. Patients who received LB had an increased risk of developing nausea (relative risk [RR] = 1.7; 95% confidence interval [CI] = 0.75-3.8), emesis (RR = 2.3; 95% CI = 0.51-10.7), and headaches (RR = 2.36; 95% CI = 0.26-21.4). Patients receiving LB had a decreased risk of developing constipation (RR = 0.78; 95% CI = 0.25-2.43), urinary retention (RR = 0.78; 95% CI = 0.21-2.85), and pruritus (RR = 0.78; 95% = 0.21-2.8) postoperatively. Relative risk values mentioned above failed to reach statistical significance. No significant difference in the hospital length of stay between both groups was found (3.9 vs 3.9 days; P = .92).

CONCLUSION

Single-dose injections of LB to the surgical site prior to wound closure did not significantly increase or decrease the incidence or risk of developing AEs postoperatively. Furthermore, no significant difference was found in the hospital length of stay between both groups.

Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study

BACKGROUND

Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsal-ventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery.

METHODS

Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n = 30) received ultrasound-guided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n = 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patient-controlled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated.

RESULTS

Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 ± 73.27 mg and 268.33 ± 71.44 mg; P < 0.001, respectively) and the difference was 28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group.

CONCLUSIONS

ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.

Intraoperative ketamine may increase risk of post-operative delirium after complex spinal fusion for adult deformity correction

BACKGROUND

For complex surgery, intraoperative ketamine administration is readily used to reduce post-operative pain. However, there have been a few studies suggesting that intraoperative ketamine may have deleterious effects and impact post-operative delirium. Therefore, we sought to identify the impact that intraoperative ketamine has on post-operative outcomes after complex spinal surgery involving ≥5 level fusions.

METHODS

The medical records of 138 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 98 (71.0%) who had intraoperative ketamine administration and 40 (29%) who did not (Ketamine-Use: n=98; No-Ketamine: n=40). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative delirium. A multivariate nominal-logistic regression analysis was used to determine the independent association between intraoperative ketamine and post-operative delirium.

RESULTS

Patient demographics and comorbidities were similar between both cohorts, including age, gender, and BMI. The median number of fusion levels operated, length of surgery, estimated blood loss, and proportion of patients requiring blood transfusions were similar between both cohorts. Postoperative complication profile was similar between the cohorts, except for the Ketamine-Use cohort having significantly higher proportion of patients experiencing delirium (Ketamine-Use: 14.3% vs. No-Ketamine: 2.6%, P=0.047). In a multivariate nominal-logistic regression analysis, intraoperative Ketamine-Use was independently associated with post-operative delirium (OR: 9.475, 95% CI: 1.026-87.508, P=0.047).

CONCLUSIONS

Our study suggests that the intraoperative use of ketamine may increase the risk of post-operative delirium. Further studies are necessary to understand the physiological effect intraoperative ketamine has on patients undergoing complex spinal fusions in order to better overall patient care and reduce healthcare resources.

Lumbar erector spinae plane block: Successful control of acute pain after lumbar spine surgery - A clinical report

We report the successful clinical case of a patient scheduled for lumbar spine surgery in which we performed a bilateral single-shot erector spinae plane block as part of a multimodal analgesic strategy for pain control. Performing the block preoperatively dismissed the need for extra intraoperative opioids other than those for intubation, and enabled the use of paracetamol for analgesia only. Further, there was no need for hypotensive techniques, as the block provided satisfactory sympathetic blockade and regional vasodilation with a clear surgical field. Postoperatively, the patient had minor opioid consumption and was able to freely move without any motor impairment or pain from early on in the Post Anaesthesia Care Unit. The use of single-shot erector spinae plane block at the lumbar level for lumbar spine surgery analgesia emphasises its wide application and analgesic efficacy.

Spinal Cord Stimulation for Acute Pain Following Surgery for Cervical Myelopathy: A Novel Treatment Strategy

BACKGROUND

Chronic pain syndromes caused by degenerative and postinfectious changes in the cervical spine continue to pose significant management challenges to neurosurgeons and pain practitioners. The identification of an individualized treatment plan, astute surgical technique, comprehensive and multimodal analgesia, and adequate rehabilitation processes do not necessarily result in diminished pain.

CASE SUMMARY

We present the case of a patient with chronic pain treated surgically for degenerative cervical myelopathy secondary to cervical spinal stenosis. Following this surgery, the patient experienced an intractable postoperative pain syndrome that had anatomical borders, and an intensity and character that were different from the background chronic pain from which he suffered. We successfully implanted a cervical spinal cord stimulation (SCS) lead in the period following his stenosis surgery, which had good therapeutic effect on the postoperative-onset pain. To the best of our knowledge, this is the first description of SCS having a strong positive effect on an acute exacerbation of neuropathic pain. At follow-up 12 months later, assessment of the patient's pain diary revealed a modal pain intensity of 3/10 on the numeric rating scale over the preceding 3 months. The Brief Pain Inventory (Short Form) scores at this time were 10/40 in the pain severity domain and 18/70 in the interference with function domain, demonstrating the long-term effectiveness of this SCS strategy.

