Intraoperative wound infiltration with bupivacaine in patients undergoing lumbar spine surgery

Pre-emptive coinfiltration of dexamethasone palmitate emulsion with ropivacaine for postoperative pain in patients undergoing major spine surgery: a study protocol for a prospective, randomised controlled, multicentre trial

INTRODUCTION

Patients undergoing major spine surgery usually experience moderate-to-severe postoperative pain. It has been shown that dexamethasone as an adjunct to local anaesthesia (LA) infiltration presented a superior analgesic benefit compared with LA alone in various types of surgeries. However, a recent meta-analysis reported that the overall benefits of dexamethasone infiltration were marginal. Dexamethasone palmitate (DXP) emulsion is a targeted liposteroid. Compared with dexamethasone, DXP has a stronger anti-inflammatory effect, longer duration of action and fewer adverse effects. We hypothesised that the additive analgesic effects of DXP on local incisional infiltration in major spine surgery may have better postoperative analgesic effect, compared with local anaesthetic alone. However, no study has evaluated this so far. The purpose of this trial is to determine whether pre-emptive coinfiltration of DXP emulsion and ropivacaine at surgical site incision will further reduce postoperative opioid requirements and pain scores after spine surgery than that with ropivacaine alone.

METHODS AND ANALYSIS

This is a prospective, randomised, open-label, blinded endpoint, multicentre study. 124 patients scheduled for elective laminoplasty or laminectomy with no more than three levels will be randomly allocated in a 1:1 ratio into two groups: the intervention group will receive local incision site infiltration with ropivacaine plus DXP; the control group will receive infiltration with ropivacaine alone. All participants will complete a 3 months follow-up. The primary outcome will be the cumulative sufentanil consumption within 24 hours after surgery. The secondary outcomes will include further analgesia outcome assessments, steroid-related side effects and other complications, within the 3 months follow-up period.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Institutional Review Board of Beijing Tiantan Hospital (KY-2019-112-02-3). All participants will provide a written informed consent. The results will be submitted for publication in a peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05693467.

Bilateral Radioscopically-Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Randomized Clinical Trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare two perioperative pain management procedures: a radioscopically-guided erector spinae plane (ESP) block versus the standard wound infiltration technique with local anaesthetics, in patients undergoing lumbosacral spine surgery.

METHODS

A randomized, double-blind clinical trial was performed, in which adults at our hospital undergoing lumbosacral surgery without fixation were randomly assigned to receive either the standard wound infiltration technique, employing long-term anaesthetics, or a radioscopically-guided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilised due to wound pain, length of hospitalisation, and complications were recorded.

RESULTS

Over the first seven postoperative hours, pain relief was superior in the ESP block group among patients who underwent discectomies or one-level decompression (p<0.0001). Using an ESP block also was statistically superior at decreasing all postoperative variables recorded in patients scheduled for multi-level decompression: VAS pain severity over the first seven hours after the procedure (p=0,0004); number of patients with wound pain 1 (p=0.049), 7 (p<0.0001) and 24 hours (p=0.007) after surgery; length of hospitalisation (p=0.0007), number of patients immobilised for wound pain (p=0.0004) and rescue morphine consumption (p<0.0001).

CONCLUSION

The ESP block is a safe procedure which seems to outperform the infiltration wound technique for postoperative pain management in patients undergoing open spinal surgery. Future studies are needed to verify its effectiveness for arthrodesis/fixation and minimally-invasive procedures, and for chronic spine pain relief.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

Background

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

Methods

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

Results

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

Conclusions

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.

Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01281-1.

Effect of Multimodal Drugs Infiltration on Postoperative Pain in Split Laminectomy of Lumbar Spine: A Randomized Controlled Trial

STUDY DESIGN

A randomized, double-blinded controlled trial.

OBJECTIVE

This study tested the effect of single-dose wound infiltration with multiple drugs for pain management after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Patients undergoing spine surgery often experience severe pain especially in early postoperative period. We hypothesized that intraoperative wound infiltration with multiple drugs would improve outcomes in lumbar spine surgery.

METHODS

Fifty-two patients who underwent one to two levels of spinous process splitting laminectomy of lumbar spine, were randomized into two groups. Infiltration group received intraoperative wound infiltration of local anesthetics, morphine sulfate, epinephrine, and nonsteroidal anti-inflammatory drugs at the end of surgery, and received patient-controlled analgesia (PCA) postoperatively. The control group received only PCA postoperatively. The primary outcome measures were amount of morphine consumption and visual analogue scale (VAS) for pain. The secondary outcome measures were Oswestry Disability Index (ODI), Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ), patient satisfaction, length of hospital stay, and side effects.

RESULTS

A total of 49 patients (23 patients for local infiltration group, and 26 patients for control group) were analyzed. There were statistically significant [P < 0.001, the effect size -5.0, 95% CI (-6.1, -3.9)] less morphine consumptions in the local infiltration group than the control group during the first 12 hours, 12 to 24 hours, and 24 to 48 hours after surgery. The VAS of postoperative pain reported by patients at rest and during motion was significantly lower in the local infiltration group than the control group at all assessment times (P < 0.001). The effect size of VAS of postoperative pain at rest and during motion were -2.0, 95% CI (-2.5, -1.4) and -2.0, 95% CI (-2.6, -1.4) respectively. ODI and RMDQ at 2 week and 3 month follow-ups in both groups had significant improvement from baseline (P < 0.001). No significant differences were found between groups (P = 0.262 for ODI and P = 0.296 for RMDQ). There were no significant differences of patient satisfaction, length of stay, and side effects between both groups (P = 0.256, P = 0.262, P = 0.145 respectively).

CONCLUSION

Intraoperative wound infiltration with multimodal drugs reduced postoperative morphine consumption, decreased pain score with no increased side effects.

LEVEL OF EVIDENCE

1.

Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed.

METHODS

This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay.

RESULTS

Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively).

CONCLUSION

This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery.

LEVEL OF EVIDENCE

1.

Wound infiltration with local anesthetics for post-operative pain relief in lumbar spine surgery: a systematic review

BACKGROUND

In this systematic review, we evaluated double-blind, randomized and controlled trials on the effect of wound infiltration with local anesthetics compared with the effect of placebo on post-operative pain after lumbar spine surgery.

METHODS

Medline, the Cochrane Library and Google Scholar were searched for appropriate trials. Qualitative analysis of post-operative effectiveness was evaluated by assessment of significant difference (P < 0.05) between study groups regarding pain relief using pain scores, supplemental analgesic consumption and time to first analgesic request as outcome measures. Data on adverse effects were extracted and evaluated.

RESULTS

Nine trials including 12 comparisons and 529 patients met the inclusion criteria. Ten comparisons presented data on pain scores. In only three of these 10 comparisons (30%), a reduction in pain score using local anesthetic infiltration was observed averaging between 8 and 40 mm on a 100 mm visual analog scale. In six out of 12 comparisons, the local anesthetic infiltration significantly reduced the supplemental opioid consumption after surgery. Observed reductions in analgesic consumption over the first 24 h averaged between 2.5 mg and approximately 15 mg of morphine. Data on opioid-related adverse effects were incomplete and difficult to interpret.

CONCLUSION

Interpretation of the results was difficult because of diversity of the studies. However, clinical significance was in general questionable, with only a few trials showing a small or a modest reduction in pain intensity, which was observed mainly immediately after the operation. Similarly, although more frequently observed, only a minor and probably not clinically relevant reduction in opioid consumption was shown.