Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes

Postoperative Opioid Consumption Patterns Diverge Between Propensity Matched Patients Undergoing Traumatic and Elective Cervical Spine Fusion

BACKGROUND CONTEXT

Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated.

PURPOSE

The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery.

STUDY DESIGN

Retrospective cohort study PATIENT SAMPLE: Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF.

OUTCOME MEASURES

Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day.

METHODS

A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use.

RESULTS

A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs. 0.65, p=0.023) and take more morphine milligram equivalents (MME) per day (0.60 vs. 0.04, p=0.014) within one year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs. 10.4%, p=0.040) and take more MMEs per day (0.70 vs. 0.05, p=0.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs. 52.1%, p<0.001) and took more MMEs per day (3.73 vs. 1.71, p<0.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=0.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate:-1.63 p=0.022).

CONCLUSION

Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

Surgical vs ultrasound-guided lumbar erector spinae plane block for pain management following lumbar spinal fusion surgery

PURPOSE

Spinal surgery is associated with severe diffuse pain in the postoperative period. Effective pain management plays an essential role in reducing morbidity and mortality. This study is designed to compare the ultrasound-guided erector spinae plane (ESP) block and surgical infiltrative ESP block for postoperative analgesia management after lumbar spinal fusion surgery.

METHODS

The patients who underwent two or three levels of posterior lumbar spinal fusion surgery were randomly allocated into one of three groups with 30 patients each (Group SE = Surgical ESP block; Group UE = ultrasound-guided ESP block; Group C = Controls). The primary aim was to compare postoperative opioid consumption, and the secondary aim was to evaluate postoperative dynamic and static pain scores and the incidence of opioid-related adverse effects.

RESULTS

There was a significant difference in terms of opioid consumption, rescue analgesia on demand, and both static and dynamic pain scores between groups at all time periods (p < 0.05). Group SE and Group UE had lower pain scores and consumed fewer opioids than the controls (p < 0.05). However, the Group UE had lower pain scores and opioid consumption than the Group SE. The sedation level of patients was significantly higher in the control group than in the other two groups. Also, nausea was more common in controls than in the other groups.

CONCLUSION

While both surgical and ultrasound-guided ESP blocks reduced opioid consumption compared to the controls, the patients who received ultrasound-guided ESP blocks experienced better postsurgical pain relief than those in the other groups (surgical ESP and controls).

Postoperative pain and pain management following selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that reduces lower limb spasticity, performed in some children with spastic diplegic cerebral palsy. Effective pain management after SDR is essential for early rehabilitation. This study aimed to describe the anaesthetic and early pain management, pain and adverse events in children following SDR.

METHODS

This was a retrospective cohort study. Participants were all children who underwent SDR at a single Australian tertiary hospital between 2010 and 2020. Electronic medical records of all children identified were reviewed. Data collected included demographic and clinical data (pain scores, key clinical outcomes, adverse events and side effects) and medications used during anaesthesia and postoperative recovery.

RESULTS

22 children (n=8, 36% female) had SDR. The mean (SD) age at surgery was 6 years and 6 months (1 year and 4 months). Common intraoperative medications used were remifentanil (100%), ketamine (95%), paracetamol (91%) and sevoflurane (86%). Postoperatively, all children were prescribed opioid nurse-controlled analgesia (morphine, 36%; fentanyl, 36%; and oxycodone, 18%) and concomitant ketamine infusion. Opioid doses were maximal on the day after surgery. The mean (SD) daily average pain score (Wong-Baker FACES scale) on the day after surgery was 1.4 (0.9), decreasing to 1.0 (0.5) on postoperative day 6 (POD6). Children first attended the physiotherapy gym on median day 7 (POD8, range 7-8). Most children experienced mild side effects or adverse events that were managed conservatively. Common side effects included constipation (n=19), nausea and vomiting (n=18), and pruritus (n=14). No patient required return to theatre, ICU admission or prolonged inpatient stay.

CONCLUSIONS

Most children achieve good pain management following SDR with opioid and ketamine infusions. Adverse events, while common, are typically mild and managed with medication or therapy. This information can be used as a baseline to improve postoperative care and to support families' understanding of SDR before surgery.

The Relationship Between Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity Scores and Early Postoperative Pain and Opioid Consumption After Lumbar Fusion

Background The Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and pain intensity measures quantify separate dimensions of pain from the patient's perspective. This study aimed to assess differences in these outcomes and to evaluate whether baseline PROMIS pain scores could be used as a leading indicator of increased pain and opioid consumption during early recovery after lumbar fusion. Methods A retrospective review of 199 consecutive patients undergoing posterolateral fusion (PLF) at a single institution was performed. All patients underwent one to three level lumbar PLF and preoperatively completed the PROMIS pain intensity and PROMIS pain interference measures. Multivariate linear regression was used to assess the relationship between preoperative PROMIS scores and postoperative pain numeric rating scale (NRS) and oral morphine milligram equivalents (OMME) by day after controlling for age, sex, and body mass index (BMI). Results In comparison to patients with the lowest preoperative pain intensity scores, those with the highest scores required significantly more OMME on postoperative day (POD) zero and one (both p<0.05) and had higher pain NRS on POD one (p=0.02). Patients with the highest pain interference scores reported higher pain NRS on POD zero (p=0.02) but required similar OMME at all time points. After controlling for age, sex, and BMI, each one-point increase in preoperative PROMIS pain interference scores was associated with increased OMME on POD zero (β=0.29, p=0.04) and POD one (β=0.64, p=0.03). Conclusions Patients with high pain intensity reported higher levels of pain and required more opioids during the first 24 hours postoperatively, while those with high pain interference reported higher levels of pain on the day of surgery but utilized similar amounts of opioids. After risk adjustment, increased baseline PROMIS pain interference scores - but not pain intensity - were associated with increased opioid use. These results suggest that both measures should be considered when identifying patients at risk for increased pain and opioid consumption after PLF.

Comparative Study Between Dexmedetomidine with Bupivacaine and Bupivacaine Alone in Erector Spinae Plane Block for Postoperative Pain Control of Posterior Lumbosacral Spine Fixation Surgeries: A Randomized Controlled Trial

Background

As posterior lumbosacral spine fixation surgeries are common spine procedures done nowadays due to different causes and mostly accompanied with moderate-to-severe postoperative pain, so should find effective postoperative analgesia for these patients. This study aimed to observe analgesic effect of dexmedetomidine combined with bupivacaine versus bupivacaine alone for erector spinae plane block ESPB for postoperative pain control of posterior lumbosacral spine fixation surgeries.

Methods

Double-blind randomized controlled study including 90 patients who were randomly allocated into 3 groups (30 patients for each): Dexmedetomidine combined with bupivacaine (DB group), bupivacaine (B group), and saline (control) (S group). US-guided ESPB was performed preoperatively bilaterally in all patients of the 3 groups. All patients received intravenous patient-controlled postoperative analgesia with morphine and 1 gm intravenous paracetamol every 8 hours. Primary clinical outcomes were active (while mobilization) and passive (at rest) visual analog scale (VAS) pain score at first 24 hours measured every 2 hours, opioid consumption (number of PCA presses), and need for rescue analgesia. Other clinical outcomes included active and passive VAS pain score at second 24 hours, measured every 4 hours, opioid consumption, need for rescue analgesia, postoperative opioid side effects, and intraoperative dexmedetomidine side effects as bradycardia and hypotension.

Results

Active and passive VAS pain scores, postoperative opioid consumption, need for rescue analgesia, and postoperative opioid side effects were significantly lower in DB group when compared to other groups (B and S groups). There were no additional intraoperative dexmedetomidine side effects as bradycardia and hypotension. The estimated effect-size r was -0.58 and Cohen's d was -1.46.

Conclusion

Addition of dexmedetomidine to bupivacaine 0.25% in ESPB for postoperative pain control in patients of posterior lumbosacral spine fixation surgeries resulted in lower active and passive VAS pain scores, decreased postoperative opioid consumption, need for rescue analgesia and postoperative opioid side effects without additional intraoperative dexmedetomidine side effects.

Clinicaltrialsgov Identifier

NCT05590234.

