Epidural Anesthesia via Catheter in Spine Surgery Effectively Reduces Postoperative Pain
Highlight from the 30th Annual Meeting of the North American Spine Society (NASS) in Chicago
Presented by Fred Geisler, MD, PhD
As part of the pain medicine-focused symposium, “Recent Advances in Managing Postoperative Pain without Opioids,” Fred Geisler, MD, PhD presented, “Use of Sustained Infusion/Drug Delivery.” Dr. Geisler is a Neurological and Spinal Surgeon previously at the Back Institute at Swedish Covenant Hospital in Chicago, IL.
“Postoperative pain control is a major point in the patient's total surgical experience and satisfaction,” stated Dr. Geisler. Operative site pain can be severe and take hours to days to resolve, which may interfere with the patient’s postoperative mobilization and healing. Dr. Geisler focused on postoperative pain management in lumbar spine surgical procedures.
Preemptive Postoperative Pain Management
“Postoperative pain management should be preemptive and not reactive,” advised Dr. Geisler. Preoperative injections of local anesthesia into the skin area prior to incision and administration of a long-acting oral opioid are options. Of course, following spine surgery, intravenous patient-controlled analgesia can be made available at the bedside.
The effectiveness of epidural anesthesia delivered via catheter is evidenced by many papers. Dr. Geisler stated, referring to a paper by Wu et al,1 “All forms of epidural analgesia provided significantly superior postoperative analgesia compared with intravenous patient-controlled analgesia.”
- Epidural anesthesia can be used adjunctively to general anesthesia for postoperative pain below the waist. The effects of an epidural spread over approximately three spinal levels and provides for slow absorption through the dura.
- The epidural catheter is a thin flexible tube introduced in the lumbar region and moved upward into the dorsal fat pad. The epidural anesthesia can be administered at the end of the surgical procedure prior to wound closure. Following closure, medication is injected as a single dose through the catheter, which is then removed prior to moving the patient to recovery.
“I've always viewed the intraoperative epidural injection as part of the general anesthesia. I talk with the anesthesiologist before. I ask permission to give it and ask them to record the time and the dose; this is helpful to the recovery room nurses,” Dr. Geisler explained. Contrary to what some spine surgeons may think, the epidural does not paralyze the patient. Rather, the patient is comfortable and the injection allows for routine neurologic examinations. Many physicians are adopting this new technique.
Dr. Geisler reported his experience. Without epidural medication, some patients in the post-anesthesia care unit (PACU) report postoperative pain as 6, 7, 8, 9 or even 10, where 10 is the worse pain imaginable. Surgical patients who received the epidural reported their postoperative pain score as zero, and in some cases higher. “Patients who received an epidural had no IV narcotics in the recovery room; their pain was well controlled,” stated Dr. Geisler. Furthermore, “the intraoperative single epidural injection appears to be safe and effective in the postoperative period, decreases the initial management, and has positive effects,” explained Dr. Geisler.
Barriers to Epidural Use
At the current time, there's no specific billing code for epidural intraoperative injection with spinal surgery, and this is a significant barrier.
Why the reluctance of spine surgeons accepting this? Dr. Geisler noted, “Well, we had very little training of epidural anesthesia drugs or doses. All side effects are not known.” In addition, he stated, “Most spine surgeons don't know that if you walk in your recovery room epidurals are given every day, and there's already a protocol for how to manage them.”