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McClure A, Silveri OC, Foddrell M, Duteil K, Madarász LE, Silveri CP. Efficacy of Liposomal Bupivacaine in Reducing Opioid Use After Posterior Lumbar Spinal Decompression and Fusion. Orthopedics 2024; 47:244-248. [PMID: 38568003 DOI: 10.3928/01477447-20240325-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Despite improvements in drug therapy and treatment of lumbar spinal disorders, dependence on opioid medication for postoperative pain control remains a concern nationwide. This study assessed the ability to diminish the reliance on opioid medication postoperatively with the Food and Drug Administration-approved local anesthetic liposomal bupivacaine in open posterior lumbar decompression and fusion procedures. In addition, the possible effects of this modality on other parameters were studied regarding patients and their recovery. MATERIALS AND METHODS A retrospective chart review of 198 patients who underwent an open posterior lumbar laminectomy and fusion surgery with instrumentation treated by a single surgeon in a single institution was conducted. Ninety-nine patients who received liposomal bupivacaine administered intraoperatively were then matched by age, sex, and procedure with the same number of patients treated prior to the availability of liposomal bupivacaine. We evaluated how the use of liposomal bupivacaine affected the requirement for postoperative opioid medication, as well as related changes in length of stay, the use of antiemetics, and urinary retention postoperatively. RESULTS The patients who received liposomal bupivacaine required less than half of the morphine milligram equivalents of narcotic medications during their hospital stay compared with patients who did not receive liposomal bupivacaine (approximately 57% reduction). CONCLUSION The findings of this study suggest that the addition of liposomal bupivacaine to traditional pain management modalities can augment pain management for patients undergoing posterior lumbar surgery, as evidenced by the significant decrease in postoperative morphine milligram equivalents required. [Orthopedics. 2024;47(4):244-248.].
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Changoor S, Giakas A, Sacks K, Asma A, Lang RS, Yorgova P, Rogers K, Gabos PG, Shah SA. The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther With Less Opioids. Spine (Phila Pa 1976) 2024; 49:E11-E16. [PMID: 37159268 DOI: 10.1097/brs.0000000000004702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
STUDY DESIGN Retrospective controlled cohort. OBJECTIVE To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). SUMMARY OF BACKGROUND DATA Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. METHODS 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. RESULTS Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. CONCLUSIONS LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stuart Changoor
- Department of Orthopedic Surgery, St. Joseph's University Medical Center, Paterson, NJ
| | - Alec Giakas
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Jefferson Health, Philadelphia, PA
| | - Karen Sacks
- Department of Anesthesia, Nemours Children's Health, Wilmington, DE
| | - Ali Asma
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - R Scott Lang
- Department of Anesthesia, Nemours Children's Health, Wilmington, DE
| | - Petya Yorgova
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Kenneth Rogers
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Peter G Gabos
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
| | - Suken A Shah
- Department of Orthopedic Surgery, Nemours Children's Health, Wilmington, DE
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Dincer A, Wang A, Kanter MJ, Olmos M, Yang M, Riesenburger RI, Kryzanski JT. Clinical Outcomes of Liposomal Bupivacaine Erector Spinae Block in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery. Neurosurgery 2023; 92:590-598. [PMID: 36512838 PMCID: PMC10158925 DOI: 10.1227/neu.0000000000002249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Postoperative pain is a barrier to early mobility and discharge after lumbar surgery. Liposomal bupivacaine (LB) has been shown to decrease postoperative pain and narcotic consumption after transforaminal lumbar interbody fusions (TLIFs) when injected into the marginal suprafascial/subfascial plane-liposomal bupivacaine (MSSP-LB). Erector spinae plane (ESP) infiltration is a relatively new analgesic technique that may offer additional benefits when performed in addition to MSSP-LB. OBJECTIVE To evaluate postoperative outcomes of combining ESP-LB with MSSP-LB compared with MSSP-LB alone after single-level TLIF. METHODS A retrospective analysis was performed for patients undergoing single-level TLIFs under spinal anesthesia, 25 receiving combined ESP-LB and MSSP-LB and 25 receiving MSSP-LB alone. The primary outcome was length of hospitalization. Secondary outcomes included postoperative pain score, time to ambulation, and narcotics usage. RESULTS Baseline demographics and length of surgery were similar between groups. Hospitalization was significantly decreased in the ESP-LB + MSSP-LB cohort (2.56 days vs 3.36 days, P = .007), as were days to ambulation (0.96 days vs 1.29 days, P = .026). Postoperative pain area under the curve was significantly decreased for ESP-LB + MSSP-LB at 12 to 24 hours (39.37 ± 21.02 vs 53.38 ± 22.11, P = .03) and total (44.46 ± 19.89 vs 50.51 ± 22.15, P = .025). Postoperative narcotic use was significantly less in the ESP-LB + MSSP-LB group at 12 to 24 hours (13.18 ± 4.65 vs 14.78 ± 4.44, P = .03) and for total hospitalization (137.3 ± 96.3 vs 194.7 ± 110.2, P = .04). CONCLUSION Combining ESP-LB with MSSP-LB is superior to MSSP-LB alone for single-level TLIFs in decreasing length of hospital stay, time to ambulation, postoperative pain, and narcotic use.