Postoperative analgesic options after spine surgery: finding the optimal treatment strategies

INTRODUCTION

Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes.

AREAS COVERED

This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques.

EXPERT OPINION

Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.

Gabapentin as part of a multimodal pain protocol for selective dorsal rhizotomy does not impact percentage of rootlets transected

PURPOSE

We aim to determine whether preoperatively initiated gabapentin for pain control impacts the percentage of rootlets cut during monitored, limited laminectomy selective dorsal rhizotomy (SDR) procedure.

METHODS

This retrospective cohort study includes participants with cerebral palsy who had SDR for treatment of spasticity between 2010 and 2019 at a single-institution tertiary care center. One-level laminectomy SDR aimed to evaluate the cauda equina roots from levels L2-S1 with EMG monitoring. Gabapentin titration began 3 weeks prior to SDR. Data was analyzed using simple linear regression. Thirty-one individuals met inclusion criteria. Mean age was 7 years, 4 months. Eighteen participants (58%) identified as male, 12 (39%) female, and one (3%) non-binary. Thirty (97%) had bilateral CP. Sixteen (52%) were GMFCS II, four (13%) GMFCS III, five (16%) GMFCS IV, and six (19%) GMFCS V.

RESULTS

Mean percentage of rootlets transected was 50.75% (SD 6.00, range 36.36-60.87). There was no relationship between the dose of gabapentin at time of SDR and percentage of rootlets cut with a linear regression slope of - 0.090 and an R2 of 0.012 (P = 0.56).

CONCLUSION

Results indicate that preoperative initiation of gabapentin did not impact the percentage of rootlets transected. Thus, gabapentin can be initiated prior to SDR at moderate dosages without impacting SDR surgical outcomes.

Immediate Postoperative Zolpidem Use Increases Risk of Falls and Implant Complication Rates Following Total Hip Arthroplasty: A Retrospective Case-Control Analysis

BACKGROUND

Zolpidem is the most widely used hypnotic in the United States and has known side effects. However, the morbidity of zolpidem use following total hip arthroplasty (THA) is not well-defined. Thus, the aim of this study was to assess the effects that zolpidem use has on medical and implant complications, falls, lengths of stay, and medical utilizations following THA.

METHODS

A retrospective query of a nationwide insurance claims database was conducted from 2010 to 2020. All cases of THA and hypnotic use were identified using procedural and national drug codes. Patients who were prescribed zolpidem within 90 days of surgery were matched to hypnotic naive patients 1:5 based on demographic and comorbidity profiles. The 90-day medical complications, falls, fragility fractures, costs, and readmission rates, as well as 2-year implant complications were compared between cohorts. A total of 50,328 zolpidem patients were matched to 251,286 hypnotic naive patients.

RESULTS

The zolpidem group had significantly higher rates of medical complications, falls, and fragility fractures when compared to the hypnotic-naive group. The zolpidem group had significantly higher rates of dislocation, mechanical loosening, and periprosthetic fracture. Likewise, healthcare utilization was significantly greater in the zolpidem group.

CONCLUSION

Zolpidem use following THA is associated with significant risk of medical and implant complications, as well as fall risks, increased costs, lengths of stay, and readmissions. The findings of this study may affect discussions between orthopaedic surgeons and their patients on the benefits of sleep quality in their recovery versus the incurred risks of zolpidem use.

LEVEL OF EVIDENCE

III, retrospective case-control study.

Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial

BACKGROUND

Postoperative pain after laminoplasty and laminectomy occurs partially from local trauma of the paraspinal tissue. Finding a multimodal analgesic cocktail to enhance the duration and effect of local infiltration analgesia is crucial. Because of the rapid onset and long duration of action of betamethasone, the authors hypothesized that, a pre-emptive multimodal infiltration regimen of betamethasone and ropivacaine reduces pain scores and opioid demand, and improves patient satisfaction following laminoplasty and laminectomy.

MATERIALS AND METHODS

This prospective, randomized, open-label, blinded endpoint study was conducted between 1 September 2021 and 3 June 2022, and included patients between the ages of 18 and 64 scheduled for elective laminoplasty or laminectomy under general anesthesia, with American Society of Anesthesiologists classification I/II. One hundred sixteen patients were randomly assigned to either the BR (Betamethasone-Ropivacaine) group or the R (Ropivacaine) group in a 1:1 ratio. Each group received pre-emptive infiltration of a total of 10 ml study solution into each level. Every 30 ml of study solution composed of 0.5 ml of betamethasone plus 14.5 ml of saline and 15 ml of 1% ropivacaine for the BR group, and 15 ml of 1% ropivacaine added to 15 ml of saline for the R group. Infiltration of epidural space and intrathecal space were avoided and the spinous process, transverse process, facet joints, and lamina were injected, along with paravertebral muscles and subcutaneous tissue. Cumulative 48 h postoperative butorphanol consumption via PCA (Patient-controlled analgesia) was the primary outcome. Intention-to-treat (ITT) principle was used for primary analysis.

RESULTS

Baseline characteristics were identical in both groups ( P >0.05). The cumulative 48 h postoperative butorphanol consumption via PCA was 3.0±1.4 mg in the BR group ( n =58), and 7.1±1.2 mg in the R group ( n =58) ( P <0.001). Overall cumulative opioid demand was lower at different time intervals in the BR group ( P <0.001), along with the estimated median time of first analgesia demand via PCA (3.3 h in the BR group and 1.6 h in the R group). The visual analog scale (VAS) score at movement and rest were also significantly lower until 3 months and 6 weeks, respectively. No side effects or adverse events associated with the intervention were observed in this study.

CONCLUSIONS

Pre-emptive analgesia with betamethasone and ropivacaine provides better postoperative pain management following laminoplasty and laminectomy, compared to ropivacaine alone. This is an effective technique worthy of further evaluation.

Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion

STUDY DESIGN

Retrospective, single-center, cohort study.

OBJECTIVE

Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration.

SUMMARY OF BACKGROUND DATA

Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting.

METHODS

Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics.

RESULTS

The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ).

CONCLUSION

Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.

Efficacy and safety of perioperative use of non-steroidal anti-inflammatory drugs for preemptive analgesia in lumbar spine surgery: a systematic review and meta-analysis

OBJECTIVE

Lumbar spine disorders have become an increasingly common health problem in recent years. Modern clinical studies have shown that perioperative analgesia at certain doses can reduce postoperative pain by inhibiting the process of peripheral sensitization and central sensitization, which is also known as "preemptive analgesia," Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of drugs that achieve antipyretic and analgesic effects by inhibiting cyclooxygenase (COX) and affecting the production of prostaglandins. Our meta-analysis aimed to assess the efficacy and safety of perioperative preemptive analgesia with non-steroidal anti-inflammatory drugs in patients with lumbar spine surgery.

METHODS

We searched PubMed, ScienceDirect, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that met the inclusion criteria. A total of 12 clinical studies were included to assess the efficacy and safety of perioperative NSAIDs preemptive analgesia for lumbar spine surgery.

RESULT

Twelve studies, including 845 patients, met the inclusion criteria. The results showed that perioperative receipt of NSAIDs for preemptive analgesia was effective and safe. Patient's postoperative morphine consumption (P < 0.05), visual analog scale (P < 0.05), and numerical rating scale (P < 0.05) were not statistically associated with postoperative complications (P > 0.05).

CONCLUSION

Our findings suggest that NSAIDs are effective and safe for preemptive analgesia in the perioperative period of lumbar spine surgery and that more and better quality RCTs and more in-depth studies of pain mechanics are still needed.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

Comparative Analysis of Inpatient Opioid Consumption Between Different Surgical Approaches Following Single Level Lumbar Spinal Fusion Surgery

STUDY DESIGN

Single-center retrospective cohort study.

OBJECTIVES

To evaluate inpatient MME administration associated with different lumbar spinal fusion surgeries.

