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

Effects of Fu's Subcutaneous Needling on Postoperative Pain in Patients Receiving Surgery for Degenerative Lumbar Spinal Disorders: A Single-Blind, Randomized Controlled Trial

Background

Fu's subcutaneous needling (FSN) is a novel acupuncture technique for pain treatment. This study investigated the effects of postsurgical FSN on postoperative pain in patients receiving surgery for degenerative spinal disorders.

Methods

This single-center, single-blind, randomized-controlled study involved patients undergoing surgery for degenerative spinal disorders. Participants were randomized into either an FSN group or a control group that received sham FSN. The primary outcomes were scores on the Brief Pain Inventory Taiwan version (BPI-T) and Oswestry Disability Index before and at 1, 24, and 48 hours after surgery. Secondary outcomes were muscle hardness, pethidine use, and inflammatory biomarker presence.

Results

Initially, 51 patients met the inclusion criteria and were allocated (26 in the FSN group and 25 in the control group). Two patients were lost to follow-up, and finally, 49 patients (25 in the FSN group and 24 in the control group) who completed the study were analyzed. The FSN group had significantly lower pain intensity measured on the BPI-T compared with the control group at 1, 24, 48, and 72 hours after surgical treatment (all p < 0.001). Additionally, pain interference as measured on the BPI-T was lower in the FSN group than in the control group 1 hour (p = 0.001), 24 hours (p = 0.018), 48 hours (p = 0.001), and 72 hours (p = 0.017) after surgical treatment. Finally, the FSN group exhibited less muscle hardness in the latissimus dorsi and gluteus maximus 24, 48, and 72 hours (all p < 0.05) after surgery compared with the control group; patients in the FSN group also exhibited less muscle hardness in the L3 paraspinal muscle 48 hours (p = 0.001) and 72 hours (p < 0.001) after surgery compared with the control group. There were no significant differences in serum CRP, IL-1β, IL-2, IL-6, and TNF-α levels between the FSN and control groups at 24 hours, 72 hours, and 1-month post-surgery (all p > 0.05).

Conclusion

FSN treatment can reduce postoperative pain in patients receiving surgery for degenerative spinal disorders. However, larger sample sizes and multicenter clinical trials are required to verify these findings.

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).

Bilateral erector spinae plane block for postoperative pain relief in lumbar spine surgery: A PRISMA-compliant updated systematic review & meta-analysis

Study design

Systematic review.

Objective

Erector spinae plane block (ESPB) is growing in popularity over the recent past as an adjuvant modality in multimodal analgesic management following lumbar spine surgery (LSS). The current updated meta-analysis was performed to analyze the efficacy of ESPB for postoperative analgesia in patients undergoing LSS.

Methods

We conducted independent and duplicate electronic database searches including PubMed, Embase and Cochrane Library till June 2023 for randomized controlled trials (RCTs) analyzing the efficacy of bilateral ESPB for postoperative pain relief in lumbar spine surgeries. Post-operative pain scores, total analgesic consumption, first analgesic requirement time, length of stay and complications were the outcomes evaluated. Statistical analysis was performed using STATA 17 software.

Results

32 RCTs including 1464 patients (ESPB/Control = 1077/1069) were included in the analysis. There was a significant pain relief in ESPB group, as compared to placebo across all timelines such as during immediate post-operative period (p < 0.001), 4 h (p < 0.001), 8 h (p < 0.001), 12 h (p < 0.001), 24 h (p = 0.001) post-surgery. Similarly, ESPB group showed a significant reduction in analgesic requirement at 8 h (p < 0.001), 12 h (p = 0.001), and 24 h (p < 0.001). However, no difference was noted in the first analgesic requirement time, time to ambulate or total length of stay in the hospital. ESPB demonstrated significantly improved overall satisfaction score for the analgesic management (p < 0.001), reduced intensive care stay (p < 0.05) with significantly reduced post-operative nausea and vomiting (p < 0.001) compared to controls.

Conclusion

ESPB offers prolonged post-operative pain relief compared to controls, thereby reducing the need for opioid consumption and its related complications.

Does Erector Spinae Plane Block Decrease Analgesia Requirements After Minimal-Invasive Posterior Transpedicular Stabilization in Patients With Vertebral Body Fracture? A Prospective, Randomized, Double-Blind Controlled Study

STUDY DESIGN

Prospective randomized placebo controlled double blind trial.

OBJECTIVE

To examine the effect of ESP block after minimally invasive posterior stabilization for vertebral fractures on opioid consumption, pain, blood loss, disability level, and wound healing complications.

METHODOLOGY

Patients indicated for minimal invasive posterior stabilisation were included to the study. Our primary outcome was the opioid consumption and Visual Analogue Scale (VAS) measured during the first 48 hours. Secondary outcomes used to measure the short-term outcome included Oswestry Disability Index (ODI) and Patient Reported Outcome Spine Trauma (PROST).

RESULTS

In total, 60 patients were included with a 93.3% follow-up. Average morphine consumption during the PACU (Post Anaesthesia Care Unit) period was 5.357 mg in ESP group and 8.607 mg in placebo group (P = .004). Average VAS during first 24 hour was 3.944 in ESP group and 5.193 in placebo group (P = .046). Blood loss was 14.8 g per screw in ESP group and 15.4 g in placebo group (P = .387). The day2 PROST value was 33.9 in ESP group and 28.8 in placebo group (P = .008) and after 4 weeks 55.2 in ESP group and 49.9 in placebo group (P = .036). No significant differences in ODI were detected.

CONCLUSION

The use of ESP block in minimally invasive spinal surgery for posterior fracture stabilization leads to a significant reduction of opioid consumption during PACU stay by 37.7%. Reduction of opioid consumption was accompanied with lower pain (VAS). We found positive effect of the ESP block on short term outcome scores, but no effect on perioperative blood loss and wound healing.

Bilateral ultrasound-guided erector spinae plane block for postoperative pain relief in major traumatic spine surgery: A randomized controlled trial

Introduction

Spine fixation surgery for traumatic vertebral fractures is associated with severe pain and is often difficult to control. Traditionally systemic opioids have been the mainstay of analgesia for these procedures, which can lead to hyperalgesia, nausea, ileus, sedation, cognitive impairment, dependence, etc., limiting usage of opioids. The Erector spinae plane block (ESPB) is a novel ultrasound-guided procedure with easily identifiable sonoanatomy. We hypothesized that a multimodal approach involving ESPB to a conventional analgesic regimen with local infiltration for patients undergoing major traumatic spine surgeries might provide better perioperative analgesia and reduce the need for postoperative opioid requirements.