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Affiliation(s)
- Alper Dincer
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
| | - Andy Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
- Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Matthew J. Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
- Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
- Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michael Yang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
| | - Ron I. Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
| | - James T. Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA;
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Pennington J, Contini S, Brown M, Goel N, Chen T. Efficacy of intrathecal morphine administration in pediatric patients undergoing selective dorsal rhizotomy. J Pediatr Rehabil Med 2023; 16:109-114. [PMID: 36806525 DOI: 10.3233/prm-220048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. METHODS This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. RESULTS Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). CONCLUSION Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.
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Affiliation(s)
| | | | | | - Nupur Goel
- Northeast Ohio Medical University, Rootstown, OH, USA
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Gannon E, Freeman M, Cornett C, Vincent S, Powers S, Lyden E. The Effects of Liposomal Bupivacaine on Long-term Outcomes and Decreasing Immediate Postoperative Opioid Use Following One-level and Two-level Posterior Lumbar Fusions. Clin Spine Surg 2023; 36:E29-E34. [PMID: 35706091 DOI: 10.1097/bsd.0000000000001354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/18/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN This is a retrospective observational study. OBJECTIVE This study aims to determine the efficacy of liposomal bupivacaine in postoperative analgesia and long-term outcomes in patients undergoing one-level and two-level posterior lumbar fusion. SUMMARY OF BACKGROUND DATA Multiple studies have investigated the use of liposomal bupivacaine in spine surgery with varying results. The potential benefits of its use include decreasing postoperative opioid use, improved pain control, and a shorter hospital stay. Several studies have supported its use in spine surgery with others showing minimal to no benefit. No studies have investigated its possible impact on long-term outcomes. MATERIALS AND METHODS A total of 42 patients (22 one-level, 20 two-level) received liposomal bupivacaine injection just before surgical closure and were compared with a historical control group of 42 patients (27 one-level, 15 two-level) that did not receive liposomal bupivacaine. Daily opioid consumption was collected and converted to oral morphine equivalents. Length of stay and daily average pain scores using the visual analog scale were also recorded. In addition, SF-36 bodily pain and physical function outcome measures were collected preoperatively and at 6 months, 1 year and 2 years postoperatively. RESULTS The liposomal bupivacaine group was found to have a significantly lower total opioid consumption compared with the control group ( P =0.001). The liposomal bupivacaine group was also found to use significantly fewer opioids on the day of surgery compared with the control group ( P <0.0001). There was no significant difference shown in the average visual analog scale pain scores, length of stay, or long-term outcomes between the 2 groups. CONCLUSIONS The use of liposomal bupivacaine in one-level and two-level posterior lumbar fusions shows promise as an adjuvant for postoperative analgesia by decreasing postoperative opioid consumption. With the varying results demonstrated with the utilization of liposomal bupivacaine in spine surgery, further investigation is warranted, namely a larger prospective randomized control study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | - Elizabeth Lyden
- Public Health-Biostatistics, University of Nebraska Medical Center, Omaha, NE