METHODS

Patients ≥18 years of age with a diagnosis of Grade I or II spondylolisthesis, stenosis, degenerative disc disease or pars defect who underwent one-level Transforaminal Lumbar Interbody Fusion (TLIF) or one-level Anterior Lumbar Interbody Fusion (ALIF) or Lateral Lumbar Interbody Fusion (LLIF) through traditional MIS, anterior-posterior position or single position approaches between L2-S1. Outcome measures included patient demographics, surgical procedure and approach, perioperative clinical characteristics, incidence of ileus and inpatient MME. Statistical analysis included one-way ANOVA with a post-hoc Tukey Test and Kruskal-Wallis Test with post-hoc Mann-Whitney test. MME was calculated as per the Centers for Medicare and Medicaid Services and previous literature. Significance set at P < .05.

RESULTS

Mean age differed significantly between MIS TLIF (55.6 ± 12.5 years) and all other groups (Open TLIF 57.1 ± 12.5, SP ALIF/LLIF 57.9 ± 9.9, TP ALIF/LLIF 50.9 ± 12.7, Open ALIF/LLIF 58.4 ± 15.5). MIS TLIF had the shortest LOS compared to all groups except SP ALIF/LLIF. Total MME was significantly different between MIS TLIF and Open ALIF/LLIF (172.5 MME vs 261.1 MME, P = .044) as well as MIS TLIF and TP ALIF/LLIF (172.5 MME vs 245.4 MME, P = .009). There were no significant differences in MME/hour and incidence of ileus between all groups.

CONCLUSION

Patients undergoing MIS TLIF had lower inpatient opioid intake compared to TP and SP ALIF/LLIF, as well as shorter LOS compared to all groups except SP ALIF/LLIF. Thus, it appears that the advantages of minimally invasive surgery are seen in minimally invasive TLIFs.

Perioperative Pain Management for Distal Radius Fractures

Distal radius fractures have a high incidence among both young and elderly patients, and in many instances require operative intervention. When operative intervention is employed, adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence. Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies.

Dexamethasone Plus Bupivacaine Versus Bupivacaine in Bilateral Transincisional Paravertebral Block in Lumbar Spine Surgeries: A Randomized Controlled Trial

OBJECTIVES

Few studies examined the analgesic effects of dexamethasone in lumbar paravertebral block, specifically the transincisional approach. This study aimed to compare dexamethasone with bupivacaine versus bupivacaine alone for bilateral transincisional paravertebral block (TiPVB) for postoperative analgesia in lumbar spine surgeries.

MATERIALS AND METHODS

Fifty patients who were aged 20 to 60 years and had American Society of Anesthesiologists Physical Status (ASA-PS) I or II of either sex were randomly allocated into 2 equal groups. Both groups received combined general anesthesia and bilateral lumbar TiPVB. However, in group 1 (dexamethasone group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL containing 4 mg of dexamethasone on each side, while, in group 2 (control group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL of saline on each side. Time to first analgesic need was the primary outcome, while total opioid consumption during the first 24 hours after surgery, the Visual Analog Scale for pain perception (0-10), and the incidence of side effects were secondary outcomes.

RESULTS

The mean time to the first analgesic requirement was significantly prolonged among patients in the dexamethasone group than the control group (mean±SD: 18.4±0.8 vs. 8.7±1.2 h, respectively) ( P <0.001). Patients in the dexamethasone group had lower total opiates consumption than the control) P <0.001). Although nonsignificant, the incidence of postoperative nausea and vomiting was more frequent among the control group ( P =0.145).

DISCUSSION

Adding dexamethasone to bupivacaine in TiPVB resulted in a prolonged analgesia-free period and lower opioid consumption in lumbar spine surgeries with comparable incidence of adverse events.

Chronic pain after spine surgery: Insights into pathogenesis, new treatment, and preventive therapy

Chronic pain after spine surgery (CPSS) is often characterized by intractable low back pain and/or radiating leg pain, and has been reported in 8-40% of patients that received lumbar spine surgery. We conducted a literature search of PubMed, MEDLINE/OVID with a focus on studies about the etiology and treatments of CPSS and low back pain. Our aim was to provide a narrative review that would help us better understand the pathogenesis and current treatment options for CPSS. This knowledge will aid in the development of optimal strategies for managing postoperative pain symptoms and potentially curing the underlying etiologies. Firstly, we reviewed recent advances in the mechanistic study of CPSS, illustrated both structural (e.g., fibrosis and scaring) and non-structural factors (e.g., inflammation, neuronal sensitization, glial activation, psychological factor) causing CPSS, and highlighted those having not been given sufficient attention as the etiology of CPSS. Secondly, we summarized clinical evidence and therapeutic perspectives of CPSS. We also presented new insights about the treatments and etiology of CPSS, in order to raise awareness of medical staff in the identification and management of this complex painful disease. Finally, we discussed potential new targets for clinical interventions of CPSS and future perspectives of mechanistic and translational research. CPSS patients often have a mixed etiology. By reviewing recent findings, the authors advocate that clinicians shall comprehensively evaluate each case to formulate a patient-specific and multi-modal pain treatment, and importantly, consider an early intraoperative intervention that may decrease the risk or even prevent the onset of CPSS.

Translational potential statement

CPSS remains difficult to treat. This review broadens our understanding of clinical therapies and underlying mechanisms of CPSS, and provides new insights which will aid in the development of novel mechanism-based therapies for not only managing the established pain symptoms but also preventing the development of CPSS.

Assessment of adequacy and appropriateness of pain management practice among trauma patients at the Ethiopian Aabet Hospital: A prospective observational study

INTRODUCTION

Pain is unpleasant sensory and emotional experiences associated with actual and/or potential tissue damage. It is the most common and prevalent reason for emergency departments (ED) visits with prevalence over 70% in the world.

AIM OF THE STUDY

The study aimed to assess the adequacy and appropriateness of pain management at Aabet Hospital, Addis Ababa, Ethiopia.

METHODS

A hospital-based prospective cross-sectional study was conducted at Aabet hospital from December 1, 2020 to March 30, 2021. Adult trauma patients having pain (at least score 1 on Numeric Rating Scale) with Glasgow Coma Scale score > 13 were eligible to participate in the study. The pain intensity was evaluated at the time of admission (o minute) and then at 60, 120, 180, and 240 minutes. The time of the first analgesics was registered. The adequacy and the appropriateness of the pain management were calculated through pain management index (PMI).

RESULTS

Two hundred thirty-two (232) participants were included in this study of which 126 (54.3%) were admitted due to road traffic accident followed by fall 44(19%). Only 21 (9.1%) study participants received the first analgesic treatment within 30 minutes while 27(11.6%) participants had no treatment at all within 240 minutes. The mean pain intensity score at admission was 5.55 ± 2.32 and reduced to 4.09 ± 2.69. Nearly half 110 (47.4%) of the study participants were treated inadequately (PMI (-) score). There was a weak and negative correlation between PMI and time to analgesia (r = - .159, p = 0.0001). The type of analgesia used, the time to analgesia, and the degree of pain may predict 65% of the variance in PMI score (R2 = 0.65, P = .001).

CONCLUSION

From the results of this study, it can be concluded that acute pain in trauma patients was under and inappropriately treated.

Utility of Ultrasound-Guided Erector Spinae Plane Blocks for Postoperative Pain Management Following Thoracolumbar Spinal Fusion Surgery

Purpose

The primary objective of this study is to determine if ultrasound-guided erector spinae plane blocks (ESPB) prior to thoracolumbar spinal fusion reduces opioid consumption in the first 24 hours postoperatively. Secondary objectives include ESPB effects on administration of opioids, utilization of intravenous patient-controlled analgesia (IV-PCA), pain scores, length of stay, and opioid related side effects.

Methods

A retrospective cohort analysis was performed on consecutive, adult patients undergoing primary thoracolumbar fusion procedures. Demographic and baseline characteristics including diagnoses of chronic pain, anxiety, depression, and preoperative use of opioids were collected. Surgical data included surgical levels, opioid administration, and duration. Postoperative data included pain scores, opioid consumption, IV-PCA duration, opioid-related side effects, ESPB-related complications, and length of stay (LOS). Statistical analysis was performed using chi-squared and t-test analyses, multivariable analysis, and covariate adjustment with propensity score.

