No Difference in Pain After Spine Surgery with Local Wound Filtration of Morphine and Ketorolac: A Randomized Controlled Trial

The efficacy and safety of ketorolac for postoperative pain management in lumbar spine surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Ketorolac is widely utilized for postoperative pain management, including back pain after lumbar spinal surgery. Several trials have assessed the efficacy of Ketorolac alone and in combination with other analgesics such as bupivacaine, morphine, epinephrine, paracetamol, and pregabalin. However, the effects and safety profile of ketorolac in these contexts remain controversial.

OBJECTIVE

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of Ketorolac administration, both as a monotherapy and in combination with other analgesics, for managing postoperative pain in adults undergoing lumbar spinal surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, CNKI, WanFang, VIP, and Cochrane library databases through July 2024 for randomized controlled trials (RCTs) assessing the analgesic efficacy of Ketorolac administration for postoperative pain of lumbar surgery. The meta-analysis was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statements. Data were extracted and analyzed using open-source meta-analysis software OpenMeta-Analyst, focusing on outcomes such as VAS pain scores, postoperative morphine requirements (PMR), length of hospital stay (LOS), and adverse effects, such as nausea, vomiting, pruritus, and constipation. The quality of evidence was assessed using the Jada scale.

RESULTS

Thirteen RCTs comprising a total of 938 patients were included. The methodological quality of the studies was high, with three studies scoring 5, six studies scoring 4, and four studies scoring 3 on the Jadad scale. Ketorolac significantly reduced pain compared to controls at 0-6 h, with a mean difference (MD) of - 1.42 (95% CI: - 2.03 to - 0.80; P < 0.0001), exceeding the Minimal Clinically Important Difference (MCID) of 1.2 to 2.0 points on the Visual Analog Scale (VAS), indicating clinically meaningful pain relief. During the 6-12-h period, the pain reduction was significant (MD =  - 0.58; 95% CI: - 0.80 to - 0.35; P < 0.0001), though below the MCID threshold. In the 12-24-h period, Ketorolac continued to show significant pain reduction (MD =  - 0.48; 95% CI: - 0.68 to - 0.28; P < 0.0001), but this reduction was also below the MCID. Heterogeneity was low in the 12-24-h period (I2 = 13%), indicating consistent results across studies. There was a significant reduction in PMR (SMD =  - 1.83; 95% CI =  - 3.42 to - 0.23; P < 0.0001), although with considerable heterogeneity among the studies (I2 = 93%, heterogeneity P < 0.01). Ketorolac administration also significantly reduced the LOS compared to controls (MD =  - 0.45 days; 95% CI =  - 0.74 to - 0.16; P = 0.0001), though this reduction, which is less than a full day (0.45 days), may have limited clinical significance. The findings suggest that Ketorolac effectively reduces pain and opioid use postoperatively, supporting its role in multimodal analgesia for lumbar spinal surgery. The significant reduction in PMR indicates a beneficial opioid-sparing effect, crucial in the context of reducing opioid-related complications. The observed reduction in LOS, while statistically significant, may not translate into substantial clinical benefit due to its limited magnitude. No significant increase in common adverse effects was noted, indicating Ketorolac's safety profile.

CONCLUSION

Ketorolac administration, either alone or in combination with other analgesics, effectively reduces postoperative pain and opioid consumption in adults following lumbar spinal surgery. And Ketorolac did not significantly increase the incidence of postoperative nausea and vomiting relative to other analgesics or placebos. While it also decreases LOS, the clinical relevance of this reduction is modest. However, the variability in study designs, dosages, and combination therapies contribute to significant heterogeneity in outcomes. Future research should focus on standardizing protocols and exploring optimal dosing strategies. Additionally, long-term safety and effectiveness studies are needed to better understand Ketorolac's role in postoperative pain management.

