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

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.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

“…Poor postoperative pain control is observed in 57% of patients following elective spine surgery [208]. Inadequate acute pain control is associated with the development of chronic pain and significant systemic inflammatory response leading to organ dysfunction and pain [209,210]. A standardized perioperative multimodal antinociceptive protocol results in adequate postoperative pain relief and improved outcomes [5].…”

“…Opioids are effective in treating acute postoperative pain following spinal surgery [210]. However, opioid-sparing techniques are important and should be applied in ERAS pathways to allow patients to recover early and reduce complications related to opioid use [210].…”

An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery

“…70,71 Less consistently included are muscle relaxants such as methocarbamol or diazepam and local anesthetics such as transdermal lidocaine patches that function via prolonging the inactivation of sodium channels within the cell membrane of neurons. 72 While multimodal approaches have previously been used in orthopedic surgery and other surgical fields, recent research has investigated the use of multimodal approaches involving these drugs specifically in postoperative pain for spine surgery. A multimodal regimen consisting of scheduled doses of acetaminophen, NSAIDs, gabapentin, lidocaine patches, and one of two muscle relaxants was compared to a non-standardized provider-dependent regimen in one retrospective cohort after posterior lumbar surgery.…”

Implementation of a Multimodal Analgesia Protocol Among Outpatient Neurosurgical Patients Undergoing Spine Surgery to Improve Patient Outcomes

“…Unfortunately, documentation of postoperative pain scores was not consistent, resulting in missing data. A QI initiative implemented by Walker et al 20 with 220 patients undergoing lumbar fusion demonstrated a decrease in hospital LOS after implementation of an MMA protocol. However, our QI project resulted in no significant change in either facility or PACU LOS.…”