Results

A total of 118 consecutive primary thoracolumbar fusions were identified between October 2019 and December 2021 (70 ESPB, 48 no-block [NB]). There were no significant demographic or surgical differences between groups. Median surgical time (262.50 mins vs 332.50 mins, p = 0.04), median intraoperative opioid consumption (8.11 OME vs 1.73 OME, p = 0.01), and median LOS (152.00 hrs vs 128.50 hrs, p = 0.01) were significantly reduced in the ESPB group. Using multivariable covariate adjustment with propensity score analysis only intraoperative opioid administration was found to be significantly less in the ESPB cohort.

Conclusion

ESPB for thoracolumbar fusion can be performed safely in index cases. There was a reduction of intraoperative opioid administration in the ESPB group, however the care team was not blinded to the intervention. Extensive thoracolumbar spinal fusion surgery may require a different approach to regional anesthesia to be similarly effective as ESPB in isolated lumbar surgeries.

Economic Trends in Commonly Used Drugs for Spinal Fusion and Brain Tumor Resection: An Analysis of the Medicare Part D Database

With the incidence of central and peripheral nervous system disorders on the rise, neurosurgical procedures paired with the careful administration of select medications have become necessary to optimize patient outcomes. Despite efforts to decrease the over-prescription of common addictive drugs, such as opioids, prescription costs continue to rise. This study analyzed temporal trends in medication use and cost for spinal fusion and brain tumor resection procedures. The Medicare Part B Database was queried from 2016 to 2020 for data regarding spinal fusion and brain tumor resection procedures, while the Part D Database was used to extract data for two commonly prescribed medications for each procedure. Pearson's correlation coefficient and linear regression were completed for the analyzed variables. The results showed a significant negative correlation between the number of spinal procedure beneficiaries and the cost of methocarbamol, as well as between the annual percent change in spinal beneficiaries and the annual percent change in oxycodone cost. Linear regression revealed that oxycodone cost was the only parameter with a statistically significant model. Moving forward, it is imperative to combat rising drug costs, regardless of trends seen in their usage. Further studies should focus on the utilization of primary data in a multi-center study.

Perioperative Factors Associated With Chronic Opioid Use After Spine Surgery

STUDY DESIGN

Retrospective case control.

OBJECTIVES

The purpose of the current study is to determine risk factors associated with chronic opioid use after spine surgery.

METHODS

In our single institution retrospective study, 1,299 patients undergoing elective spine surgery at a tertiary academic medical center between January 2010 and August 2017 were enrolled into a prospectively collected registry. Patients were dichotomized based on renewal of, or active opioid prescription at 3-mo and 12-mo postoperatively. The primary outcome measures were risk factors for opioid renewal 3-months and 12-months postoperatively. These primarily included demographic characteristics, operative variables, and in-hospital opioid consumption via morphine milligram equivalence (MME). At the 3-month and 12-month periods, we analyzed the aforementioned covariates with multivariate followed by bivariate regression analyses.

RESULTS

Multivariate and bivariate analyses revealed that script renewal at 3 months was associated with black race (P = 0.001), preoperative narcotic (P < 0.001) or anxiety/depression medication use (P = 0.002), and intraoperative long lumbar (P < 0.001) or thoracic spine surgery (P < 0.001). Lower patient income was also a risk factor for script renewal (P = 0.01). Script renewal at 12 months was associated with younger age (P = 0.006), preoperative narcotics use (P = 0.001), and ≥4 levels of lumbar fusion (P < 0.001). Renewals at 3-mo and 12-mo had no association with MME given during the hospital stay or with the usage of PCA (P > 0.05).

CONCLUSION

The current study describes multiple patient-level factors associated with chronic opioid use. Notably, no metric of perioperative opioid utilization was directly associated with chronic opioid use after multivariate analysis.

Republication of "How Will the Foot and Ankle Orthopedic Community Respond to the Growing Opioid Epidemic?"

In the midst of the current opioid crisis, it has become critically important to properly manage opioid-prescribing patterns for the treatment of postoperative pain. There is currently a scarcity of literature specifying prescription and consumption patterns following orthopedic surgery and specifically foot and ankle surgery. Clinical guidelines for postoperative pain management are deficient.

Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions

BACKGROUND

As the literature grows on opioid use, the impact of simultaneous cannabis use has hitherto been mostly unexplored. In this study, we assessed the effects of cannabis use on postoperative opioid utilization in opioid-naive patients undergoing single level fusions of the lumbar spine.

METHODS

Using an all-payer claims database, the medical records of 91 million patients were analyzed to identify patients who had undergone single level lumbar fusions between January 2010 and October 2020. Rates of opioid utilization at 6 months following index procedure (morphine milligram equivalents/day), the development of opioid use disorder (OUD), and the rates of opioid overuse were assessed.

RESULTS

Following examination of 87,958 patient records, 454 patients were matched and distributed equally into cannabis user and noncannabis user cohorts. At 6 months following index procedure, cannabis users were equal to nonusers in their rates of prescribed opioid utilization (49.78%, P > 0.99). Cannabis users used smaller daily dosages compared to nonusers (51.1 ± 35.05 vs. 59.72 ± 41, P = 0.003). On the other hand, the proportion of patients diagnosed with OUD was found to be significantly higher among patients using cannabis (18.94% vs. 3.96%, P < 0.0001).

CONCLUSIONS

Compared to noncannabis users, opioid-naive patients who are cannabis users undergoing lumbar spinal fusions are at a higher risk of developing opioid dependence following surgery, despite having decreased daily dosages of opioids overall. Further studies should explore the factors associated with the development of OUD and the details of concurrent marijuana use to effectively treat pain while limiting the potential for abuse.

Pregabalin as an effective treatment for acute postoperative pain following spinal surgery without major side effects: protocol for a prospective, randomized controlled, double-blinded trial

BACKGROUND

Patients experience considerable postoperative pain after spinal surgery. As the spine is located at the centre of the body and supports body weight, severe postoperative pain hinders upper body elevation and gait which can lead to various complications, including pulmonary deterioration and pressure sores. It is important to effectively control postoperative pain to prevent such complications. Gabapentinoids are widely used as preemptive multimodal analgesia, but their effects and side effects are dose-dependent. This study was designed to examine the efficacy and side effects of varying doses of postoperative pregabalin for the treatment of postoperative pain after spinal surgery.

METHODS

This is a prospective, randomized controlled, double-blind study. A total of 132 participants will be randomly assigned to the placebo (n = 33) group or to the pregabalin 25 mg (n = 33), 50 mg (n = 33), or 75 mg (n = 33) groups. Each participant will be administered placebo or pregabalin once prior to surgery and every 12 h after surgery for 72 h. The primary outcome will be the visual analogue scale pain score, total dose of administered intravenous patient-controlled analgesia, and frequency of rescue analgesic administered for 72 h from arrival to the general ward after surgery, subdivided into four periods: 1-6 h, 6-24 h, 24-48 h, and 48-72 h. The secondary outcomes will be the incidence and frequency of nausea and vomiting due to intravenous patient-controlled analgesia. Safety will be assessed by monitoring the occurrence of side effects such as sedation, dizziness, headache, visual disturbance, and swelling.

DISCUSSION

Pregabalin is already widely used as preemptive analgesia and, unlike nonsteroidal anti-inflammatory drugs, is not associated with a risk of nonunion after spinal surgery. A recent meta-analysis demonstrated the analgesic efficacy and opioid-sparing effect of gabapentinoids with significantly decreased risks of nausea, vomiting, and pruritus. This study will provide evidence for the optimal dosage of pregabalin for the treatment of postoperative pain after spinal surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05478382. Registered on 26 July 2022.

A double-blinded, placebo-controlled, randomized study to evaluate the efficacy of perioperative dextromethorphan compared to placebo for the treatment of postoperative pain: a study protocol

Background

Pain management is a critical component of comprehensive postsurgical care, as it influences patient safety and outcomes, and inadequate control has been associated with the development of chronic pain syndromes. Despite recent improvements, the management of postoperative pain following total knee arthroplasty (TKA) remains a challenge. The use of opioid-sparing, multimodal analgesic regimens has broad support, but there is a paucity of high-quality evidence regarding optimal postoperative protocols and novel approaches are needed. Dextromethorphan stands out among both well-studied and emerging pharmacological adjuncts for postoperative pain due its robust safety profile and unique pharmacology. The purpose of this study is to evaluate the efficacy of multi-dose dextromethorphan for postoperative pain control following TKA.

