Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Enhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>There was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>OFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.</jats:p></jats:sec>

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

“…The remaining 22 articles met inclusion criteria. Of the 22 ERAS studies that met criteria, 12 were controlled ''before-and-after'' studies, 22,25-30,32-36 8 were prospective noncontrolled trials, 19,21,23,24,31,37,39,40 1 was a retrospective matched cohort study, 38 and 1 was a retrospective noncontrolled study. 20 Publication dates ranged from 2004 to 2019.…”

“…As per the Centre for Evidence-Based Medicine guidelines for therapeutic studies, 17 the 12 controlled ''before-and-after'' studies 22, [25][26][27][28][29][30][32][33][34][35][36] and the retrospective controlled study 38 are graded as level of evidence 2B. 17 The remaining noncontrolled retrospective study 20 is graded as level of evidence 4.…”

Preemptive Infiltration with Betamethasone and Ropivacaine for Postoperative Pain in Laminoplasty or Laminectomy (PRE-EASE): study protocol for a randomized controlled trial

“…At present, several pain-controlling methods are available, with opioids being the cornerstone for management of severe acute postoperative pain [2,7]. However, there are many compelling reasons to avoid opioids in surgical patients due to their numerous side effects [8].…”

Preemptive Infiltration with Betamethasone and Ropivacaine for Postoperative Pain in Laminoplasty or Laminectomy (PRE-EASE): A Study Protocol for a Randomized Controlled Trial

“…2,7 However, there are many compelling reasons to avoid opioid in surgical patients due to its numerous side effects. 8 Methods for systemic administration include: oral analgesics, intermittent intravenous, intramuscular injections, patientcontrolled intravenous analgesia, etc. 1 Nevertheless, the aforementioned methods may have a lot of side effects, and are usually used after the occurrence of pain.…”