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Forrester DA, Miner H, Shirazi C, Kavadi N. Liposomal bupivacaine in posterior spine surgery: A piece of the puzzle for postoperative pain. J Orthop 2022; 33:55-59. [PMID: 35864926 PMCID: PMC9293726 DOI: 10.1016/j.jor.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/05/2022] [Accepted: 07/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background Liposomal bupivacaine (LB) is a local analgesic that may be used at the time of surgery to limit postoperative pain around the surgical site. Its efficacy in decreasing pain, decreasing narcotic consumption, decreasing length of stay, and improving mobility is an area of intense research. The purpose of this study was to determine whether LB use was associated with improved patient-reported pain scores in the first 72 h following posterior spinal surgery, decreased postoperative narcotic need, and decreased length of stay. Methods One hundred and five patients undergoing elective posterior cervical or lumbar surgery were included in retrospective analysis. Forty-eight patients who received LB intraoperatively were compared with a historical cohort of 56 patients who underwent similar procedures and did not receive postsurgical infiltration with local analgesia. The same pain medication protocol was utilized postoperatively. Results Demographics, clinical characteristics, and total morphine milligram equivalents did not differ significantly between the groups. The treatment group averaged a decreased length of stay (1.85 days treatment, 2.68 days control, p = 0.057). Treatment with LB was associated with lower pain levels at 24 h (5.2 treatment, 6.4 control, p = 0.04) and 48-72 h (4.9 treatment, 6.6 control, p = 0.007) after surgery. Conclusions LB improved patient perception of pain in the acute postoperative time period.Intraoperative LB injection, coupled with focused early mobilization efforts and multimodal pain control, may lead to improved patient-reported outcomes, shorter length of stay, and decreased risk of perioperative complications.
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Affiliation(s)
- D. Alex Forrester
- Department of Orthopedic Surgery and Rehabilitation, Oklahoma University Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK, 73117, USA
| | - Harrison Miner
- Department of Orthopedic Surgery and Rehabilitation, Oklahoma University Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK, 73117, USA
| | - Cameron Shirazi
- Department of Orthopedic Surgery and Rehabilitation, Oklahoma University Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK, 73117, USA
| | - Niranjan Kavadi
- Department of Orthopedic Surgery and Rehabilitation, Oklahoma University Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK, 73117, USA
- Department of Orthopedic Surgery, Oklahoma City Veterans Affairs Health Care System, 921 NE 13th Street, Oklahoma City, OK, 73104, USA
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Corley JA, Charalambous LT, Mehta VA, Wang TY, Abdelgadir J, Than KD, Abd-El-Barr MM, Goodwin CR, Shaffrey CI, Karikari IO. Perioperative Pain Management for Elective Spine Surgery: Opioid Use and Multimodal Strategies. World Neurosurg 2022; 162:118-125.e1. [PMID: 35339713 DOI: 10.1016/j.wneu.2022.03.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
In recent years, physicians and institutions have come to recognize the increasing opioid epidemic in the United States, thus prompting a dramatic shift in opioid prescribing patterns. The lack of well-studied alternative treatment regimens has led to a substantial burden of opioid addiction in the United States. These forces have led to a huge economic burden on the country. The spine surgery population is particularly high risk for uncontrolled perioperative pain, because most patients experience chronic pain preoperatively and many patients continue to experience pain postoperatively. Overall, there is a large incentive to better understand comprehensive multimodal pain management regimens, particularly in the spine surgery patient population. The goal of this review is to explore trends in pain symptoms in spine surgery patients, overview the best practices in pain medications and management, and provide a concise multimodal and behavioral treatment algorithm for pain management, which has since been adopted by a high-volume tertiary academic medical center.