Methods

This is a single-center, multi-dose, randomized, double-blinded, placebo-controlled trial. A total of 160 participants will be randomized 1:1 to receive either 60 mg oral dextromethorphan hydrobromide preoperatively, as well as 30 mg 8 h and 16 h postoperatively, or matching placebo. Outcome data will be obtained at baseline, during the first 48 h, and the first two follow-up visits. The primary outcome measure will be total opioid consumption at 24 h postoperatively. Secondary outcomes related to pain, function, and quality of life will be evaluated using standard pain scales, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) questionnaire, the Patient-Reported Outcomes Measurement Information System (PROMIS-29) questionnaire, and clinical anchors.

Discussion

This study has a number of strengths including adequate power, a randomized controlled design, and an evidence-based dosing schedule. As such, it will provide the most robust evidence to date on dextromethorphan utilization for postoperative pain control following TKA. Limitations include not obtaining serum samples for pharmacokinetic analysis and the single-center study design.

Trial registration

This trial has been registered on the National Institute of Health’s ClinicalTrials.gov (NCT number: NCT05278494). Registered on March 14, 2022.

Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix

Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.

Effects of Multimodal Analgesia on Recovery From Percutaneous Spinal Cord Stimulator Implantation

OBJECTIVE

We aimed to determine the relationship between number and type of analgesic modalities utilized and postoperative pain after percutaneous spinal cord stimulator implantation. Secondary measures include opioid requirements, discharge times, and effects of specific modalities.

MATERIALS AND METHODS

This single-center retrospective cohort at Brooke Army Medical Center from April 2008 through July 2017 reviewed 70 patients undergoing stimulator implantation by a pain specialist. Data included: home opioid regimen; preoperative/postoperative medications and pain; intraoperative medications; and discharge times. Analysis utilized a Wilcoxon nonparametric mode, and chi-square testing for specific modalities. We compared outcomes based on the number of modalities administered and whether patients received specific medications.

RESULTS

Patients averaged receiving 3.8 modalities (standard deviation 1.4). Patients receiving ≥5 modalities had increased pain from preoperative to postoperative scores by two points, while those who received ≤4 had no increase (p < 0.01). Patients receiving ketamine had a median three point increase in pain scores from their baseline vs no change for others (p < 0.05). Patients receiving four modalities had shorter phase one recovery times vs ≤ 2 (median 66 vs 91.5 min; p = 0.01). Patients receiving ≥4 modalities had shorter times vs ≤3 (median 74 vs 88.5 min; p < 0.01). Patients receiving NSAIDs had shorter times than others (median 78 vs 87 min; p < 0.05).

CONCLUSIONS

Ketamine administration and use of ≥5 analgesic modalities were associated with more postoperative pain for unclear reasons. Patients receiving NSAIDs or ≥4 analgesic modalities had shorter recovery times. These data may lead to further work that could optimize ambulatory practices for stimulator implantation. More work is warranted on this subject.

Protocolo multimodal farmacológico perioperatorio para la cirugía de columna en pediatría

Introducción: La cirugía de columna es uno de los procedimientos con mayor morbimortalidad dentro de la población pediátrica; el manejo farmacológico del dolor en dicha población aún no se encuentra estandarizado. La analgesia multimodal trata de responder a esta problemática. Objetivo: Sobre la base de una revisión sistemática de la bibliografía, desarrollar un detallado protocolomultimodal farmacológico para el manejo del dolor pre- y posoperatorio intra/extrahospitalario para la cirugía de columna en niños. Materiales y Métodos: Se realizó una revisión sistemática de textos completos en inglés o español en PubMed, Embase, Cochrane Library y LILACS Database publicados entre 2000 y 2021; se aplicó el diagrama de flujo PRISMA. Resultados: De 756 artículos preseleccionados, 38 fueron incluidos en la evaluación final. Dada la dificultad bioética de desarrollar trabajos en formato de ensayos clínicos con fármacos y combinaciones de ellos en la población pediátrica, desarrollamos un protocolo detallado de manejo del dolor pre- y posoperatorio por vía intravenosa/oral, intra- y extrahospitalario, para aplicar en niños sometidos a cirugía de columna. Conclusión: Logramos desarrollar un detallado protocolo multimodal farmacológico para el perioperatorio intra- y extrahospitalario de cirugía de columna en niños, sencillo y reproducible, tendiente a acelerar la recuperación funcional del paciente y disminuir los costos socioeconómicos globales.Nivel de Evidencia: II

Acute Pain Management Pearls: A Focused Review for the Hospital Clinician

Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.

Ultrasound-guided sub-multifidus block for postoperative pain after lumbar spine surgery - a prospective case series

We describe this series of 15 cases who were scheduled for single level lumbar spine decompression with instrumentation. Here we describe ultrasound (US) guided sub-multifidus block (SMFB). Injections of local anesthetic deep to the multifidus muscle provided reliable block of dorsal rami of spinal nerves at multiple levels in this series. With US the multifidus muscle can be identified both in axial and parasagittal planes. Needle tip is easily visualized beneath the multifidus and medial to transverse process. A good quality analgesia was documented by pain scores. There were no adverse events. This block needs to be compared with routine multimodal analgesia or with the recently describe thoracolumbar interfascial plane block to compare safety and analgesic efficacy.

The effect of a quality improvement project on post-operative opioid use following outpatient spinal surgery

BACKGROUND

Prescribing opioids upon discharge after surgery is common practice; however, there are many inherent risks including dependency, diversion, and medical complications. Our prospective pre- and post-intervention study investigates the effect of a standardized analgesic prescription on the quantity of opioids prescribed and patients' level of pain and satisfaction with pain control in the early post-operative period.

METHODS

With the implementation of an electronic medical record, a standardized prescription was built employing multimodal analgesia and a stepwise approach to analgesics based on level of pain. Patients received an education handout pre-operatively explaining the prescription. Consecutive patients over a three-month period undergoing elective spine surgery as day or overnight stay cases who received usual care were compared to a similar cohort who received the standardized prescription and education. Patient satisfaction with post-operative pain control, post-operative pain scores, number of refills required, and opioids prescribed in oral morphine equivalents (OMEs) were compared before and after implementation of the standardized analgesic prescription.

RESULTS

Twenty-six patients received usual care (Control group) and 26 patients received the standardized prescription and education handout (Intervention group). There were significantly fewer OMEs prescribed in the Intervention group compared to the Control group. There was no difference between groups in: patient post-operative pain intensity score, post-operative satisfaction score, or number of refills required.

CONCLUSIONS

This study demonstrates that a standardized prescription consisting of an appropriate amount of opioid and non-opioid analgesics is effective in reducing the OMEs prescribed post-operatively in elective spine surgery procedures, without compromising patient pain control or satisfaction or increasing the number of refills required.

Effect of Sufentanil Combined with Gabapentin on Acute Postoperative Pain in Patients Undergoing Intraspinal Tumor Resection: Study Protocol for a Randomized Controlled Trial

Purpose

Patients undergoing intraspinal tumor resection usually experience severe postoperative pain. Inadequate postoperative analgesia usually leads to severe postsurgical pain, which could cause patients to suffer from many other related complications. Recently, an increasing number of studies have found that gabapentin can relieve hyperalgesia, postoperative pain, and postoperative inflammation. However, there have been no reports on the use of gabapentin combined with sufentanil preoperatively for acute pain following intraspinal tumor resection.

Study Design and Methods

This is a protocol for a randomized, placebo-controlled, and double-blinded trial. One-hundred and sixty-eight participants with chronic pain related to the intraspinal tumor will be randomized into the gabapentin and placebo groups in a 1:1 ratio. In the gabapentin group, patients will be given 300 mg gabapentin orally 36 h, 24 h, and 12 h before surgery; the placebo group will receive a placebo orally at the same time points preoperatively. To estimate the efficacy and safety endpoints, all the researchers and patients will be blinded until the completion of this study. The primary outcome will be the consumption of sufentanil within 48 h postoperatively. The secondary outcomes include the visual analog scale pain score and Von Frey mechanical pain threshold 36 h and 24 h before and 24 h and 48 h after surgery, the incidence of postoperative nausea, vomiting, and drowsiness, the length of hospital stay and medical expenses.