Material and Methods

A randomized control prospective trial was conducted on 34 ASA grade I -II patients aged 18 to 65 years who were scheduled to undergo elective posterior spine fixation surgery with ASIA B to E after traumatic spine fracture under general anesthesia. Patients were randomized to Group A which included patients who received general anesthesia with ESPB, and Group B, or the control group, included patients who received general anesthesia with systemic analgesics and postoperative local infiltration without ESPB. Intraoperative total fentanyl consumption, VAS score at 0, 3, 6, 12, 18, and 24 hours, time to activate patient-controlled analgesia (PCA) pump, total morphine consumption, and opioid-related side effects were monitored and compared in both groups.

Results

Postoperative PCA morphine consumption was significantly lower in group A patients who received ESPB than those in the control group (17.06 ± 9.59 vs 37.82 ± 9.88 P value = <0.0001). VAS scores at rest and movement at 0, 3, 6, 9, 12, 18, and 24 hours were significantly lower (P value = 0.05) in the ESPB group compared with the control group at all time points.

Conclusion

Bilateral ultrasound-guided Erector spinae plane block, when administered in traumatic spine patients undergoing spine fixation surgery, provides better analgesia with statistically decreased VAS scores and less postoperative opioid requirement.

Adding Ketamine to Epidural Morphine Does Not Prolong Postoperative Analgesia After Lumbar Laminectomy or Discectomy

BACKGROUND

Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery.

METHODS

American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery.

RESULTS

Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively ( P =0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period ( P =0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups.

CONCLUSIONS

The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy.

Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series

PURPOSE

Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery.

METHODS

A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity.

RESULTS

Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted.

CONCLUSION

95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

MCV-UNet: a modified convolution & transformer hybrid encoder-decoder network with multi-scale information fusion for ultrasound image semantic segmentation

In recent years, the growing importance of accurate semantic segmentation in ultrasound images has led to numerous advances in deep learning-based techniques. In this article, we introduce a novel hybrid network that synergistically combines convolutional neural networks (CNN) and Vision Transformers (ViT) for ultrasound image semantic segmentation. Our primary contribution is the incorporation of multi-scale CNN in both the encoder and decoder stages, enhancing feature learning capabilities across multiple scales. Further, the bottleneck of the network leverages the ViT to capture long-range high-dimension spatial dependencies, a critical factor often overlooked in conventional CNN-based approaches. We conducted extensive experiments using a public benchmark ultrasound nerve segmentation dataset. Our proposed method was benchmarked against 17 existing baseline methods, and the results underscored its superiority, as it outperformed all competing methods including a 4.6% improvement of Dice compared against TransUNet, 13.0% improvement of Dice against Attention UNet, 10.5% improvement of precision compared against UNet. This research offers significant potential for real-world applications in medical imaging, demonstrating the power of blending CNN and ViT in a unified framework.

The effect of preemptive retrolaminar block on lumbar spinal decompression surgery

PURPOSE

Spinal decompression surgery causes severe pain. Retrolaminar block (RLB) is block, which is done by infiltration of local anesthetic to block spinal nerves between the lamina and superior costotransversospinalis muscle. The primary aim of this study is to evaluate the effectiveness of RLB on postoperative analgesia in patients undergoing spinal surgery. Secondary aims are effects on additional anesthetic and analgesic consumption.

METHODS

The sixty (60) patients who underwent lumbar spinal surgery between May 2020 and May 2021 under general anesthesia with or without applied preemptive RLB for postoperative analgesia were included in this prospective observational study. Group I received ultrasound-guided preemptive RLB. In Group II, no intervention was performed. Postoperative VAS scores were compared in groups as primary outcome, perioperative additional anesthetic and analgesic needs were compared as secondary outcome.

RESULTS

There was a significant difference between the groups in favor of the RLB group in terms of postoperative VAS scores at rest [1.33 (0.33-3.509)] and movement [2.40 (1.20-4.00)] (p < 0.001). Perioperative sevoflurane consumption was significantly low in block group (p < 0.001). Postoperative tramadol consumption was lower in Group I compared with Group II [Group 1: 200 (100-300); Group 2: 37.5 (0-200); p < 0.001].

CONCLUSION

Preemptive RLB may be used to reduce patients' pain in lumbar decompression surgery as well as to be part of a multimodal analgesia and anesthesia regimen to reduce anesthetic and analgesic drug consumption. Trial registration numberClinicalTrials.gov (No. NCT04209907).

Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands

STUDY DESIGN

Prospective multicenter database post-hoc analysis.

OBJECTIVES

Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity.

METHODS

Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up.

RESULT

Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed.

CONCLUSIONS

In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXT

Perioperative pain management affects cost and outcomes in elective spine surgery.

PURPOSE

This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization.

STUDY DESIGN

This was a retrospective comparative study.

PATIENT SAMPLE

Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores.

OUTCOME MEASURES

Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis.

METHODS

Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc.

RESULTS

In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts.

CONCLUSIONS

Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Opioid-free versus opioid-based anesthesia in major spine surgery: a prospective, randomized, controlled clinical trial

BACKGROUND

Major spine surgery is associated with severe postoperative pain and increased opioid consumption. Opioid-free anesthesia (OFA) is thought to provide adequate intraoperative analgesia with reduced postoperative opioid consumption. The aim of this study is to compare the impact of intraoperative OFA approach to the conventional opioid-based anesthesia (OBA) on postoperative pain, opioid consumption, and related side effects in patients undergoing multilevel spinal fusion surgery.

METHODS

Forty-eight patients undergoing elective major spine surgery were randomly allocated to either receive intraoperative dexmedetomidine and lidocaine (OFA group) or fentanyl during induction and intraoperative remifentanil (OBA group). All patients received intraoperative sevoflurane, propofol, rocuronium, ketamine, dexamethasone, ondansetron and postoperative paracetamol and patient-controlled analgesia device set to deliver intravenous morphine for 48 hours after surgery. Postoperative pain was measured using numerical rating scale. Opioid side effects were documented, when present.

RESULTS

OFA group required less morphine in the first 24 hours post-surgery (17.28±12.25 mg versus 27.96±19.75 mg, P<0.05). The incidence of postoperative nausea and vomiting (PONV) was significantly lower in the OFA group. More patients in the OFA group required antihypertensive medications compared to patients in the OBA group (P<0.05). In the post anesthesia care unit, OFA patients had a significantly longer stay than OBA patients (114.1±49.33 min versus 89.96±30.71 min, P<0.05).

CONCLUSIONS

OFA can be an alternative to OBA in patients undergoing multilevel spine fusion surgery. OFA reduces opioids consumption in the first 24 hours and PONV.