CONCLUSION

While SCS has hitherto been untested as a therapy for acute-onset pain, this report demonstrates its utility as a salvage treatment in select cases of uncontrollable postoperative pain.

Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review

Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

Association Between Recombinant Human Bone Morphogenetic Proteins and Postoperative Opioid Use in Lumbar Fusion Procedure Patients: A Propensity Score-Matched Analysis

BACKGROUND

Little is known about the effectiveness of recombinant human bone morphogenetic proteins (rhBMPs) in reducing the demand for opioids after surgery. We investigated the association between rhBMP use and the likelihood of achieving opioid independence and changes in opioid demand in the first postoperative year.

METHODS

Using the Multi-Payer Claims Database from 2007 to 2010, patients aged >20 years who had undergone a degenerative disc disease-indicated lumbar fusion procedure and had had ≥1 opioid prescription in the 3 months before surgery were identified. Propensity score matching (1:1) of rhBMP-exposed and rhBMP-unexposed patients was used to mitigate confounding. The outcomes of interest were opioid independence and decreases in opioid doses in morphine equivalent units, assessed at 3-6 and 9-12 months after the procedure. Logistic regression and analysis of covariance models were used.

RESULTS

The data from 318 patients were analyzed. Most patients were women (61%) and aged <65 years (68%). Few had achieved opioid independence at 3-6 (n = 71; 22.3%) or 9-12 (n = 115; 36.2%) months postoperatively. During the 3-6-month window, the rhBMP group reduced their opioid use rates (estimated mean difference. -28.4 vs. -19.5; P = 0.69) and achieved opioid independence (21.4% vs. 23.3%; odds ratio, 0.92; 95% confidence interval, 0.54-1.56; P = 0.74) at rates that were statistically comparable to their matched comparators. Similar patterns were observed during the 9-12-month window.

CONCLUSION

We found no evidence to suggest that rhBMP use during spinal fusion procedures is associated with either the discontinuation or decrease of opioid analgesic therapy. The continued opioid use after surgery warrants further clinical and research attention.

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

Background

Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis.

Methods

Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay.

Results

LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline.

Conclusions

In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations.

Level of Evidence

2.

Experiências de adolescentes e suas famílias a curto prazo após cirurgia para correção de escoliose

Resumo Objetivo O estudo foi realizado para revelar vivências de adolescentes e suas famílias a curto prazo após a cirurgia para correção de escoliose. Métodos Este estudo teve um delineamento descritivo qualitativo, e os dados foram coletados de adolescentes com história de cirurgia para correção de escoliose (n=17) e seus familiares (n=9), através de entrevistas em profundidade. Os dados assim obtidos foram analisados usando análise de conteúdo. Resultados Surgiram cinco temas principais: queixas físicas, ambiente desconhecido (centro cirúrgico e unidade de terapia intensiva), mudanças emocionais, querendo que seus pais fiquem com eles e preocupações com o futuro. Tanto os adolescentes como seus familiares relataram que os adolescentes experimentaram não só problemas físicos e emocionais mas também preocupações com o futuro após a cirurgia. Conclusão Os enfermeiros devem ficar junto com os adolescentes e suas famílias e permitir que eles expressem seus sentimentos antes da cirurgia. É importante informá-los antes da cirurgia para aliviar sua ansiedade e melhorar a adaptação. Criar um ambiente adequado em salas de recuperação e unidades de terapia intensiva, onde os adolescentes podem frequentemente ver seus pais, pode ajudá-los a ter um psiquismo melhor. Além disso, programas educacionais devem ser propostos para serem oferecidos no momento da alta e métodos interativos devem ser usados para permitir que eles compartilhem seus pensamentos sobre o futuro.

Predictors of Long-term Opioid Use Following Lumbar Fusion Surgery

STUDY DESIGN

A population-based retrospective cohort study.

OBJECTIVE

The aim of this study was to examine risk factors for long-term opioid use following lumbar spinal fusion surgery in a nationally representative cohort of commercially insured adults.

SUMMARY OF BACKGROUND DATA

Opioid prescription rates for the management of low back pain have more than doubled in the US over the past decade. Although opioids are commonly used for the management of pain following lumbar spinal fusion surgery, to date, no large-scale nationally representative studies have examined the risk factors for long-term opioid use following such surgical intervention.

METHODS

Using one of the nation's largest commercial insurance databases, we conducted a retrospective cohort study of 8377 adults, aged 21 to 63 years, who underwent lumbar spinal fusion surgery between January 1, 2009, and December 31, 2012. Long-term opioid use was defined as ≥365 days of filled opioid prescriptions in the 24 months following lumbar fusion. Multivariable logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals for the risk of long-term opioid use following lumbar fusion.