Discussion

This trial is to evaluate the efficacy and safety of gabapentin combined with sufentanil for postoperative analgesia in patients who complain of pain before intraspinal tumor resection. The findings will provide a new strategy for multimode perioperative analgesia management in these patients.

Pain Plan Implementation Effect: Analysis of Postoperative Opioid Use, Hospital Length of Stay, and Clinic Resource Utilization for Patients Undergoing Elective Spine Surgery

INTRODUCTION

The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery.

METHODS

This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries.

RESULTS

There was a statistically significant decrease in hospital LOS ( P = 0.028), inpatient opioid use ( P = 0.001), and the average number of steps per communication encounter ( P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities ( P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P < 0.001) and medium-magnitude surgeries (49% reduction, P < 0.001). For small-magnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P < 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference ( P = 0.734). Outpatient opioid prescription quantities were markedly decreased in small-magnitude surgeries only. The total number of communication encounters was not statistically significant in any group. However, the number of steps within a communication encounter was significantly decreased ( P = 0.010), and staff survey respondents reported more efficient and effective postoperative pain management for Pain Plan patients.

DISCUSSION

Pain Plan implementation markedly decreased hospital LOS, inpatient opioid use and outpatient opioid prescription quantities, and clinic resource utilization in elective spine surgery patients.

Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain

Background

This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery.

Materials and methods

This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated.

Results

A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12–3.20), female sex (OR: 2.28; 95% CI: 1.24–4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65–7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1.

Conclusion

The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.

Methylprednisolone as an Adjunct to Local Infiltration on Laminoplasty or Laminectomy before Wound Closure: A Randomized Controlled Trial

TrialDesign. Patients undergoing laminoplasty and laminectomy often experience severe postoperative pain. Local infiltration analgesia during spine surgery significantly reduces postoperative pain, which only upholds for a short time. Whether methylprednisolone and local anaesthetics are better than local anaesthetics alone in postoperative analgesia is yet to be determined. The primary aim of this research was the postoperative evaluation of efficacy and safety of methylprednisolone when used as an adjunct to local anaesthesia, ropivacaine, before wound closure after surgical procedures, laminoplasty or laminectomy. Methods. 132 patients were divided with a ratio of 1 : 1 into methylprednisolone-ropivacaine and ropivacaine alone groups. Every 30 ml of local infiltration solution consisted of 15 ml of 1% ropivacaine with 14 ml of saline along with 1 ml of 40 mg methylprednisolone and 15 ml of 1% ropivacaine with 15 ml of saline in methylprednisolone-ropivacaine group and ropivacaine group, respectively. The standardization of the study solution depended on the number of levels involved in surgery. Primary outcome was the 48-hour cumulative sufentanil demand. Results. Demographic characters and surgical variables among the groups were identical. The average 48-hour cumulative sufentanil demand was 32.5 ± 20.6 μg in the methylprednisolone-ropivacaine group and 50.9 ± 27.2 μg in the ropivacaine group ( $p<0.001$ ). The estimated median time of demand of the first analgesia via patient-controlled analgesia (PCA) pump was 2.5 hours and 2 hours in the methylprednisolone-ropivacaine group and the ropivacaine group, respectively (hazard ratio (HR) was 0.53, with 95% Cl 0.33 to 0.87 and Log-rank of $p=0.0019$ ). Conclusion. The infiltration of methylprednisolone as adjunct ropivacaine before wound closure is a safe and efficient strategy for pain management following laminoplasty or laminectomy.

A Double-Blind, Randomized Controlled Pilot Trial to Assess the Analgesic Efficacy of Ultrasound-Guided Preemptive Caudal Morphine as an Adjunct to Bupivacaine for Lumbosacral Spine Surgeries in Adults

Background

The analgesic efficacy of preemptive administration of caudal morphine for spine surgeries in adults is not well studied. In a double-blinded, randomized controlled trial, safety and analgesic efficacy of preemptive, single-shot caudal morphine and bupivacaine was compared with caudal bupivacaine alone in lumbosacral spine surgeries.

Methods

After Institutional Ethics Committee approval, 40 patients aged 18-60 yrs planned for lumbosacral spine surgery were randomized to groups of 20 patients each. After induction and prone positioning, an ultrasound-guided caudal block was performed with morphine 50 µg/kg with 20 ml 0.25% bupivacaine in the study group (LM) and only bupivacaine in the control group (LA). Postoperatively, both groups received intravenous morphine via patient-controlled analgesia (PCA) pump (No basal, 1 mg/bolus, 10 minutes lockout interval). Intraoperative fentanyl use, postoperative 24-h morphine consumption, visual analogue pain scores (VAS) and adverse effects of morphine were noted.

Results

Demographics and baseline data were comparable. Postoperative 24-hour morphine requirement was more in LA group (34.3 ± 10.7 mg vs 19.65 ± 11.8 mg, p=0.0001). Total intraoperative supplemental fentanyl requirement was similar (79.25 ± 67.60 µg in LA vs 54 ± 50.20 µg in LM group, p=0.28). VAS scores at 2/4/6/12-hour in group-LM were significantly less than group-LA (p=0.005, 0.002, 0.001 and 0.047) but were comparable at 18 and 24 hours (p=0.25, 0.42). Postoperative incidence of adverse effects of morphine was comparable.

Conclusions

Ultrasound-guided, single-shot preemptive administration of caudal morphine with bupivacaine is a safe and effective modality of analgesia for patients undergoing lumbosacral spine surgeries.

Ultrasound-Guided Erector Spinae Plane Block in Thoracolumbar Spinal Surgery: A Systematic Review and Meta-Analysis

Introduction

Neurosurgical spinal surgeries such as micro- discectomy and complex fusion surgeries remain the leading causes of disability-adjusted life-year. Major spinal surgeries often result in severe postprocedural pain due to massive dissection of the underlying tissues. While opioids offer effective pain control, they frequently lead to side effects, such as post-operative nausea and vomiting, pruritus, constipation, and respiratory depression. ESPB was successfully used in spinal surgery as a component of a multimodal analgesic regimen and it eliminated the requirements for opioids. The primary purpose of this systematic review and meta-analysis was to compare post-operative opioid consumption between ESPB and placebo.

Methods

To conduct this systematic review, we used the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)” guidelines. We conducted a search for relevant articles available in the following databases: Google Scholar, PubMed, and the Cochrane Library published up to March 2022.

Results

The total morphine consumption within 24 h after surgery was lower in the ESPB group, the mean difference (in mg of morphine) with 95% CI is −9.27 (−11.63, −6.91). The pain intensity (0–10) at rest measured 24 h after surgery was lower in the ESPB group, the MD with 95% CI is −0.47 (−0.77, −0.17). The pain intensity during movement measured 24 h after surgery was lower in the ESPB group, the MD with 95% CI is −0.73 (−1.00, −0.47). Post-operative nausea and vomiting were significantly lower in the ESPB group, the risk ratio with 95% CI is 0.32 (0.19, 0.53).

Conclusion

Ultrasound-guided ESPB was superior to placebo in reducing post-operative opioid consumption, pain intensity, post-operative nausea and vomiting, and prolonging the time to first rescue analgesia. There were no ESPB-related serious complications reported.

Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review

Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.

SABER-Bupivacaine Reduces Postoperative Pain and Opioid Consumption After Arthroscopic Subacromial Decompression: A Randomized, Placebo-Controlled Trial

INTRODUCTION

Shoulder arthroscopy can result in substantial postoperative pain. Sucrose acetate isobutyrate extended-release bupivacaine (SABER-Bupivacaine; trade name Posimir) is a novel depot formulation of bupivacaine designed to provide analgesia at the surgical site for up to 72 hours. The objective of this study was to evaluate the effect of SABER-Bupivacaine on pain and opioid consumption after arthroscopic subacromial decompression and to assess short-term and long-term safety.