The effect of an ultrasound-guided sacral erector spinae plane block on the postoperative pain of lumbar discectomy: a randomized controlled trial

BACKGROUND

Pain management is essential after discectomy, the surgical treatment for lumbar disc herniation. This study evaluated the effect of sacral erector spinae plane block (SESPB) versus standard analgesic methods on postoperative analgesia and opioid consumption in lumbar discectomy operations.

METHODS

Over 18 years of age, ASA 1-3 group, 54 patients undergoing elective lumbar discectomy were included in the prospective, randomized, controlled, double-blind, study. They were randomly divided into groups, SESPB and non-block (control). Both groups completed surgery under general anesthesia. At the end of the surgery, group SESPB received a bilateral 20 cc block with 0.25% bupivacaine at the level of the second sacral vertebra. Both groups received tramadol via a patient-controlled analgesia (PCA) device. The primary outcome was total opioid consumption in the first 24 hours after surgery. Pain assessment by Visual Analog Scale (VAS), rescue analgesic requirements, time to first rescue analgesic requirement and adverse effects were recorded 24 hours postoperatively.

RESULTS

Total tramadol consumption was 168.8±143 mg (P<0.04) higher in the control group. The first six-hour VAS scores and the number of rescue analgesic users were lower in the SESPB group (P<0.01). The first rescue analgesic use time was 440±140.3 minutes in SESPB group and 47.5±116.1 minutes in control group (P<0.01). Nausea-vomiting was more frequent in the control group (P<0.01) and patient satisfaction was higher in the SESPB group (P<0.01).

CONCLUSIONS

In lumbar discectomy surgery, ultrasound-guided SESPB provided adequate analgesia by reducing opioid consumption and pain scores without complications.

The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery.

METHODS

Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity.

RESULTS

We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025).

CONCLUSIONS

Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.

Perioperative Methadone for Spine Surgery: A Scoping Review

Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.

Effects of Workload on Return to Work After Elective Lumbar Spine Surgery

STUDY DESIGN

Retrospective analysis was performed of a multi-center Canadian Spine Outcomes and Research Network (CSORN) surgical database.

OBJECTIVE

To determine the rate and time to return to work (RTW) based on workload intensity after elective degenerative lumbar spine surgery.

METHODS

Patients working pre-operatively, aged greater than 18, who underwent a primary one- or two-level elective lumbar spine surgery for degenerative conditions between January 2015 and October 2020 were evaluated. The percentage of patients who returned to work at 1 year and the time to RTW post-operatively were analyzed based on workload intensity.

RESULTS

Of the 1290 patients included in the analysis, the overall rate of RTW was 82% at 1 year. Based on workload there was no significant difference in time to RTW after a fusion procedure, with median time to RTW being 10 weeks. For non-fusion procedure, the sedentary group had a statistically significantly quicker time to RTW than the light-moderate (P < .005) and heavy-very heavy (<.027) groups.

CONCLUSIONS

The rate of RTW ranged between 84% for patients with sedentary work to 77% for patient with a heavy-very heavy workload. Median time to resumption of work was about 10 weeks following a fusion regardless of work intensity. There was more variability following non-fusion surgeries such as laminectomy and discectomy reflecting the patient's job demands.

Risk factors for prolonged length of stay after first single-level lumbar microdiscectomy

OBJECTIVE

The objective is to identify risk factors that potentially prolong the hospital stay in patients after undergoing first single-level open lumbar microdiscectomy.

METHODS

A retrospective single-centre study was conducted. Demographic data, medical records, intraoperative course, and imaging studies were analysed. The outcome measure was defined by the number of days stayed after the operation. A prolonged length of stay (LOS) stay was defined as a minimum of one additional day beyond the median hospital stay in our patient collective. Bivariate analysis and multiple stepwise regression were used to identify independent factors related to the prolonged hospital stay.

RESULTS

Two hundred consecutive patients who underwent first lumbar microdiscectomy between 2018 and 2022 at our clinic were included in this study. Statistical analysis of factors potentially prolonging postoperative hospital stay was done for a total of 24 factors, seven of them were significantly related to prolonged LOS in bivariate analysis. Sex (p = 0.002, median 5 vs. 4 days for females vs. males) and age (rs = 0.35, p ≤ 0.001, N = 200) were identified among the examined demographic factors. Regarding preoperative physical status, preoperative immobility reached statistical significance (p ≤ 0.001, median 5 vs. 4 days). Diabetes mellitus (p = 0.043, median 5 vs. 4 days), anticoagulation and/or antiplatelet agents (p = 0.045, median 5 vs. 4 days), and postoperative narcotic consumption (p ≤ 0.001, median 5 vs. 4 days) as comorbidities were associated with a prolonged hospital stay. Performance of nucleotomy (p = 0.023, median 5 vs. 4 days) was a significant intraoperative factor. After linear stepwise multivariable regression, only preoperative immobility (p ≤ 0.001) was identified as independent risk factors for prolonged length of postoperative hospital stay.

CONCLUSION

Our study identified preoperative immobility as a significant predictor of prolonged hospital stay, highlighting its value in preoperative assessments and as a tool to pinpoint at-risk patients. Prospective clinical trials with detailed assessment of mobility, including grading, need to be done to verify our results.

Erector Spinae Plane Block on Postoperative Pain and Opioid Consumption After Lumbar Spine Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

Evaluate the effectiveness of the erector spinae plane (ESP) block in lumbar spine surgeries.

DESIGN

Systematic review with meta-analysis.

METHODS

PubMed, Cochrane Library, CINAHL, Google Scholar, and other gray literature were searched for eligible studies. Risk ratio (RR), mean difference (MD), and standardized mean difference were used to estimate outcomes with suitable effect models. The quality of evidence was assessed using the Risk of Bias algorithm and the grades of recommendation, assessment, development, and evaluation (GRADE) approach.

FINDINGS

Twenty-two randomized controlled trials involving 1,327 patients were included. The erector spinae plane (ESP) block demonstrated a lower cumulative pain score within the first 48 hours at rest (MD, -1.03; 95% CI, -1.19 to -0.87; P < .00001) and during activity (MD, -1.16; 95% CI, -1.24 to -1.08; P < .00001). In addition, ESP block decreased opioid consumption (MD, -6.25; 95% CI, -8.33 to -4.17; P < .00001) and prolonged the time to first analgesic rescue (MD, 5.66; 95% CI, 3.11-8.20; P < .0001) resulting in fewer patients requesting rescue analgesic (RR, 0.33; 95% CI, 0.13-0.83; P = .02), lower incidence of postoperative nausea and vomiting (RR, 0.29; 95% CI, 0.10-0.79; P = .02) with improved patient satisfaction score (standardized mean difference, 2.17; 95% CI, 1.40-2.94; P < .00001).

