Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study

Abstract

Background The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. Methods Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1–4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. Results For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. Conclusion ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).

The Effect of Preoperative, Low-Dose Intrathecal Morphine on Patient Outcomes Following Lumbar Fusion Surgery: Can We Teach an Old Dog New Tricks?

“…A retrospective cohort study of 2 groups, one receiving ITM alone and the other receiving ITM + bupivacaine, demonstrated decreased LOS and perceived patient pain levels in the ITM + bupivacaine group. 25 While our results did not demonstrate significant differences in LOS in lumbar fusion patients, the opportunity for optimal intraoperative pain control regimens exists, which may decrease LOS overall. Given the efficacy of MMA administration in spinal surgery, the potential for new protocols that include ITM and other adjunct anesthetics should be explored to minimize pain and improve outcomes among lumbar fusion patients.…”

Anestesia caudal preventiva en dolor de espalda después de discectomía lumbar: estudio controlado aleatorizado

“…Preoperative pain of the patient, noxious inputs occurring during the operation, inflammatory process due to peripheral-central neuromodulators, and ectopic neural activity cause central sensitization and, thus, both exacerbation and long-term acute pain. The mechanism-oriented analgesia method, which aims to reduce the nociceptive effect caused by all pre-operative, intraoperative, and/or postoperative warnings rather than when the analgesic treatment is applied, is called preventive analgesia 9 .…”