METHODS

In this double-blind, placebo-controlled trial, 78 subjects were randomized in a 2:1 ratio to SABER-Bupivacaine 5 mL or SABER-placebo 5 mL injected into the subacromial space just before skin closure. Twenty-nine additional subjects were randomized on an exploratory basis to bupivacaine hydrochloride 20 mL, also injected subacromially. Subjects rated pain intensity on a 0 to 10 scale over the first 3 postoperative days and received intravenous or oral morphine for breakthrough pain. The coprimary efficacy end points were pain intensity on 90° shoulder flexion and cumulative morphine intake from 0 to 72 hours after surgery. The time to first use of opioid rescue analgesia was a secondary end point.

RESULTS

The mean (SD) pain intensity was 5.16 (1.94) for SABER-Bupivacaine and 6.43 (1.77) for placebo (P = 0.012). The median consumption of intravenous morphine equivalents was 4.0 mg for SABER-Bupivacaine and 12.0 mg for placebo (P = 0.010). The median time to first use of morphine rescue was 12.4 hours for SABER-Bupivacaine and 1.2 hours for placebo (P = 0.014). The corresponding values for bupivacaine hydrochloride were 5.16 (2.38), 8.0 mg, and 1.4 hours. The incidence and severity of treatment-emergent adverse events were similar for all treatment groups, and no functional or radiographic differences were noted at the 6-month follow-up.

DISCUSSION

Compared with placebo, SABER-Bupivacaine reduced pain and opioid analgesic consumption over 72 hours after arthroscopic subacromial decompression and prolonged the time to first use of opioid rescue analgesia. No safety signals were noted during the immediate postoperative period or at 6-month follow-up.

Neurostimulation as an Efficacious Nonpharmacologic Analgesic following Arthroscopic Rotator Cuff Repair

This case highlights the importance of pursuing nonpharmacologic analgesic modalities in orthopedic surgery to combat the current opioid epidemic. Presented is a patient who underwent an arthroscopic rotator cuff repair and biceps tenodesis operation and through the use of neurostimulation (in the form of auricular electrostimulation), fully recovered from surgery without the usage of any opioid or nonsteroidal anti-inflammatory medications. The patient was fitted with a novel auricular electrostimulation device (DyAnsys Primary Relief) in the immediate postoperative period that provided constant neurostimulation for 10 days, this neurostimulator was the only analgesic modality used in this case, and the patient reported minimal postoperative pain. The utility of this case centers around the lack of postoperative opioid use, presenting the idea that postsurgical orthopedic pain can be managed in a nonpharmacologic capacity, combatting the fields' ongoing opioid epidemic.

Perioperative Multimodal Analgesia for Adults undergoing surgery of the Spine- Systematic Review and Meta-analysis of Three or More Modalities

BACKGROUND

Multimodal analgesia is a strategy which may be employed to improve pain management in the perioperative period in patients undergoing surgery of the spine. However, there is no review evidence available on quantitative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the impact of maximal (three or more analgesic agents) multimodal analgesic medication in patients undergoing surgery of the spine.

METHODS

We included randomized controlled trials (RCT's) evaluating the use of three or more multimodal analgesia components (maximal multi modal analgesia) in patients undergoing spinal surgery. We excluded patients receiving neuraxial or regional analgesia. The control group consisted of placebo, standard care (any therapeutic modality including two or less analgesic components). Primary outcomes were post-operative pain scores at rest, at twenty-four, and forty eight hours. We searched the MEDLINE via Ovid SP; EMBASE via Ovid SP; and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used Cochrane's standard methods.

RESULTS

We identified consistently improved analgesic endpoints across all pre-determined primary and secondary outcomes. A total of eleven eligible studies evaluated the primary outcome of pain at rest at twenty four hours. Patients receiving maximal multimodal analgesia were identified to have lower pain scores with an average of MD [-1.03], p<0.00001. Length of hospital stay was decreased in patients receiving multimodal analgesia MD [-0.55], p<0.00001.

CONCLUSION

Perioperative maximal multimodal analgesia consistently improves visual analogue scale outcomes in adult population in the immediate post-operative period, with a moderate quality of evidence. There is significant decrease in hospital length of stay in patients receiving maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.

An enhanced recovery after surgery pathway: LOS reduction, rapid discharge and minimal complications after anterior cervical spine surgery

BACKGROUND

Enhance recovery after surgery (ERAS) is a new and promising paradigm for spine surgery. The purpose of this study is to investigate the effectiveness and safety of a multimodal and evidence-based ERAS pathway to the patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

The patients treated with the ACDF-ERAS pathway were compared with a historical cohort of patients who underwent ACDF before ERAS pathway implementation. Primary outcome was length of stay (LOS). Secondary outcomes included cost, MacNab grading, complication rates and 90-day readmission and reoperation. And perioperative factors and postoperative complications were reviewed.

RESULTS

The ERAS protocol was composed of 21 components. More patients undergoing multi-level surgery (n ≥ 3) were included in the ERAS group. The ERAS group showed a shorter LOS and a lower cost than the conventional group. The postoperative satisfaction of patients in ERAS group was better than that in conventional group. In addition, the rate of overall complications was significantly higher in the conventional group than that in the ERAS group. There were no significant differences in operative time, postoperative drainage, or 90-day readmission and reoperation.

CONCLUSIONS

The ACDF-tailored ERAS pathway can reduce LOS, cost and postoperative complications, and improve patient satisfaction without increasing 90-day readmission and reoperation.

Postoperative rehabilitation of neurosurgical patients after spinal cord surgery – results of our own study

Aim. To assess the extent to which cognitive and emotional disorders in patients undergoing spinal cord surgery affect the quality of rehabilitation and, based on the data obtained, to suggest optimization of rehabilitation measures. Materials and methods. The study included 60 patients (30 men and 30 women) whose condition required spinal cord surgery. All patients underwent assessment of somatic and neurological status, as well as quantitative neuropsychological testing. The influence of cognitive and emotional disorders before and after surgery on the severity of pain syndrome and movement disorders was assessed. When included in the study, patients were randomized into the main (30 people) and control (30 people) group. The patients of the main group received cognitive-motor training, which was carried out using the methodological manual Cognitive Training for Patients with Moderate Cognitive Impairment, developed by the staff of the Department of Nervous Diseases and Neurosurgery of the Sechenov First Moscow State Medical University (Sechenov University). Cognitive, emotional, motor disorders, severity of pain syndrome, as well as the quality of life and adherence of patients to cognitive-motor training were assessed 3 and 6 months after the surgical intervention.The severity of cognitive and emotional disorders in patients of the main and control groups did not differ before the operation. Results. After the operation, the severity of cognitive impairments was significantly higher in patients of the control group (p=0.03). Patients in the control group were significantly worse than patients in the main group in performing memory tasks (p=0.00), they also had a significantly lower rate of mental processes (p=0.00). These differences persisted 3 months after surgery (p=0.00). A week after the surgical intervention, the severity of anxiety and depression was significantly higher in patients in the control group (p=0.01). The positive effect of the operation in the form of pain reduction was achieved in all patients, but in the control group there was an increase in the severity of the pain syndrome after six months of observation compared with that after three months. An increase in the severity of the pain syndrome was associated with an increase in depression, anxiety, and cognitive impairment. The analysis showed that patients of the main group with high adherence to cognitive training showed significantly greater positive dynamics both in terms of cognitive functions and in terms of anxiety and depression (p0.05). A survey of patients after inclusion in the study with the provision of prospective recommendations for clinical care showed the following: 58 patients (96.7% of patients) noted that the proposed recommendations for clinical care, from their point of view, would significantly improve their postoperative prognosis. Important points that should be reflected in the clinical guidelines for the management of patients with spinal cord surgery, from the point of view of patients, were: discussion with the doctor of the picture of their illness, duration of hospitalization, expected outcome, prognosis (60 patients, 100%), medical education rehabilitation skills (51 patients, 85% of patients), communicating with patients who have already undergone a similar operation earlier in this surgical department (49 patients, 81.7%), ensuring continuity and discussing the entire rehabilitation route before surgery (60 patients, 100%). Conclusion. Cognitive and emotionally disorders determine the quality of life and rehabilitation of patients who have undergone surgery on the spinal cord. Our results allow us to recommend the inclusion of cognitive-motor training in the rehabilitation program for patients after spinal neurosurgical operations.