CONCLUSIONS

ESP block can provide effective postoperative pain control for lumbar spine surgery, improve patient satisfaction, and reduce the amount of postoperative opioid use.

Effectiveness of Corticosteroid Therapy in Enhancing Early Postoperative Recovery in Lumbar Spinal Stenosis Patients: A Retrospective Study

BACKGROUND The degree of postoperative symptom improvement in patients with lumbar spinal stenosis (LSS) is crucial to their postoperative rehabilitation process and functional exercise. Corticosteroids have certain anti-inflammatory effects. This study aimed to explore whether small doses of corticosteroids would improve postoperative neurological symptoms in patients with lumbar spinal stenosis. MATERIAL AND METHODS Patients with lumbar spinal stenosis who underwent open surgery were divided into a corticosteroid therapy group (CTG) and a non-corticosteroid therapy group (NCTG). They were followed up for 24 months after surgery. The numeric rating scale (NRS) for leg pain (NRS-LP) and leg numbness (NRS-LN), Oswestry Disability Index (ODI) scores, and Short Form Health Survey (SF-36) scores of the 2 groups were compared at different time points to evaluate the therapeutic effect. RESULTS Of the 232 eligible patients enrolled, 128 received corticosteroids and 104 did not. At the 1-month postoperative follow-up, patients in the CTG had significantly lower NRS-LP and NRS-LN scores than those in the NCTG (P=0.017; P=0.043). At the 3-month follow-up, the NRS-LP and ODI scores of patients in the CTG were significantly lower than those of the NCTG (P=0.015; P=0.027), and SF-36 scores were significantly higher than that of the NCTG (P=0.012). At the 6-month follow-up, the SF-36 scores of patients in the CTG was significantly higher than that of the NCTG (P=0.008). CONCLUSIONS Small doses of corticosteroid therapy for postoperative lumbar spinal stenosis reduced symptoms and improved quality of life scores after surgery. However, it had little long-term impact on final patient outcomes.

Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Matched cohort comparison.

OBJECTIVE

To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF.

MATERIALS AND METHODS

Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups.

RESULTS

Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1.

CONCLUSIONS

In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF.

LEVEL OF EVIDENCE

Level 3.

Cluster Analysis reveals Socioeconomic Disparities among Elective Spine Surgery Patients

This work demonstrates the use of cluster analysis in detecting fair and unbiased novel discoveries. Given a sample population of elective spinal fusion patients, we identify two overarching subgroups driven by insurance type. The Medicare group, associated with lower socioeconomic status, exhibited an over-representation of negative risk factors. The findings provide a compelling depiction of the interwoven socioeconomic and racial disparities present within the healthcare system, highlighting their consequential effects on health inequalities. The results are intended to guide design of fair and precise machine learning models based on intentional integration of population stratification.

Effectiveness and Safety of Intrathecal Morphine for Pediatric Patients Undergoing Scoliosis Surgery: A Systematic Review and Meta-Analysis

Adolescent idiopathic scoliosis (AIS) often necessitates spinal fusion surgery in pediatric patients, posing significant challenges in postoperative pain management. Standard care involves the administration of intravenous opioids perioperatively, often requiring high doses to achieve adequate analgesia following an operation. This increases the risk of adverse events, may delay recovery and prolong hospital stay, and increases the likelihood of future abuse and dependence. In this systematic review and meta-analysis, we assess the safety and effectiveness of intrathecal morphine (ITM) in pediatric patients undergoing posterior spinal fusion. Ovid Embase and MEDLINE were searched in October 2023 for articles that directly compared ITM use with standard pain management approaches for pediatric patients undergoing posterior spinal fusion. Our primary outcome was postoperative pain scores. Secondary outcomes included opioid usage details, adverse events, and blood loss. Of the 384 unique studies identified, nine studies (one randomized control trial, one prospective review, and seven retrospective reviews) met the inclusion criteria. The total number of patients within the ITM and control groups were 1384 and 676, respectively. Meta-analysis revealed significantly lower pain scores in the ITM group (standardized mean difference (SMD): -1.30 (-2.29, -0.31); p = 0.01). Similarly, ITM patients had significantly lower opioid usage, both intraoperatively (mean difference (MD): -0.71 mg/kg (-0.99, -0.44); p < 0.00001) as well as postoperatively (SMD: -2.10 (-3.48, -0.73); p = 0.003), and significantly lower blood loss (MD: -0.88 L (-1.34, -0.43); p = 0.0001). The occurrence of adverse events was similar across both groups. Our analysis of the available data demonstrates that a low to moderate dose of ITM is a safe and effective adjunct to improve standard postoperative care without increasing the risk of respiratory depression. When compared to control, ITM patients had superior analgesia while using fewer opioids had significantly reduced intraoperative blood loss when ITM was administered before spinal fusion, and had a similar complication profile. While further studies are warranted to establish optimal dosing, these findings underscore the potential of ITM as a valuable addition to multimodal pain management.

A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study

BACKGROUND

There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management.

METHODS

The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay.

RESULTS

There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05).

CONCLUSION

Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication.

CLINICAL RELEVANCE

In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain.

LEVEL OF EVIDENCE: 4

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Analysis of factors associated with the use of Korean medicine after spinal surgery using a nationwide database in Korea

Many patients in Korea use Korean Medicine (KM) after spine surgery, but related research is lacking. Therefore, this retrospective cohort study aimed to analyze factors affecting the use and costs of KM using nationally representative data from the National Health Insurance Service-National Sample Cohort, South Korea. Patients who underwent spinal surgery for spinal diseases from 2011 to 2014 were followed up for 5 years, and their medical care was described. The association between patient and spinal surgery characteristics and the use of KM was analyzed. A two-part model was used to analyze factors affecting the use of KM in patients undergoing spinal surgery. Of 11,802 patients who underwent spinal surgery, 11,367 who met the inclusion criteria were included. Overall, 55.5% were female, 32.3% were aged ≥ 70 years, and 50.2% received KM treatment during the follow-up period. Open discectomy was the most common surgical procedure performed (58.6%), and 40.2% of surgeries were performed because of lumbar disc disorder. Female sex, older age, high Charlson Comorbidity Index score, and use of KM before surgery were associated with increased KM use and expenditure after surgery. In conclusion, patient characteristics, rather than surgical characteristics, appeared to be more strongly associated with the use of KM after surgery, particularly prior experience with KM use. This study is significant in that it analyzed the entire spine surgery to provide a comprehensive view of the use of KM after spine surgery and analyzed the impact of various factors related patients and surgical characteristics on KM use. The results of this study may be useful to patients with spinal diseases, clinicians, and policymakers.

