Pain Management After Spinal Surgery

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

INTRODUCTION

Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion.

METHODS

This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups.

RESULTS

The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods ( P -value = 0.023 and P -value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups ( P -value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group ( P -values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups ( P -value = 0.169).

DISCUSSION

Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use.

CLINICAL TRIAL REGISTRATION

Identifier: NCT05413902.

Etoricoxib Can Reduce Post-Operative Morphine Consumption and Pain Score in Patients Undergoing Lumbar Laminectomy Compare to Acetaminophen: A Randomized Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

This prospective trial aimed to compare the effectiveness of etoricoxib and acetaminophen in terms of post-operative morphine consumption and pain score in patients undergoing lumbar laminectomy.

METHODS

Forty lumbar-laminectomy patients aged between 18 and 50 years were enrolled, randomized, and allocated into either the etoricoxib group or the acetaminophen group. The measures assessed were the amount of morphine consumed and pain visual analog score (VAS) at 12, 24, and 48 hours after surgery. Adverse events were recorded.

RESULTS

Patients in the etoricoxib group had statistically significantly lower morphine consumption than those in the acetaminophen group at 12 hours (P-value = .006), 24 hours (P-value = .006) and 48 hours (P-value = .011). Patients in the etoricoxib group had lower VAS scores than those in the acetaminophen group at 0, 12, 24, 48 hours, the difference being statistically significant at 48 hours (P < .001).

CONCLUSIONS

Compared to acetaminophen, etoricoxib can significantly reduce post-operative morphine consumption and improve the pain score at 12, 24, and 48 hours.

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.

Parecoxib Reduced Postsurgical Pain and Facilitated Movement More Than Patient Controlled Analgesia

Background

Postoperative pain management is an imperative issue for patients undergoing lumbar spinal fusion surgery. Delayed pain relief is associated with poor clinical outcomes. This study compared the effects of intravenously administered patient-controlled analgesia (PCA) with intravenous parecoxib, both commonly used methods for analgesic pain control after surgery.

Methods

A non-randomized study was used to recruit 68 patients who were scheduled to receive lumbar spinal fusion surgery at a hospital in Taiwan from April through December of 2020. The group treated with parecoxib received an initial perioperative dose of parecoxib 40 mg during a 30-min period and then postoperative intravenous parecoxib at 40 mg per 12-h period, for 72 h. Those with PCA received morphine (0.4 mg/ml), droperidol (0.02 mg/ml), diphenhydramine (0.48 mg/ml), midazolam (0.02 mg/ml) and saline solution during the 3-day study course. Major outcomes, including visual scale pain score and Barthel index of activities of daily living, were collected via review of medical records at 4 times: 12, 24, 48 and 72 h after surgery. Comparative effects between two groups were assessed by the generalized estimating equations.

Results

After adjusting for potential confounders, the administration of parecoxib was associated with a significant decrease in pain scores and an increase in the Barthel Index, when compared with the PCA group (all p < 0.05). Notably, both effects would maintain for 72 h after surgery.

Discussion

This is the first trial of which the authors are aware, that supports intravenous parecoxib as significantly enhancing patient mobility, in addition to having pain control efficacy, when compared with PCA. This study could be used as a reference when instituting interventions to improve the adaptation process and clinical prognoses after lumbar spinal fusion surgery.

Prospective randomized appraisal of the best pain relief option after L4/L5 discectomy

OBJECTIVES

To determine the efficacy of paracetamol and tramadol analgesia via patient controlled pump and intermittent administration using the Short-Form McGill Pain Questionnaire after L4/L5 discectomy in neurosurgical patients.

METHODS

Fourteen months prospective quantitative study with 200 neurosurgical patients' participation who underwent elective discectomy of the L4/L5 intervertebral disc extrusion. The study was conducted due to a patient-controlled analgesia pump and intermittent analgesia application. Pain was assessed using the Short-Form McGill Pain Questionnaire in the Croatian language during the zero, first, and second postoperative day.

RESULTS

Perception of pain was reduced in patient controlled analgesia pump groups after the second measurement during the first postoperative day [95% CI: -3.89, -0.76], regardless of administered analgesic (p< 0.001). After the final measurement, at 7 PM on the second postoperative day, the differences were not significant (p= 0.070). This study results are registered and allocated in the Australian New Zealand Clinical Trials Registry (ANZCTR).

DISCUSSION

Analgesia administration via patient-controlled pump contributes to the alleviation of postoperative pain after L4/L5 disc extrusion surgery regardless of administered analgesic.