Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients

Haffner, Max R.; Saiz, Augustine M.; Nathe, Ryan; Hwang, Joshua; Migdal, Christopher; Klineberg, Eric O.; Roberto, Rolando Figueroa

doi:10.1016/j.spinee.2019.07.005

Cited by 19 publications

(22 citation statements)

References 30 publications

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“…A complex interplay between surgical incision and preexisting factors drives a cascade of central and peripheral sensitization, inflammation, and neuromodulation that intensifies and prolongs postoperative pain beyond the point of physical healing. Preemptive analgesia attenuates these processes to confer reduced postoperative pain, decreased opioid requirements, and potentially less-frequent development of persistent postsurgical pain across diverse procedures [15,53,[164][165][166][167][168][169][170][171][172]. Preemptive analgesics can generally be administered orally with sips of water one to two hours prior to operating time.…”

Section: Preoperative Phasementioning

confidence: 99%

“…Traditional dogma has suggested avoiding NSAIDs in spinal/orthopedic fusion surgeries because of the risk of nonunion. More recent and higher quality data suggests short-term NSAID use at normal doses does not affect spinal fusion rates and is valuable for postoperative analgesia and opioid minimization [60,167,217]. High-quality prospective studies are needed to definitively assess this risk.…”

Section: Preoperative Phasementioning

confidence: 99%

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Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Section: Preoperative Phasementioning

confidence: 99%

Section: Preoperative Phasementioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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“…Given the side effects of opioids, effective multimodal medication regimens are needed to reduce postoperative opioid use and improve outcomes without increasing pain levels in older patients. Previous studies had demonstrated the associations between PMPM and outcomes including cost reduction, less morphine consumption, shorter length of hospitalization, and lower complications rates in various patient cohorts with an average age range of 50-70 years [9,[18][19][20][21]. However, few studies reported PMPM implementation in older patients undergoing lumbar fusion surgery.…”

Section: Introductionmentioning

confidence: 99%

The Impact of Perioperative Multimodal Pain Management on Postoperative Outcomes in Patients (Aged 75 and Older) Undergoing Short-Segment Lumbar Fusion Surgery

Wang

Zhang

Wang

et al. 2022

Pain Research and Management

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Background. Due to the presence of multimorbidity and polypharmacy, patients aged 75 and older are at a higher risk for postoperative adverse events after lumbar fusion surgery. More effective enhanced recovery pathway is needed for these patients. Pain control is a crucial part of perioperative management. The objective of this study is to determine the impact of multimodal pain management on pain control, opioid consumption, and other outcomes. Methods. This is a retrospective review of a prospective collected database. Consecutive patients who underwent elective posterior lumbar fusion surgery (PLF) from October 2017 to April 2021 in our hospital were reviewed. Perioperative multimodal pain management (PMPM) group (from January 2019 to April 2021) in which patients received multimodal analgesia was case-matched to the control group (from October 2017 to December 2018) in which patients were treated under the conventional patient-controlled analgesia (PCA) method. Postoperative visual analogue scale (VAS), opioid consumption, complications within 3 months, and other outcomes were collected and compared between groups. Results. A total of 122 consecutive patients (aged 75 and older) were included in the PMPM group and compared with previous 122 patients. The PMPM group had a lower maximal VAS score (3.0 ± 1.7 vs. 3.7 ± 2.0, p < 0.001 ) and frequency of additional opioid consumption (6.6% vs. 19.7%, p = 0.001 ) on POD3 than the control group. The rates of postoperative complications were lower in the PMPM group compared with the control group (25% vs. 49%, p = 0.006 ) during a 3-month follow-up period. Conclusions. This study demonstrates that the PMPM protocol is effective in pain control and reducing additional opioid consumption when compared with conventional analgesia, even for patients aged 75 and older. Moreover, these improvements occur with a lower incidence of postoperative complications within three months after PLF surgery.

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“…Spinal fusion surgery is one of the most painful surgical procedures [ 3 ]. Many patients undergoing spinal surgery are opioid-tolerant, making postoperative pain difficult to control may need additional opioid medication in the perioperative period [ 4 ]. Many complex variables affect the postoperative course, with postsurgical factors playing a significant role [ 5 , 6 ].…”

Section: Introductionmentioning

confidence: 99%

Enhanced Recovery After Surgery Protocol for Lumbar Spinal Surgery With Regional Anesthesia: A Retrospective Review

Kurnutala

Dibble

Kinthala

et al. 2021

Cureus

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BackgroundIn the USA, spinal fusion surgery incurs the highest hospital cost. Despite the recent advances in the application of enhanced recovery after surgery (ERAS) protocols in these surgeries, the efficacy of these protocols in improving the perioperative outcomes remains unclear. We conducted a retrospective review as a quality improvement (QI) project to analyze the efficacy of the ERAS protocol with intraoperative modified thoracolumbar interfascial plane (mTLIP) block to determine whether these interventions reduce the length of stay (LOS) and opioid requirements during the postoperative period. MethodsRetrospective reviews of adult patients (>18 yrs) who underwent elective lumbar spinal fusion or laminectomy at our institute were reviewed. Patients were administered oral gabapentin and acetaminophen preoperatively. Prior to incision, an mTLIP block was performed using liposomal bupivacaine. Intraoperatively, ketamine, ketorolac, and tranexamic acid were administered. Postoperative, pain control was treated with scheduled acetaminophen, ketorolac, and low-dose ketamine infusion. Hydromorphone and oxycodone were administered for breakthrough pain. Patients who underwent a similar procedure without ERAS protocol were chosen as controls to assess the efficacy of ERAS protocol. Data pertaining to patient demographics, operative and perioperative use of analgesics, LOS, 90-day readmissions, and morbidity were collected. Patients who underwent laminectomy and spinal fusion surgery were analyzed separately ResultsA total of 65 patients were identified; laminectomy (n-24), spinal fusion surgery (n-41). In the laminectomy patients, treatment group (n-12) and the control group (n-12). Treatment group receiving the ERAS protocol with the regional anesthesia via the mTLIP (n= 12) opioid requirement was reduced by 51.42% [P = 0.03], and LOS was reduced by 2.04 days [P = 0.01] [0.75 days vs. 2.79 days]). In the spinal fusion patients, treatment group (n-15) and control group (n-26). Treatment group receiving the ERAS protocol with the use of regional anesthesia via the mTLIP group (n= 15), opioid requirement was reduced by 38.33% [P = 0.04]. No difference in LOS was observed at 5.4 days vs. 4.88 days (P = 0.28). ConclusionERAS protocol in patients undergoing lumbar spinal surgery incorporated the use of regional anesthesia via the mTLIP block, we observed there is a statistically significant reduction in the LOS for lumbar laminectomy and a significant reduction in opioid administration for lumbar laminectomies and spinal fusion surgery.

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Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients

Cited by 19 publications

References 30 publications

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

The Impact of Perioperative Multimodal Pain Management on Postoperative Outcomes in Patients (Aged 75 and Older) Undergoing Short-Segment Lumbar Fusion Surgery

Enhanced Recovery After Surgery Protocol for Lumbar Spinal Surgery With Regional Anesthesia: A Retrospective Review

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