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.

Erector Spinae Plane Blocks for Circumferential Lumbar Spinal Fusion: Retrospective Cohort Study

BACKGROUND

Circumferential lumbar spine fusions are extensive procedures that involve accessing the lumbar spine from multiple approaches. These surgeries often make postoperative pain control challenging, and efforts have been made to find alternative methods of analgesia that do not rely solely on opioids. The use of erector spinae plane (ESP) blocks has been found to be effective in controlling pain while decreasing narcotic requirements in patients undergoing thoracolumbar spine surgery. The purpose of this study is to evaluate the efficacy of ESP blocks for postoperative pain control and its effect on opioid consumption in patients undergoing circumferential lumbar spinal fusion.

METHODS

A retrospective review was performed on patients undergoing 1- or 2-level elective anterior lumbar interbody fusion with open posterior decompression and posterolateral fusion. An analysis was performed to determine the effect of ESP blocks on hospital length of stay (LOS), pain scores using the visual analog scale, and opioid consumption using morphine milligram equivalents.

RESULTS

144 patients were included in the cohort analysis, of whom 36 patients received a preoperative ESP block and 108 did not. Demographic data, comorbidities, and number of levels fused were equally distributed between groups. Patients who received an ESP block had shorter LOS (3.0 vs 4.0 days, P = 0.005) and lower cumulative morphine milligram equivalent in the first 48 hours after surgery (123.7 vs 141.2, P = 0.05). Visual analog scale scores did not significantly differ between patients group except for on postoperative day 4 and at 12-month follow-up.

CONCLUSIONS

The use of ESP blocks for patients undergoing 1- or 2-level circumferential fusion via an anterior lumbar interbody fusion with concomitant posterior open procedures was associated with decreased postoperative inpatient opioid requirements and LOS. This cohort study supports the growing body of evidence that ESP blocks are a useful adjunct for multimodal pain control.

LEVEL OF EVIDENCE

3 CLINICAL RELEVANCE: The data and results of this study provide clinical evidence supporting the use of ESP blocks in patients undergoing circumferential lumbar spine fusion procedures.

Enhanced Recovery After Surgery Protocols and Spinal Deformity

The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.

A Randomised Controlled Study on Epidural Morphine and Bupivacaine for Post-Operative Analgesia After Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Randomised control study.

OBJECTIVE

Different parenteral analgesics are used to alleviate post-operative pain after transforaminal lumbar interbody fusion (TLIF) but limited by their efficacy and side effects. We performed a RCT to evaluate the safety and efficacy of epidural Morphine-Bupivacaine on post-operative pain management after TLIF.

METHODS

Consecutive patients (n=100) of TLIF were divided randomly into study (SG) and control groups (CG). At the end of procedure, SG (n=50) received epidural instillation of morphine 5 mg and bupivacaine .25% - 2 mL, along with 6 mL of .25% bupivacaine infiltration in the deep fascia before wound closure. The functional outcomes were assessed at regular intervals (4, 8, 12, 24, 36, 48, 72, 96 hours) with VAS, nausea and vomiting scale, Ramsay sedation scale and breakthrough analgesia needed, time to ambulation and other complications.

RESULTS

The mean VAS score at 4 hours in SG was significantly less (1.16 ± .88) than the CG (3.32 ± 1.0) (P = .000). This significant difference was maintained at each time point during the first 48 hours (P < .004). Similarly, the mean NRS score in SG at 4 hours was 1.02 ± .89, and in CG 3.3 ± .69 (P = .0000) which was maintained at all intervals of assessment till 48 hours (P = .0137). The mean time to first ambulation was significantly less in the SG (4.46 ± 1.04 hours) than CG (11.64 ± 2.3 hours) (P < .001). There were no drug-related complications.

CONCLUSION

Epidural instillation of bupivacaine and morphine is safe and enables better pain relief in the initial 48 hours which helps in early mobilisation, and enhanced functional recovery.

Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail as a Local Anesthetic for Lumbar Decompression Surgery: A Single Institutional Experience

OBJECTIVE

The goal of this study is to discuss our initial experience with a multimodal opioid-sparing cocktail containing ropivacaine, epinephrine, clonidine, and ketorolac (RECK) in the postoperative management of lumbar decompression surgeries.

METHODS

Patients were either administered no local anesthetic at the incision site or were administered a weight-based amount of RECK into the paraspinal musculature and subdermal space surrounding the operative site once the fascia was closed. We performed a retrospective chart review of all patients 18 years of age or older undergoing lumbar laminectomy and lumbar diskectomy surgeries between December 2019 and April 2021. Outcomes including total opioid use, measured as morphine milligram equivalent, length of stay, and postoperative visual analog scores for pain, were collected. Relationships between variables were analyzed with Student's t-test, chi-square tests, and Fisher exact tests.

RESULTS

A total of 121 patients undergoing 52 lumbar laminectomy and 69 lumbar diskectomy surgeries were identified. For lumbar laminectomy, patients who were administered RECK had decreased opioid use in the postoperative period (11.47 ± 12.32 vs. 78.51 ± 106.10 morphine milligram equivalents, P = 0.019). For patients undergoing lumbar diskectomies, RECK administration led to a shorter length of stay (0.17 ± 0.51 vs. 0.79 ± 1.45 days, P = 0.019) and a lower 2-hour postoperative pain score (3.69 ± 2.56 vs. 5.41 ± 2.28, P = 0.006).

CONCLUSIONS

The RECK cocktail has potential to be an effective therapeutic option for the postoperative management of lumbar decompression surgeries.

Perioperative Predictors in Patients Undergoing Lateral Lumbar Interbody Fusion for Minimum Clinically Important Difference Achievement

OBJECTIVE

To identify perioperative predictors of minimum clinically important difference (MCID) for patients undergoing lateral lumbar interbody fusion (LLIF) for the patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back, VAS leg, Oswestry Disability Index (ODI), and Patient Health Questionnaire-9 (PHQ-9).

METHODS

Patients undergoing LLIF were identified through retrospective review of a single-surgeon database. Overall MCID achievement was determined as the number of unique patients achieving ΔPROM thresholds of PROMIS-PF = 4.5, VAS back = 2.1, VAS leg = 2.8, ODI = 14.9, and PHQ-9 = 3.0 over a 2-year postoperative period. Univariate and multivariable logistic regression were used to determine perioperative predictors for MCID achievement.