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Affiliation(s)
- Jacquelyn A Corley
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
| | | | - Vikram A Mehta
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Timothy Y Wang
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jihad Abdelgadir
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Muhammad M Abd-El-Barr
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - C Rory Goodwin
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Isaac O Karikari
- Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Efficacy of liposomal bupivacaine in spine surgery: a systematic review. Spine J 2021; 21:1450-1459. [PMID: 33618032 DOI: 10.1016/j.spinee.2021.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spine surgery with posterior approaches may involve extensive manipulation of native structures, resulting in significant postoperative pain. Liposomal bupivacaine (LB) is an injectable analgesic that has demonstrated efficacy in decreasing postoperative pain and opioid requirements in patients across multiple surgical subspecialties. PURPOSE To consolidate and analyze the findings of retrospective cohort-matched studies and prospective randomized controlled trials investigating the use of LB in spine surgery. STUDY DESIGN A systematic review. STUDY SAMPLE Retrospective cohort-matched studies and randomized controlled trials (RCTs) investigating the efficacy of injected LB in spinal surgery compared with a control/no treatment group. METHODS MEDLINE, Cochrane controlled trials register, and Google Scholar were searched to identify all studies that examined the effect of LB use on outcomes in spine surgery. Our search identified 10 articles that independently evaluated the effect of LB on reduction of postoperative opioid use, pain scores, hospital length of stay, cost, and incidence of adverse effects. The principles of GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) were applied to assess the quality of evidence from each study. RESULTS Ten studies were analyzed (1,112 total patients). LB was associated with significantly lower millimolar morphine equivalents (MME) of postoperative opioids, especially in opiate-tolerant patients, visual analog scale (VAS) scores, area under the curve (AUC) of cumulative pain scores, numeric pain scale scores, and hospital length of stay (LOS), with comparable or lower odds of adverse effects relative to controls. CONCLUSIONS Low-quality evidence suggests that liposomal bupivacaine may safely decrease postoperative opioid requirements, pain scores, and length of stay in patients undergoing spine surgery, whereas moderate-quality evidence does not support its use at this time. Therefore, additional standardized well-powered prospective studies are necessary to more clearly assess the efficacy of LB in spine surgery.
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Wang S, Wang B, Yu X, Ma T, Ntambale MC, Yan J, Ding Q, Zhang R, Wu H, Liu C. Efficacy of gelatin sponge impregnated with ropivacaine on postoperative pain after transforaminal lumbar interbody fusion: a comparative study. BMC Musculoskelet Disord 2021; 22:660. [PMID: 34362341 PMCID: PMC8343912 DOI: 10.1186/s12891-021-04541-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the efficacy of gelatin sponge impregnated with ropivacaine on postoperative pain after transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative diseases. METHODS We retrospectively reviewed patients who underwent TLIF in our department between August 2018 and January 2020. Patients were divided to ropivacaine group and saline group. A ropivacaine group whom received gelatin sponge impregnated with ropivacaine during operation, and a saline group whom were intraoperatively administered by gelatin sponge impregnated with saline. The two groups were compared in reference to postoperative hospital stay, postoperative complications and visual analog scale (VAS) scores. The consumption of postoperative diclofenac sodium suppository use was also recorded. The Oswestry Disability Index (ODI) scores and Japanese Orthopedic Association (JOA) scores were used for functional evaluation at 1 year postoperatively. RESULT A total of 127 patients were evaluated in this retrospective study. The mean postoperative hospital stay in the ropivacaine group was significantly lower than saline group. The VAS score was significantly lower in patients receiving gelatin sponge impregnated with ropivacaine as compared with patients in saline group on postoperative day 1, 2, 3 and 4. The number of patients who need the administration of diclofenac sodium suppository and the mean consumption of postoperative diclofenac sodium suppository was significantly lower in the ropivacaine group as compared with saline group. CONCLUSION The application of gelatin sponge impregnated with ropivacaine around the nerve root in patients undergoing TLIF can effectively control the postoperative pain and reduce postoperative hospital stay.
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Affiliation(s)
- Shanxi Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Bo Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Xiaojun Yu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Tian Ma
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Mubotu C Ntambale
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Jiyuan Yan
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Qing Ding
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Ruizhuo Zhang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China
| | - Hua Wu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China.
| | - Chaoxu Liu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue 1095, Wuhan, 430030, People's Republic of China.
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Chung AS, Crandall D, Revella J, Adeniyi B, Chang YHH, Chang MS. Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery? Global Spine J 2021; 11:896-902. [PMID: 32677519 PMCID: PMC8258814 DOI: 10.1177/2192568220931053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients. METHODS Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study. RESULTS A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 (P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 (P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts. CONCLUSIONS The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer's recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.