The impact of perioperative nonsteroidal anti-inflammatory drugs on the postoperative outcomes of spinal surgery: a meta-analysis of 23 randomized controlled trials

In recent years, nonsteroidal anti-inflammatory drug (NSAIDs), which are considered to affect the prognosis of spinal surgery, have been widely used in perioperative analgesia in spinal surgery, but the relationship between these two factors remains unclear. The purpose of this study was to explore the effect of perioperative use of NSAIDs on the prognosis of patients treated with spinal surgery. We systematically searched PubMed, Embase, and Cochrane Library for relevant articles published on or before July 14, 2023. We used a random-effect model for the meta-analysis to calculate the standardized mean difference (SMD) with a 95% confidence interval (CI). Sensitivity analyses were conducted to analyze stability. A total of 23 randomized clinical trials including 1457 participants met the inclusion criteria. Meta-analysis showed that NSAIDs were significantly associated with postoperative morphine use (mg) (SMD = -0.90, 95% CI -1.12 to -0.68) and postoperative pain (SMD = -0.71, 95% CI -0.85 to -0.58). These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses. The current study shows that perioperative use of NSAIDs appears to be an important factor in reducing postoperative pain and morphine use in patients undergoing spinal surgery. However, well-designed, high-quality randomized controlled trials (RCTs) are still required.

The Impact of Ketorolac Utilization on Outcomes for Lumbar Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Ketorolac is one of the most potent nonsteroidal anti-inflammatory drugs commonly used in spine surgery. The purpose of this study is to examine the impact of ketorolac utilization with or without other medications on a patient's postoperative course after lumbar surgery.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed using PubMed, CINAHL, MEDLINE, and Web of Science in July 2023. Inclusion criteria were RCTs that used ketorolac for lumbar surgery.

RESULTS

Thirteen RCTs were included (N = 997; mean age, 54.6 ± 7.8 years; n = 535 in the ketorolac group) in this systematic review. There was no significant difference in the 24-hour and total postoperative morphine utilization (P = 0.185 and P = 0.109, respectively), 24-hour and final postoperative pain scores (0-10 scale) (P = 0.065 and P = 0.582, respectively), and length of stay at the hospital (P = 0.990) between patients in the ketorolac group and patients in the non-ketorolac group who underwent lumbar surgery. Overall, patients had similar rates of major complications (3.7% vs. 5.4%) and minor complications (42.1% vs. 51.7%) between groups after lumbar surgery. However, patients in the ketorolac group had a significantly lower rate of nausea and/or vomiting compared with the non-ketorolac group after lumbar surgery (21.6% vs. 37.1%, respectively; P = 0.018).

CONCLUSIONS

There is no significant difference in 24-hour and total postoperative morphine utilization, pain scores, or length of stay, with similar complication rates after lumbar surgery between patients receiving ketorolac and patients not receiving ketorolac via meta-analysis of RCTs.

Dexamethasone and dexmedetomidine as adjuvants to ropivacaine do not prolong analgesia in wound infiltration for lumbar spinal fusion: a prospective randomized controlled study

BACKGROUND AND OBJECTIVES

Local anesthetics (LAs) are widely used to infiltrate into surgical wounds for postoperative analgesia. Different adjuvants like dexamethasone and dexmedetomidine, when added to LA agents, could improve and prolong analgesia. The aim of this trial was to evaluate the analgesic efficacy and opioid-sparing properties of dexamethasone and dexmedetomidine when added to ropivacaine for wound infiltration in transforaminal lumbar interbody fusion (TLIF).

METHODS

We conducted a controlled study among 68 adult patients undergoing TLIF, which was prospective, randomized and double-blind in nature. The participants were divided into four equal groups at random. Group R was given 150 mg of 1% ropivacaine (15 mL) and 15 mL of normal saline. Group R + DXM received 150 mg of 1% ropivacaine (15 mL) and 10 mg of dexamethasone (15 mL). Group R + DEX received 150 mg of 1% ropivacaine (15 mL) and 1 µg/kg of dexmedetomidine (15 mL). Lastly, group R + DXM + DEX was given 150 mg of 1% ropivacaine (15 mL), 10 mg of dexamethasone and 1 µg/kg of dexmedetomidine (15 mL). The primary focus was on the length of pain relief provided. Additionally, secondary evaluations included the amount of hydromorphone taken after surgery, the numerical rating scale and safety assessments within 48 h after the operation.