RESULTS

Two-hundred and ninety patients were identified. For PROMIS-PF MCID achievement, increased preoperative PROMIS-PF and postoperative day (POD) 1 VAS pain were significant negative predictors. For VAS back, primary fusion with revision decompression was a negative predictor, whereas increased preoperative VAS back score was a positive predictor of MCID achievement. For VAS leg, increased preoperative VAS leg score was a positive predictor. For ODI, increased POD 0 VAS pain score was a negative predictor, whereas increased preoperative ODI was a positive predictor. For PHQ-9, increased preoperative PHQ-9 score was a positive predictor.

CONCLUSIONS

In patients undergoing LLIF, perioperative predictors for MCID achievement were highly dependent on PROM. Preoperative PROM was the most consistent perioperative predictor for achieving MCID. Increased acute postoperative pain and primary fusion after failed index decompression were significant predictors of failing to achieve MCID. Surgeons may use these findings in prognostication and management of postoperative expectations.

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.

Efficacy of Essential Oils in Relieving Cancer Pain: A Systematic Review and Meta-Analysis

Over 80% of patients affected by cancer develops cancer-related pain, one of the most feared consequences because of its intractable nature, particularly in the terminal stage of the disease. Recent evidence-based recommendations on integrative medicine for the management of cancer pain underline the role of natural products. The present systematic review and meta-analysis aims at appraising for the first time the efficacy of aromatherapy in cancer pain in clinical studies with different design according to the most updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 recommendations. The search retrieves 1002 total records. Twelve studies are included and six are eligible for meta-analysis. The present study demonstrates significant efficacy of the use of essential oils in the reduction of the intensity of pain associated with cancer (p < 0.00001), highlighting the need for earlier, more homogeneous, and appropriately designed clinical trials. Good certainty body of evidence is needed for effective and safe management of cancer-related pain using essential oils by establishment of a step-by-step preclinical-to-clinical pathway to provide a rational basis for clinical use in integrative oncology. PROSPERO registration: CRD42023393182.

Effects of bilateral erector spinae plane block for posterior lumbar spine surgery in elderly patients

OBJECTIVES

With the rapid development of aging population, the number of elderly patients undergoing posterior lumbar spine surgery continues to increase. Lumbar spine surgery could cause moderate to severe postoperative pain, and the conventional opioid-based analgesia techniques have many side effects, which are barriers to the recovery after surgery of the elderly. Previous studies have demonstrated that erector spinae plane block (ESPB) could bring about favorable analgesia in spinal surgery. As far as the elderly are concerned, the analgesic and recovery effects of ESPB on posterior lumbar spine surgery are not completely clear. This study aims to observe the effects of bilateral ESPB on elderly patients undergoing posterior lumbar spine surgery, and to improve the anesthesia techniques.

METHODS

A total of 70 elderly patients of both sex, who were selected from May 2020 to November 2021, scheduled for elective posterior lumbar spine surgery, and in the age of 60-79 years, with American Society of Anesthesiologists class Ⅱ-Ⅲ, were divided into a ESPB group and a control (C) group using a random number table method, with 35 patients each. Before general anesthesia induction, 20 mL 0.4% ropivacaine was injected to the transverse process of L3 or L4 bilaterally in the ESPB group and only saline in the C group. The score of Numerical Rating Scale (NRS) indicating pain at rest and on movement within 48 h after operation, time of first patient control analgesia (PCA), cumulative consumptions of sufentanil within 48 hours, Leeds Sleep Evaluation Questionnaire (LSEQ) scores on the morning of day 1 and day 2 after operation, Quality of Recovery-15 (QoR-15) scores at 24 and 48 h after operation, full diet intake times, perioperative adverse reactions such as intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation were compared between the 2 groups.

RESULTS

A total of 70 patients were enrolled and 62 subjects completed the study, including 32 in the ESPB group and 30 in the C group. Compared with the C group, the postoperative NRS scores at rest at 2, 4, 6, and 12 h and on movementat at 2, 4, and 6 h were lower, time of first PCA was later, sufentanil consumptions were significantly decreased during 0-12 h and 12-24 h after operation, LSEQ scores on the morning of day 1 and QoR-15 scores at 24 and 48 h after operation were higher, full diet intakes achieved earlier in the ESPB group (all P<0.05). There were no significant differences in the incidences of intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation between the 2 groups (all P>0.05).

CONCLUSIONS

Providing favorable analgesic effects with reduced opioids consumption, bilateral ESPB for posterior lumbar spine surgery in the elderly patients could also improve postoperative sleep quality, promote gastrointestinal functional restoration, and enhance recovery with few adverse reactions.

Ultrasound-Guided Modified Thoracolumbar Fascial Plane Block in Tianji Robot-Assisted Lumbar Internal Fixation: A Prospective, Randomized, and Non-Inferiority Study

Purpose

Ultrasound-guided modified thoracolumbar fascial plane block (MTLIP) has been reported effective for postoperative pain control following lumbar surgery. Although trauma of the Tianji robot-assisted lumbar internal fixation is reduced, the degree of pain cannot be ignored.MTLIP may improve operation efficiency and reduce puncture complications.This study aimed to explore whether MTLIP is not inferior to thoracolumbar fascial plane block (TLIP) in the treatment of lumbar internal fixation.

Methods

This prospective double-blinded, non-inferiority randomized trial enrolled patients underwent Tianji robot-assisted lumbar internal fixation between April and August 2022 to either MTLIP or TLIP. The primary outcome was an effective dermatomal block area after 30 min. Secondary outcomes included the numeric rating scale (NRS) scores, nerve block operation time, puncture times, image clarity, patient satisfaction, intraoperative opioid consumption, complications/adverse reactions, and Oswestry Disability Index (ODI).

Results

Sixty participants were randomized to MTLIP (n=30) and TLIP (n=30). The effective dermatomal block area 30 min after block was non-inferior in the MTLIP group (283.6 ± 62.6 cm²) compared with the TLIP group (261.4±53.2 cm²) (P=0.145; estimated mean difference: -22.17, 95% CI: -52.19, 7.85; smaller than the non-inferiority margin of 39.5). Compared with TLIP, MTLIP showed shorter operation time, smaller puncture times, and better target definition and satisfaction scores (all P<0.001). Sufentanil amount, remifentanil amount, PCIA sufentanil dosage, parecoxib amount, NRS scores (increased with time in the two groups but without inter-group differences), and complications were not significantly different between the two groups (all P>0.05).

Conclusion

This non-inferiority trial supports the hypothesis that MTLIP yields a non-inferior effective dermatomal block area compared with TLIP for Tianji robot-assisted lumbar internal fixation.

Clinical Trials Registration

Chinese Clinical Trial Registry (ChiCTR2200058687);.