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Affiliation(s)
- Andrew S. Chung
- Sonoran Spine Center, Phoenix, AZ, USA,Andrew S. Chung, Sonoran Spine Center, 1255 W Rio Salado Pkwy #107, Tempe, AZ 85281, USA.
| | - Dennis Crandall
- Sonoran Spine Center, Phoenix, AZ, USA,Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | - Jan Revella
- Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | - Biodun Adeniyi
- Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
| | | | - Michael S. Chang
- Sonoran Spine Center, Phoenix, AZ, USA,Sonoran Spine Research and Education Foundation, Phoenix, AZ, USA
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11
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Lu VM, Daniels DJ, Haile DT, Ahn ES. Effects of intraoperative liposomal bupivacaine on pain control and opioid use after pediatric Chiari I malformation surgery: an initial experience. J Neurosurg Pediatr 2021; 27:9-15. [PMID: 33007744 DOI: 10.3171/2020.6.peds20370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric Chiari I malformation decompression is a common neurosurgical procedure. Liposomal bupivacaine (LB) is a novel formulation that can have an impact on postoperative recovery for particular procedures, but its potential role in pediatric neurosurgery is largely unexplored. The authors sought to describe and assess their initial experience with LB in pediatric Chiari I malformation decompression to better define its potential role as an analgesic agent in a procedure for which the postoperative course is often remarkably painful. METHODS A retrospective review of all pediatric Chiari procedures performed at the authors' institution between 2018 and 2020 was conducted. Patients were divided into those who were treated with a single intraoperative dose of LB (LB group) and those who were not (control group). Comparisons of total opioid use and pain control were made using chi-square and Wilcoxon rank-sum tests. RESULTS A total of 18 patients were identified, 9 (50%) in the LB group and 9 (50%) in the control group. Overall, there were 13 (72%) female and 5 (28%) male patients with a mean age of 15.9 years. No surgical complications were observed over a mean length of stay of 2.7 days. Within the first 24 hours after surgery, the LB group had significantly lower total opioid use than the control group (17.5 vs 47.9 morphine milligram equivalents, respectively; p = 0.03) as well as lower mean pain scores reported by patients using a 10-point visual analog scale (3.6 vs 5.5 for the LB vs control groups, p = 0.04). However, from the first 24 postoperative hours to discharge, total opioid use (p = 0.51) and mean pain scores (p = 0.09) were statistically comparable between the two groups. There were 2/9 (22%) LB patients versus 0/9 (0%) control patients who did not require opioid analgesia at any point during hospitalization. CONCLUSIONS The use of a single intraoperative dose of LB in pediatric Chiari I malformation surgery appears to be safe and has the potential to reduce pain scores and opioid use when administered during the first 24 postoperative hours. From that time period to discharge, however, there may be no significant difference in total opioid use or pain scores.
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Affiliation(s)
| | | | - Dawit T Haile
- 2Pediatric Anesthesiology, Mayo Clinic, Rochester, Minnesota
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Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children: A Controlled Cohort Study. Clin Spine Surg 2020; 33:E533-E538. [PMID: 32324672 DOI: 10.1097/bsd.0000000000000996] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective comparative cohort study. OBJECTIVE To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). CONCLUSIONS This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. LEVEL OF EVIDENCE Level III.
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Siam EM, Abo Aliaa DM, Elmedany S, Abdelaa ME. Erector spinae plane block combined with general anaesthesia versus conventional general anaesthesia in lumbar spine surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1821501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ezzzt M. Siam
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Doaa M. Abo Aliaa
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Sally Elmedany
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Mohamed E. Abdelaa
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Pace V, Gul A, Prakash V, Park C, Placella G, Raine G. Wound Infiltration with Levobupivacaine, Ketorolac, and Adrenaline for Postoperative Pain Control after Spinal Fusion Surgery. Asian Spine J 2020; 15:539-544. [PMID: 32872752 PMCID: PMC8377213 DOI: 10.31616/asj.2020.0107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/09/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design This study enrolled patients in from a single center who underwent primary spinal fusion procedure and divided them into two groups (group-control study). Purpose Good local infiltration can reduce postoperative analgesic requirements and enable expedited discharge. Administration of a combination of levobupivacaine (200 mg/100 mL, 0.9% normal saline), ketorolac (30 mg), and adrenaline (0.5 mg) as a wound infiltrate is recommended at an optimum combination. Overview of Literature There is currently no consensus on the optimum intraoperative local infiltration of spinal surgery patients undergoing operative fusion. Methods Patients who were enrolled in two spinal centers (over 24 months) undergoing primary spinal fusion procedures were allocated into two groups, comparing the type of local infiltration used at the time of the procedure. Group 1 received the combination of levobupivacaine (200 mg), ketorolac (30 mg), and adrenaline (0.5 mg), while group 2 received other types of local anesthetics. Primary outcome measures include patient-controlled analgesia (PCA) use, morphine consumption, and length of hospital stay. Secondary outcome measure are as follows: days of physiotherapy, pain score, side effects, and complications. Results There are a total of 140 patients enrolled. Seventy-five patients enrolled were allocated to group 1, receiving the study combination, and 65 patients were assigned in group 2, receiving other local infiltrations. All primary outcome measures (consumption of morphine, use of PCA, and length of stay) were significantly higher in group 2 than the study combination (p<0.05). The secondary outcomes of pain scores and days of physiotherapy values were also significantly higher in group 2 (p<0.05). Patient satisfaction questionnaires gave significantly better results in group 1 (p<0.05). There were no significant statistical differences with regard to any postoperative complications between the two groups. Conclusions Our data suggest that the studied wound infiltration is a safe and feasible option that could provide good postoperative pain control without significant side effects. It also allowed to reduce dependence of opioids and PCA, earlier postoperative mobilization, lower pain scores postoperatively, and reduced hospital stay.