Early Opioid Consumption Patterns After Anterior Cervical Spine Surgery

STUDY DESIGN

This is a prospective observational study.

OBJECTIVE

The aim was to record daily opioid use and pain levels after 1-level or 2-level anterior cervical discectomy and fusion (ACDF) or cervical disc arthroplasty (CDA).

SUMMARY OF BACKGROUND DATA

Data to inform opioid prescription guidelines following ACDF or CDA is lacking. Understanding postoperative opioid consumption behaviors is critical to provide appropriate postdischarge prescriptions.

METHODS

Patients undergoing 1-level or 2-level primary ACDF or CDA were consecutively enrolled at 2 participating institutions between March 2018 and March 2019. Patients with opioid dependence (defined as daily use ≥6 mo before surgery) were excluded. Starting postoperative day 1, daily opioid use and numeric pain rating scale pain levels were collected through a Health Insurance Portability and Accountability Act-compliant, automated text-messaging system. To facilitate clinical applications, opioid use was converted from oral morphine equivalents into "pills" (oxycodone 5 mg equivalents). After 6 weeks or upon patient-reported cessation of opioid use, final survey questions were asked. Refill data were verified from the state prescription registry. Risk factors for patients in top quartile of consumption were analyzed.

RESULTS

Of 57 patients, 48 completed the daily queries (84.2%). Mean age of the patient sample was 50.2±10.9 years. Thirty-two patients (66.7%) underwent ACDF and 16 CDA (33.3%); 64.6% one level; 35.4% two levels. Median postdischarge use was 6.7 pills (range: 0-160). Cumulative opioid use did not vary between the 1-level and 2-level groups (median pill consumption, 10 interquartile range: 1.3-31.3 vs. 4 interquartile range: 0-18, respectively, P=0.085). Thirteen patients (27.1%) did not use any opioids after discharge. Of those patients that took opioids after discharge, half ceased opioids by postoperative day 8. Preoperative intermittent opioid use was associated with the top quartile of opioid consumption (9.1% vs. 50%, P=0.006).

CONCLUSION

Given that most patients use few opioids, patients could be offered the option of a 12 oxycodone 5 mg (90 oral morphine equivalents) discharge prescription, accompanied by education on appropriate opioid use and disposal.

Analgesic Efficacy and Safety of Local Infiltration Following Lumbar Decompression Surgery: A Systematic Review of Randomized Controlled Trials

This systematic review aims to appraise available clinical evidence on the efficacy and safety of wound infiltration with adjuvants to local anesthetics (LAs) for pain control after lumbar spine surgery. A database search was conducted to identify randomized controlled trials (RCTs) pertinent to wound infiltration with analgesics or miscellaneous drugs adjunctive to LAs compared with sole LAs or placebo. The outcomes of interest were postoperative rescue analgesic consumption, pain intensity, time to first analgesic request, and the occurrence of adverse events. Twelve double-blind RCTs enrolling 925 patients were selected for qualitative analysis. Most studies were of moderate-to-good methodological quality. Dexmedetomidine reduced analgesic requirements and pain intensity within 24 h postoperatively, while prolonged pain relief was reported by one RCT involving adjunctive clonidine. Data on local magnesium seem promising yet difficult to interpret. No clear analgesic superiority could be attributed to steroids. Τramadol co-infiltration was equally effective as sole tramadol but superior to LAs. No serious adverse events were reported. Due to methodological inconsistencies and lack of robust data, no definite conclusions could be drawn on the analgesic effect of local infiltrates in patients undergoing lumbar surgery. The probable positive analgesic efficacy of adjunctive dexmedetomidine and magnesium needs further evaluation.

Efficacy of erector spinae plane block on postoperative pain in patients undergoing lumbar spine surgery

BACKGROUND

Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect of erector spinae plane block (ESPB) effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score.

MATERIAL AND METHODS

Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated.

RESULTS

Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times.

CONCLUSION

ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia.

The feasibility and efficacy of perioperative auricular acupuncture technique via intradermal needle buried for postoperative movement-evoked pain after open radical gastrectomy: A randomized controlled pilot trial

INTRODUCTION

Auricular acupuncture is widely used in the treatment of pain. Recently, the most commonly used method of auricular acupuncture is to embed an intradermal needle into the skin to enhance analgesia through continuous stimulation. We aimed to explore the efficacy and feasibility of this form of auricular acupuncture in the treatment of postoperative movement-evoked pain.

METHODS

This single-blind randomized controlled pilot trial was conducted between 23/8/2019 and 10/1/2020. Forty patients were recruited and randomised to either the control group (n = 20) or the experimental group (n = 20). Patients in the control group received sham auricular acupuncture, while patients in the experimental group received auricular acupuncture. A standard routine analgesia was performed in both groups. The patients with NRS score≥4 were given rescue analgesia. Postoperative pain, use of opioids and other analgesics, postoperative recovery and patient's satisfaction were recorded.

RESULTS

The credibility and feasibility of auricular acupuncture for postoperative pain were high in both groups. After auricular acupuncture, the scores of the postoperative movement-evoked pain had a tendency to decrease, but no significant difference was observed between two groups at any time point (P = 0.234∼0.888). The data on postoperative pain at rest confirmed that no significant difference was observed between two groups within 48 h of surgery (P = 0.134∼0.520), and the postoperative pain at rest scores decreased over time; however, from the third day, the pain at rest scores of the experimental group were decreased, and significant differences were observed between the two groups (P = 0.039∼0.047). As for use of rescue analgesic, total opioid consumption and the incidence of postoperative nausea and vomiting, there were no significant differences between the two groups (P = 0.311, P = 0.101, P = 0.661) . In terms of patients' satisfaction, the score of the experimental group was higher than that of the control group, and a significant difference was observed between the two groups (P = 0.000). As for adverse events, two participants reported pain and one patient reported discomfort at the insertion sites during the process of auricular acupuncture intervention, but they both were minor and tolerable.

CONCLUSION

Auricular acupuncture may have a relief effect on mild postoperative pain at rest with pain score below 3, suggesting that it may be a feasible adjuvant method to relieve mild pain at rest. However, more multi-centre and large-sample studies are needed to verify this result.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Efficacy of liposomal bupivacaine in spine surgery: a systematic review

BACKGROUND CONTEXT

Spine surgery with posterior approaches may involve extensive manipulation of native structures, resulting in significant postoperative pain. Liposomal bupivacaine (LB) is an injectable analgesic that has demonstrated efficacy in decreasing postoperative pain and opioid requirements in patients across multiple surgical subspecialties.

PURPOSE

To consolidate and analyze the findings of retrospective cohort-matched studies and prospective randomized controlled trials investigating the use of LB in spine surgery.

STUDY DESIGN

A systematic review.

STUDY SAMPLE

Retrospective cohort-matched studies and randomized controlled trials (RCTs) investigating the efficacy of injected LB in spinal surgery compared with a control/no treatment group.

METHODS

MEDLINE, Cochrane controlled trials register, and Google Scholar were searched to identify all studies that examined the effect of LB use on outcomes in spine surgery. Our search identified 10 articles that independently evaluated the effect of LB on reduction of postoperative opioid use, pain scores, hospital length of stay, cost, and incidence of adverse effects. The principles of GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) were applied to assess the quality of evidence from each study.

RESULTS

Ten studies were analyzed (1,112 total patients). LB was associated with significantly lower millimolar morphine equivalents (MME) of postoperative opioids, especially in opiate-tolerant patients, visual analog scale (VAS) scores, area under the curve (AUC) of cumulative pain scores, numeric pain scale scores, and hospital length of stay (LOS), with comparable or lower odds of adverse effects relative to controls.

CONCLUSIONS

Low-quality evidence suggests that liposomal bupivacaine may safely decrease postoperative opioid requirements, pain scores, and length of stay in patients undergoing spine surgery, whereas moderate-quality evidence does not support its use at this time. Therefore, additional standardized well-powered prospective studies are necessary to more clearly assess the efficacy of LB in spine surgery.

Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations

BACKGROUND

Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.

OBJECTIVES

We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.

DESIGN AND DATA SOURCES

A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.

RESULTS

Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.

CONCLUSIONS

The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.