Ultrasound-guided erector spinae plane block for postoperative short-term outcomes in lumbar spine surgery: A meta-analysis and systematic review

BACKGROUND

Patients undergoing lumbar spine surgery usually suffer from moderate to severe acute pain. Erector spinae plane block (ESPB) has been applied to relieve acute pain in various surgeries and improve postoperative outcomes. This study aimed to further identify the efficacy and safety of erector spinae plane block in patients undergoing lumbar spine surgery. This study also evaluates the outcomes of the erector spinae plane block compared with other regional blocks.

METHODS

We searched PubMed, Web of Science, Cochrane library, Embase, and CINAHL databases to identify all randomized controlled trials evaluating the effects of ESPB on postoperative pain after lumbar spine surgery. The primary outcome is postoperative total opioid consumption in 24 hours. The secondary outcomes are postoperative pain scores, intraoperative opioid consumption, time to first rescue analgesia, number of patients requiring rescue analgesia, first time to ambulation after surgery, length of hospital stay, patients' satisfaction score, and postoperative side effects such as postoperative nausea and vomiting, itching.

RESULTS

A total of 19 randomized controlled trials are included in the final analysis. Compared with no/sham block, ultrasound-guided erector spinae plane block can decrease perioperative opioid consumption including intraoperative opioid consumption: standardized mean difference (SMD) = -3.04, 95% confidence interval (CI) (-3.99, -2.09), P < .01, and opioid consumption postoperatively: (SMD = -2.80, 95% CI [-3.61, -2.00], P < .01); reduce postoperative pain at 2, 6, 12, 24, and 48 hours both at rest and movement; meanwhile shorten time to hospital length of stay: (SMD = -1.01, 95% CI [-1.72, 0.30], P = .006), decrease postoperative nausea and vomiting (RR = 0.35, 95% CI [0.27, 0.46], P < .00001), and improve patient satisfaction (SMD = -2.03, 95% CI [-0.96, 3.11], P = .0002). But ultrasound-guided ESPB doesn't shorten the time to ambulation after surgery (SMD = -0.56, 95% CI [-1.21, 0.08], P = .09). Additionally, ESPB is not superior to other regional blocks (e.g., thoracolumbar interfascial plane/midtransverse process to pleura block).

CONCLUSION

This meta-analysis demonstrates that ultrasound-guided ESPB can provide effective postoperative analgesia in patients undergoing lumbar spine surgery and improve postoperative outcomes, and it deserves to be recommended as an analgesic adjunct in patients undergoing lumbar spine surgeries.

Contrast Spread After Erector Spinae Plane Block at the Fourth Lumbar Vertebrae: A Cadaveric Study

INTRODUCTION

In recent years, the erector spinae plane block (ESPB) has seen widespread use to treat acute and chronic pain in the regions of the thoracic spine. While limited data suggest its increasing utilization for pain management distal to the thoracic, abdomen and trunk, the anesthetic spread and analgesic mechanism of ESPB at the level of the lumbar spine has not been fully described or understood.

METHODS

This is an observational anatomic cadaveric study to assess the distribution of solution following an ESPB block performed at the fourth lumbar vertebrae (L4) using ultrasound guidance to evaluate the spread of a 20 ml solution consisting of local anesthetic and methylene blue. The study was performed in an anatomy lab in a large academic medical center. Following injection of local anesthetic with contrast dye, cadaveric dissection was performed to better understand the extent of contrast dye and to determine the degree of staining to further predict analgesic potential. We reviewed the findings of other ESPB cadaveric studies currently available for comparison.

RESULTS

Following cadaveric dissection in an anatomy lab, the contrast dye was observed in the ESP space, and staining was found most cranially at L2 and extending caudally underneath the sacrum. Evaluating the depth of its spread, we found it to be confined to the posterior compartment of the spine sparing the nerve roots bilaterally, which is consistent with the only other cadaveric study of ESPB performed at L4.

CONCLUSION

Our results demonstrate the clinical utility of lumbar ESPB where posterior confinement of local anesthesia is preferred. However, further investigation is needed to determine the efficacy of ESPB in lower extremity analgesia which is predicated on ventral nerve root involvement.

Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind, randomized controlled trial

PURPOSE

The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery.

METHODS

A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10-15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded.

RESULTS

The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred.

CONCLUSION

The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

Intradermal and Intramuscular Bupivacaine Reduces Opioid Use Following Noninstrumented Spine Surgery

OBJECTIVE

To evaluate the efficacy of intraoperative bupivacaine hydrochloride wound infiltration as an adjunct means of pain relief following noninstrumented posterior spine surgery.

METHODS

A retrospective cohort analysis was performed of all patients who underwent posterior spinal decompression surgery at the University of California, San Diego, and at the San Diego VA Medical Center between June 2020 and July 2021, following a change in practice to including bupivacaine infiltration at the end of the surgery. Patients were stratified into groups based on whether they received intrawound bupivacaine during surgery. Demographic and clinical data were extracted from the electronic health record. Postoperative opioid use, visual analog pain scores, heart rate, and blood pressure were compared.

RESULTS

The analysis included 43 patients; 21 received bupivacaine infiltration, and 22 did not. No complications were encountered in the perioperative period. Patients who received bupivacaine consumed significantly less opioids over the 72 hours following surgery, had slightly lower pain scores, and experienced slightly lower heart rates. No significant difference was found between groups with respect to systolic blood pressure, operative time, or length of hospital stay.

CONCLUSIONS

Intraoperative infiltration of the exposed paraspinous musculature and peri-incisional subdermal layer with bupivacaine significantly reduced postoperative opioid consumption for 72 hours after surgery and slightly reduced pain ratings and conferred superior heart rate control. This low-cost intervention produced significant patient benefit with minimal risk and no significant increase in surgical time or hospital stay.

Comparison of postoperative IL-6 and IL-10 levels following Erector Spinae Plane Block (ESPB) and classical Thoracolumbar Interfascial Plane (TLIP) block in a posterior lumbar decompression and stabilization procedure: a randomized controlled trial

BACKGROUND AND OBJECTIVES

The erector spinae plane block (ESPB) and classical thoracolumbar interfascial plane (TLIP) block can reduce postoperative pain in lumbar surgery. In this study, we compared the efficacy of ESPB and classical TLIP block in providing perioperative analgesia in patients undergoing lumbar posterior decompression and stabilization by comparing postoperative pain, opioid consumption, and IL-6 and IL-10 serum concentrations between ESPB and classical TLIP block.