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Affiliation(s)
- Valerio Pace
- Department of Trauma and Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Arif Gul
- Department of Trauma and Orthopaedics, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Varadarajan Prakash
- Department of Trauma and Orthopaedics, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Chang Park
- Department of Trauma and Orthopaedic Surgery, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Giacomo Placella
- Department of Trauma and Orthopaedics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Geoffrey Raine
- Department of Anaesthetics, The Princess Alexandra Hospital NHS Trust, Harlow, UK
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Bodendorfer BM, Shu HT, Lee CS, Ivey J, Mo FF, Wall RT. Unintentional Epidural Anesthesia Mimicking Cauda Equina Syndrome from Suprafascial Injection of Liposomal Bupivacaine After Lumbar Foraminotomy: A Case Report. JBJS Case Connect 2020; 10:e1900605. [PMID: 32649143 DOI: 10.2106/jbjs.cc.19.00605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE This case report describes a 46-year-old woman undergoing right-sided L5 to S1 decompression who received liposomal bupivacaine (LB) for postoperative analgesia and developed unintentional epidural anesthesia with symptoms mimicking cauda equina syndrome. The patient's symptoms resolved 72 hours postoperatively, approximately the length that LB typically lasts. At the 16-month follow-up, the patient demonstrated complete neurological function with no lower extremity strength or sensation deficits. CONCLUSIONS Tracking of LB into the epidural space after lumbar surgery may cause transient epidural anesthesia with symptoms that mimic cauda equina syndrome.
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Affiliation(s)
- Blake M Bodendorfer
- 1Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, District of Columbia 2Department of Anesthesiology, Georgetown University Medical Center, Washington, District of Columbia
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Opioid Alternatives in Spine Surgery: A Narrative Review. J Neurosurg Anesthesiol 2020; 34:3-13. [PMID: 32568816 DOI: 10.1097/ana.0000000000000708] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/19/2020] [Indexed: 11/26/2022]
Abstract
Adequate analgesia is known to improve outcomes after spine surgery. Despite recent attention highlighting the negative effects of narcotics and their addiction potential, opioids have been the mainstay of management for providing analgesia following spine surgeries. However, side effects including hyperalgesia, tolerance, and subsequent dependence restrict the generous usage of opioids. Multimodal analgesia regimens acting through different mechanisms offer significant opioid sparing and minimize the side effects of individual drugs. Hence, they are being increasingly incorporated into enhanced recovery protocols. Multimodal analgesia includes drugs such as N-methyl-D-aspartate antagonists, nonsteroidal anti-inflammatory drugs and membrane-stabilizing agents, neuraxial opioids, local anesthetic infiltration, and fascial compartment blocks. Analgesia started before the painful stimulus, termed preemptive analgesia, facilitates subsequent pain management. Both nonsteroidal anti-inflammatory drugs and neuraxial analgesia have been conclusively shown to reduce opioid requirements after spine surgery, and there is a resurgence of interest in the use of low-dose ketamine or methadone. Neuraxial narcotics offer enhanced analgesia for a longer duration with lower dosage and side effect profiles compared with systemic opioid administration. Fascial compartment blocks are increasingly used as they provide effective analgesia with fewer adverse effects. In this narrative review, we will discuss multimodality analgesic regimens incorporating opioid-sparing adjuvants to manage pain after spine surgery.