RESULTS

Based on the p value (P > 0.05), there was no significant variance in the duration of pain relief or the total usage of hydromorphone after surgery across the four groups. Similarly, the numerical rating scale scores at rest and during activity at 6-, 12-, 24- and 48-h post-surgery for all four groups showed no difference (P > 0.05). However, the incidence of delayed anesthesia recovery was slightly higher in group R + DEX and group R + DXM + DEX when compared to group R or group R + DXM. Furthermore, there were no significant differences between the four groups in terms of vomiting, nausea, dizziness or delayed anesthesia recovery.

CONCLUSION

For wound infiltration in TLIF, the addition of dexamethasone and dexmedetomidine to ropivacaine did not result in any clinically significant reduction in pain or opioid consumption and could prompt some side effects.

A prospective single-arm study on the efficacy and safety of short-course oral corticosteroids followed by topical corticosteroids in patients with severe chronic rhinosinusitis with nasal polyps

BACKGROUND

Little evidence exists regarding an integrated multidimensional evaluation methodology to analyze the within-patient effects of medical treatment for chronic rhinosinusitis with nasal polyps (CRSwNP). We aimed to use an integrated evaluation model to analyze the effects of short-course oral corticosteroid (OCS) followed by intranasal corticosteroid spray (INCS) therapy in patients with severe CRSwNP.

METHODS

In all, 32 patients with severe CRSwNP received oral methylprednisolone for three weeks followed by intranasal budesonide spray for nine weeks in this prospective single-arm study. An evaluation model integrating the concepts of the core outcome set (COS), clinical control and minimum clinically important difference (MCID) was longitudinally evaluated.

RESULTS

All uncontrolled patients at baseline showed similar progressive improvements from baseline and more than 1 MCID response across core outcomes during the OCS period, with severe CRSwNP being partly controlled in 31 (96.9%) patients and uncontrolled in 1 (3.1%) patient at 3 weeks. During the subsequent INCS period, 14 (43.8%) patients gradually deteriorated to an uncontrolled status at 12 weeks, whereas 18 (56.2%) exhibited partly controlled CRSwNP until 12 weeks.

CONCLUSIONS

In more than half of the patients, severe CRSwNP was partly controlled with the initial OCS followed by INCS therapy. An integrated evaluation model was used to facilitate the comprehensive evaluation of within-patient response, especially in patients with different responses to the same treatment.

TRIAL REGISTRATION

ChiCTR1900024287.

Surgeon-Placed Erector Spinae Plane Catheters for Multilevel Lumbar Spine Fusion: Technique and Outcomes Compared With Single-Shot Blocks

BACKGROUND

Postoperative pain management of multilevel lumbar fusion remains challenging. There are few reports of opioid-sparing regional analgesia for spine surgery. We present a novel method for surgeon-placed erector spinae plane (ESP) catheters for multilevel lumbar spine fusion and compare pain- and opioid-related outcomes in a matched cohort who received anesthesiologist-placed ESP blocks.

METHODS

A retrospective matched pilot study of 18 patients: 6 received intraoperative, bilateral ESP catheters. Tunneled catheters were placed under the intact ESP at the proximal end of the incision. Continuous infusions of ropivacaine (0.2%) were started in the postanesthesia care unit (PACU) after emergence from anesthesia and maintained for 48 hours. Catheter patients were matched 1:2 with 12 patients who received preincision single-shot ESP blocks administered by an anesthesiologist, according to age, gender, American Society of Anesthesiologists class, body mass index, and number of spinal levels fused. All patients were provided opioid intravenous patient-controlled analgesia (IV-PCA). Numeric rating scale pain scores (NRS, 0-10), length of stay (LOS), opioid consumption (oral morphine equivalents, mg), opioid side effects, and complications (motor weakness, local anesthetic toxicity, infection, technical issues, and failure), were compared in the PACU and on the nursing floor.

RESULTS

Only 1/6 patients with ESP catheter used opioid IV-PCA, compared with 11/12 who received ESP blocks. There were no differences in total opioid consumption (catheters: 135 ± 141 mg; blocks: 183 ± 112 mg; P = 0.448) or median (interquartile range) LOS (catheters: 73 [50,107] hours; blocks: 90 [72,116] hours, P = 0.708). NRS pain was significantly higher in the PACU after ESP catheters (5.9 ± 1.7) vs ESP blocks (3.3 ± 2.4; P = 0.036), but no differences were found at later timepoints (5.0 ± 1.6 vs 4.3 ± 1.1, respectively; P = 0.383). No catheter-related complications were found.

