Multimodal Analgesic Regimen for Spine Surgery

Abstract

Background Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores. Methods Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h. Results The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, –6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being –9 (97.5% CI, –23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being –0.4 (97.5% CI; –0.8, 0.1, P = 0.094). Conclusions An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Opioid-free Anesthesia for Patients With Joint Hypermobility Syndrome Undergoing Craneo-cervical Fixation: a Case-series Study Focused on Anti-hyperalgesic Approach

“…We cannot a rm that OFA management is an independent factor in reducing postoperative pain. However, OFA management plus postoperative use of lidocaine, ketamine, and dexmedetomidine infusions as part of robust multimodal analgesia can explain our results (10).…”

“…Enhanced Recovery After Surgery (ERAS) protocols have incorporated some opioid-free anesthetic techniques (OFA) thanks to the use of infusions of coadjuvant drugs with anti-hyperalgesic and analgesic properties with mechanisms of action different to opioids. The medical literature supports the use of intravenous infusions of lidocaine, ketamine and dexmedetomidine as a balanced way to substitute or reduce opioids in the perioperative period (6)(7)(8)(9)(10).…”

“…Considering that OIH and CS are important causes of this complex and painful condition, the restriction of the use of opioids and the use of drugs with potent anti-hyperalgesic effects seems to be a reasonable option for the management of perioperative pain in patients with EDS-HT/JHS and cranio-cervical instability undergoing cranio-cervical xation/fusion surgery (CCF) (8)(9)(10)(11).…”

Low Incidence of Opioid-Induced Respiratory Depression Observed with Oliceridine Regardless of Age or Body Mass Index: Exploratory Analysis from a Phase 3 Open-Label Trial in Postsurgical Pain

“…The recently reported failure of multimodal analgesia to reduce postoperative opioid use [16,17] as well as the growing opioid epidemic [37] further highlight the clinical need for effective opioids with a safer profile in high-risk patients. Conventional opioids that bind to the l-opioid receptor activate two distinct pathways, the G-protein and b-arrestin [21].…”

“…In recent years, with the introduction of enhanced recovery after surgery (ERAS) protocols, a variety of multimodal analgesic pathways based on opioid-free analgesia in the postoperative period have been developed [15,16]. However, the use of nonopioid multimodal analgesics used in ERAS pathways has not consistently shown a benefit for the relevant reduction of pain or opioid use [16,17]. Indeed, the Center of Disease Control and Prevention suggests that in acute postsurgical pain, the benefits of a limited course of opioids may outweigh the risks if pain management is inadequate with nonopioid therapies [18].…”