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Katsevman GA, Allison AA, Fang W, Confer J, Elhamdani S, Hoyt A, Garavaglia JM, Marsh RA. Retrospective Assessment of the Use of Liposomal Bupivacaine in Lumbar Fusions in Immediate Postoperative Hospital Care. World Neurosurg 2020; 141:e820-e828. [PMID: 32540284 DOI: 10.1016/j.wneu.2020.06.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Liposomal bupivacaine (LB) is approved by the U.S. Food and Drug Administration for administration into surgical sites for postsurgical analgesia. The liposomal formulation allows for sustained effects up to 72 hours. METHODS A retrospective study assessed patients undergoing lumbar interbody surgery. Visual analog scale pain scores and amount of opioids consumed were recorded at 12-hour intervals for 72 hours postoperatively, as were patterns of discharge and hospital length of stay (LOS). RESULTS A total of 122 patients (97 LB vs. 25 control group) were reviewed. Median LOS was shorter in the LB cohort compared with controls (1.94 vs. 3.08 days, respectively; P = 0.0043). When assessing the percentage of discharges between groups at 12-hour intervals, there were significantly more discharges in the LB cohort at 36-48 hours (P = 0.0226), and no differences elsewhere. There was a decrease in intravenous opioids consumed at 48-60 hours in the LB cohort compared with controls (P = 0.0494), a difference not detected at other time points or with oral or total opioids. Mean visual analog scale scores were significantly higher in the LB cohort compared with controls at 0-12 hours (5.2 vs. 3.9, respectively; P = 0.0079), but insignificantly different subsequently up to 72 hours. The LB cohort and controls were not significantly different in total amount of opioids consumed, overall pain scores, or regarding how the opioid amount consumed or pain scores changed over time. CONCLUSIONS The use of LB in lumbar interbody fusion decreases patients' LOS but has little effect on reducing overall pain scores or opioid use in the 72-hour postoperative hospital period.
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Affiliation(s)
- Gennadiy A Katsevman
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
| | - Andrew A Allison
- Department of Pharmacy, WVU Medicine, Morgantown, West Virginia, USA
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, West Virginia University Health Sciences Center Erma Byrd Biomedical Research Center, Morgantown, West Virginia, USA
| | - Jennifer Confer
- Department of Pharmacy, Cabell Huntington Hospital, Huntington, West Virginia, USA
| | - Shahed Elhamdani
- Department of Neurosurgery, Marshall University, Huntington, West Virginia, USA
| | - Alastair Hoyt
- Department of Neurosurgery, Marshall University, Huntington, West Virginia, USA
| | | | - Robert A Marsh
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
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Walker CT, Gullotti DM, Prendergast V, Radosevich J, Grimm D, Cole TS, Godzik J, Patel AA, Whiting AC, Little A, Uribe JS, Kakarla UK, Turner JD. Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion. Neurosurgery 2019; 87:130-136. [DOI: 10.1093/neuros/nyz312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery.
OBJECTIVE
To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol.
METHODS
A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution.
RESULTS
A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P > .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P < .001) and 24 to 72 hr postoperatively (4.7 vs 3.4, P < .001), PRE vs POST, respectively. Maximum pain scores and time to achieving appropriate pain control also significantly improved during these same intervals (all P < .05). A concomitant decrease in opioid consumption during the first 72 hr was seen (110 vs 71 morphine milligram equivalents, P = .02). There was an observed reduction in opioid-related adverse events per patient (1.31 vs 0.83, P < .001) and hospital length of stay (4.6 vs 3.9 days, P = .03) after implementation of the protocol.
CONCLUSION
Implementation of an evidence-based, multimodal analgesia protocol improved postoperative outcomes, including pain scores, opioid consumption, and length of hospital stay, after posterior lumbar spinal fusion.
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Affiliation(s)
- Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - David M Gullotti
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Virginia Prendergast
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John Radosevich
- Department of Pharmacy, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Doneen Grimm
- Department of Pharmacy, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Arpan A Patel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Udaya K Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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