CONCLUSION

Surgeon-placed ESP catheters represent a simple technique to provide regional analgesia, particularly in centers lacking regional anesthesiology services. Risks, benefits, and efficacy compared to other techniques require prospective study.

LEVEL OF EVIDENCE: 3

Postoperative pain treatment after spinal fusion surgery: a systematic review with meta-analyses and trial sequential analyses

Supplemental Digital Content is Available in the Text.

Patients undergoing spinal surgery are at high risk of acute and persistent postoperative pain. Therefore, adequate pain relief is crucial. This systematic review aimed to provide answers about best-proven postoperative analgesic treatment for patients undergoing lumbar 1- or 2-level fusions for degenerative spine diseases. We performed a search in PubMed, Embase, and The Cochrane Library for randomized controlled trials. The primary outcome was opioid consumption after 24 hours postoperatively. We performed meta-analyses, trial sequential analyses, and Grading of Recommendations assessment to accommodate systematic errors. Forty-four randomized controlled trials were included with 2983 participants. Five subgroups emerged: nonsteroidal anti-inflammatory drugs (NSAIDs), epidural, ketamine, local infiltration analgesia, and intrathecal morphine. The results showed a significant reduction in opioid consumption for treatment with NSAID (P < 0.0008) and epidural (P < 0.0006) (predefined minimal clinical relevance of 10 mg). Concerning secondary outcomes, significant reductions in pain scores were detected after 6 hours at rest (NSAID [P < 0.0001] and intrathecal morphine [P < 0.0001]), 6 hours during mobilization (intrathecal morphine [P = 0.003]), 24 hours at rest (epidural [P < 0.00001] and ketamine [P < 0.00001]), and 24 hours during mobilization (intrathecal morphine [P = 0.03]). The effect of wound infiltration was nonsignificant. The quality of evidence was low to very low for most trials. The results from this systematic review showed that some analgesic interventions have the capability to reduce opioid consumption compared with control groups. However, because of the high risk of bias and low evidence, it was impossible to recommend a “gold standard” for the analgesic treatment after 1- or 2-level spinal fusion surgery.

The Analgesic Benefits of Ketorolac to Local Anesthetic Wound Infiltration Is Statistically Significant But Clinically Unimportant: A Comprehensive Systematic Review and Meta-Analysis

Objective: Even though ketorolac-infiltration is said to provide superior postoperative analgesic benefits in different surgical procedures, its safety and efficacy remain to be validated because of the lack of high-quality evidence. We aimed to summarize the efficacy and safety of ketorolac-infiltration based on published randomized-controlled trials (RCTs). Approach: This work followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, assessing the methodological quality of systematic reviews and the Cochrane Collaboration recommendations. We searched for RCTs evaluating the efficacy of ketorolac-infiltration in adults in the PubMed, Web of Science, Embase, Cochrane Library, Chinese databases, and Google Scholar. The two co-primary outcomes of this meta-analysis were rescue analgesic consumption in the 24-h postoperative period and rest pain scores. Results: Twelve trials (761 patients) were analyzed. Ketorolac-infiltration provided a clinically unimportant benefit in morphine consumption (mean difference, -2.81 mg; 95% confidence interval [CI], -5.11 to -0.50; p = 0.02; moderate-quality evidence). Low-to-moderate quality evidence supported a brief (2-6 h), clinically subtle, but statistically consistent effect of surgical site ketorolac-infiltration in reducing wound pain at rest. High-quality evidence supported shorter hospital stays for surgical patients receiving local ketorolac-infiltration when compared to controls (mean difference, -0.12 days; 95% CI, -0.17 to -0.08; p < 0.00001). Further, ketorolac-infiltration does not improve any opioid-related side effects. Innovation: Ketorolac-infiltration provides statistically significant but clinically unimportant benefits for improving postoperative wound pain. Conclusion: Overall, despite the fact that current moderate-to-high quality of evidence does not support routine using of ketorolac as an adjuvant to local anesthetic for wound infiltration, these findings underscore the importance of optimizing agents and sustained delivery parameters in postoperative local anesthetic practice. Clinical Trials.gov ID: CRD42021229095.