METHOD

This was a prospective, double-blinded, randomized controlled trial in tertiary referral hospitals. Forty patients were randomized into two equal groups, each receiving either ESPB or classical TLIP block. The primary outcome was the difference in IL-6 and IL-10 serum concentrations at baseline and 6 h after lumbar posterior decompression and stabilization. The secondary outcome was total opioid consumption and pain score 24 h post-operatively.

RESULT

There were no significant differences between the ESPB and classical TLIP block groups in pain score, IL-6 and IL-10 concentration change, and total opioid consumption post-operatively. There was a significant difference in the time until the first dose of morphine was needed between the ESPB and classical TLIP block groups (300 min vs. 547.5 min; p = 0.002).

CONCLUSION

ESPB and classical TLIP block performance during lumbar surgery have comparable pain scores, IL-6 and IL-10 concentration differences pre- and post-operation, and total opioid consumption post-operatively. However, classical TLIP block provides a prolonged duration of analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04951024.

Comparison of the feasibility and validity of a one-level and a two-level erector spinae plane block combined with general anesthesia for patients undergoing lumbar surgery

Background

Spinal surgery causes severe postoperative pain. An erector spinae plane (ESP) block can relieve postoperative pain, but the optimal blocking method has not been defined. The aim of this study is to compare the feasibility of a one-level and a two-level lumbar ESP block and their effect on intraoperative and postoperative analgesia in lumbar spinal surgery.

Methods

A total of 83 adult patients who were scheduled for posterior lumbar interbody fusion were randomly divided into two groups. Patients in Group I (n = 42) received an ultrasound-guided bilateral one-level ESP block with 0.3% ropivacaine, while patients in Group II (n = 41) received a bilateral two-level ESP block. Blocking effectiveness was evaluated, including whether a sensory block covered the surgical incision, sensory decrease in anterior thigh, and quadriceps strength decrease. Intraoperative anesthetic dosage, postoperative visual analogue scale scores of pain, opioid consumption, rescue analgesia, and opioid-related side effects were analyzed.

Results

Of the total number, 80 patients completed the clinical trial and were included in the analysis, with 40 in each group. The time to complete the ESP block was significantly longer in Group II than in Group I (16.0 [14.3, 17.0] min vs. 9.0 [8.3, 9.0] min, P = 0.000). The rate of the sensory block covering the surgical incision at 30 min was significantly higher in Group II than in Group I (100% [40/40] vs. 85.0% [34/40], P = 0.026). The rate of the sensory block in the anterior thigh was higher in Group II (43.8% [35/80] vs. 27.5% [22/80], P = 0.032), but the rate of quadriceps strength decrease did not differ significantly between the groups. The mean effect-site remifentanil concentration during intervertebral decompression was lower in Group II than in Group I (2.9 ± 0.3 ng/ml vs. 3.3 ± 0.5 ng/ml, P = 0.007).There were no significant differences between the groups in terms of intraoperative analgesic consumption, postoperative analgesic consumption, and postoperative VAS pain scores at rest and with movement within 24 h. There were no block failures, block-related complications, and postoperative infection.

Conclusions

Among patients undergoing posterior lumbar interbody fusion, the two-level ESP block provided a higher rate of coverage of the surgical incision by the sensory block when compared with the one-level method, without increasing the incidence of procedure-related complications.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2100043596.

In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes

Objective

To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation.

Methods

This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes.

Results

A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications.

Conclusions

Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.

The Effect of Online Prescription Drug Monitoring on Opioid Prescription Habits After Elective Single-level Lumbar Fusion

INTRODUCTION

The United States opioid epidemic is a well-documented crisis stemming from increased prescriptions of narcotics. Online prescription drug monitoring programs (PDMPs) are a potential resource to mitigate narcotic misuse by tracking controlled substance prescriptions. Therefore, the purpose of this study was to evaluate opioid prescription trends after implementation of an online PDMP in patients who underwent single-level lumbar fusion.

METHODS

Patients who underwent a single-level lumbar fusion between August 27, 2017, and August 31, 2020, were identified and placed categorically into one of two cohorts: an "early adoption" cohort, September 1, 2017, to August 31, 2018, and a "late adoption" cohort, September 1, 2019, to August 31, 2020. This allowed for a 1-year washout period after Pennsylvania PDMP implementation on August 26, 2016. Opioid use data were obtained by searching for each patient in the state government's online PDMP and recording data from the year before and the year after the patient's procedure.

RESULTS

No significant difference was observed in preoperative opioid prescriptions between the early and late adoption cohorts. The late adoption group independently predicted decreased postoperative opioid prescriptions (β, 0.78; 95% confidence interval [CI], 0.65 to 0.93; P = 0.007), opioid prescribers (β, 0.81; 95% CI, 0.72 to 0.90; P < 0.001), pharmacies used (β, 0.90; 95% CI, 0.83 to 0.97; P = 0.006), opioid pills (β, 0.61; 95% CI, 0.50 to 0.74; P < 0.001), days of opioid prescription (β, 0.57; 95% CI, 0.45 to 0.72; P < 0.001), and morphine milligram equivalents prescribed (β, 0.53; 95% CI, 0.43 to 0.66; P < 0.001).

CONCLUSIONS

PDMP implementation was associated with decreased postoperative opioid prescription patterns but not preoperative opioid prescribing behaviors.

LEVELS OF EVIDENCE

4.

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.

Effects of Palmitoylethanolamide (PEA) on Nociceptive, Musculoskeletal and Neuropathic Pain: Systematic Review and Meta-Analysis of Clinical Evidence

Some 30−50% of the global population and almost 20% of the European population actually suffer from chronic pain, which presents a tremendous burden to society when this pain turns into a disability and hospitalization. Palmitoylethanolamide (PEA) has been demonstrated to improve pain in preclinical contexts, but an appraisal of clinical evidence is still lacking. The present study aimed at addressing the working hypothesis for the efficacy of PEA for nociceptive musculoskeletal and neuropathic pain in the clinical setting. The systematic search, selection and analysis were performed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. The primary outcome was pain reduction, as measured by a pain assessment scale. The secondary outcome was improvement in quality of life and/or of parameters of function. The results obtained for a total of 933 patients demonstrate the efficacy of PEA over the control (p < 0.00001), in particular in six studies apart from the two randomized, double-blind clinical trials included. However, the results are downgraded due to the high heterogeneity of the studies (I2 = 99%), and the funnel plot suggests publication bias. Efficacy in achieving a reduction in the need for rescue medications and improvement in functioning, neuropathic symptoms and quality of life are reported. Therefore, adequately powered randomized, double-blind clinical trials are needed to deepen the domains of efficacy of add-on therapy with PEA for chronic pain. PROSPERO registration: CRD42022314395.