RESULTS

After adjusting for covariates, the following factors were associated with an increased risk of long-term opioid use following surgery: duration of opioid use in the year before lumbar surgery [Referent (0 days); Quartile 1 (1-22 days) OR = 2.27, 95% CI = 1.48-3.49; Quartile 2 (23-72 days): OR = 5.94, 95% CI = 4.00-8.83; Quartile 3: (73-250 days) OR = 25.31, 95% CI = 17.26-37.10; Quartile 4 (≥250 days) OR = 219.95, 95% CI = 148.53-325.71)], refusion surgery (OR = 1.32, 95% CI = 1.02-1.72), and diagnosis of depression (OR = 1.43, 95% CI = 1.18-1.74). Receipt of anterior fusion was associated with a modest decrease in the risk of long-term opioid use (OR = 0.79, 95% CI = 0.63-0.99).

CONCLUSION

These findings may provide clinically relevant information to physicians, patients, and their families regarding the risk factors for opioid dependence following lumbar fusion surgery.

LEVEL OF EVIDENCE

3.

Efficacy and Safety of Transdermal Buprenorphine versus Oral Tramadol/Acetaminophen in Patients with Persistent Postoperative Pain after Spinal Surgery

PURPOSE

Control of persistent pain following spinal surgery is an unmet clinical need. This study compared the efficacy and safety of buprenorphine transdermal system (BTDS) to oral tramadol/acetaminophen (TA) in Korean patients with persistent, moderate pain following spinal surgery.

METHODS

Open-label, interventional, randomized multicenter study. Adults with persistent postoperative pain (Numeric Rating Scale [NRS] ≥ 4 at 14-90 days postsurgery) were enrolled. Patients received once-weekly BTDS (n = 47; 5 μg/h titrated to 20 μg/h) or twice-daily TA (n = 40; tramadol 37.5 mg/acetaminophen 325 mg, one tablet titrated to 4 tablets) for 6 weeks. The study compared pain reduction with BTDS versus TA at week 6. Quality of life (QoL), treatment satisfaction, medication compliance, and adverse events (AEs) were assessed.

FINDINGS

At week 6, both groups reported significant pain reduction (mean NRS change: BTDS -2.02; TA -2.76, both P < 0.0001) and improved QoL (mean EQ-5D index change: BTDS 0.10; TA 0.19, both P < 0.05). The BTDS group achieved better medication compliance (97.8% versus 91.0%). Incidence of AEs (26.1% versus 20.0%) and adverse drug reactions (20.3% versus 16.9%) were comparable between groups.

IMPLICATIONS

For patients with persistent pain following spinal surgery, BTDS is an alternative to TA for reducing pain and supports medication compliance. This trial is registered with Clinicaltrials.gov: NCT01983111.

Prolonged Analgesic Effect of PRF-108 and PRF-110 on Post-operative Pain in Pigs

INTRODUCTION

Local anesthetic infusion techniques have been reported to reduce opiate requirements and pain scores following different kinds of surgery, including orthopedic surgery, inguinal hernia, and Cesarean surgery in women.

METHODS

PRF-108 and PRF-110 formulations were applied to the wound space in an incisional model in pigs to test the hypothesis that these formulations have better and longer analgesic effects than the commercially available ropivacaine solution (Naropin(®), AstraZeneca).

RESULTS

The data show significantly better analgesic activity with PRF-108 and PRF-110 compared to ropivacaine. The duration of the analgesic efficacy of PRF-108 and PRF-110 was at least five times longer than that was measured following treatment with ropivacaine. The data further suggest that active clearance from the injection site (the wound) is much slower for PRF-108 and PRF-110 than for the commercial ropivacaine solution.

CONCLUSION

Assessing the local concentration of PRF compounds and commercially available ropivacaine solution suggests that active clearance from the injection site (the wound) is much slower for PRF-108 and PRF-110 than for ropivacaine.

FUNDING

PainReform.

Does continuous wound infiltration enhance baseline intravenous multimodal analgesia after posterior spinal fusion surgery? A randomized, double-blinded, placebo-controlled study

PURPOSE

There has been a growing interest in continuous local anaesthetic wound infiltration as a non-opioid technique for postoperative pain relief. The impact of this modality on baseline analgesia after spinal fusion surgery has however been inconclusive. We tested whether continuous wound infiltration with ropivacaine can enhance postoperative analgesia compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.

METHODS

In this randomized, double-blinded, placebo-controlled study, a multiholed 19-gauge catheter was placed at the end of the surgical procedure through the wound to permit the continuous administration (8 ml/h) of ropivacaine 0.2 % (ropivacaine group; n = 19 patients) or saline (control group; n = 20 patients) during the first 48 postoperative hours (H48). Both groups received intraoperative low-dose ketamine, a combination of acetaminophen, non-steroidal anti-inflammatory drug, and nefopam over the same postoperative period, and morphine delivered by a patient-controlled analgesia (PCA) device.

RESULTS

Morphine consumption was comparable between the two groups both at H48, 38 mg (26:52) (median, 25th:75th percentile) (control group) versus 43 mg (19:74) (ropivacaine group), and at H24, 18 mg (16:22) versus 22 mg (9:35) respectively. Pain scores at rest and during mobilization, quality of postoperative sleep, and morphine-related side effects were comparable between the two groups at H24 and H48.

CONCLUSION

Our findings indicate that no additional analgesia was provided with continuous wound infiltration of ropivacaine compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.

TRIAL REGISTRATION

Clinicaltrials.gov #NCT01743794.