Nonopioid Multimodal Analgesia for Pre- and Post-Operative Spine Surgery

Highlight from the North American Spine Society 32nd Annual Meeting

Multimodal analgesia, including use of nonopioid analgesia has emerged as a way to improve pain control following spine surgery and help limit the risk of opioid use, said Mark Kurd, MD, at a session titled, The Opioid Predicament: Implications for Spine Physicians and Surgeons, presented at the North American Spine Society (NASS) 32nd Annual Meeting. Dr. Kurd is Assistant Professor of Orthopaedic Surgery at Thomas Jefferson University and spine surgeon at the Rothman Institute, Philadelphia, PA.
spinal anesthesia being administeredA study examining best evidence in multimodal pain management in spine surgery found good evidence for gabapentinoids, acetaminophen, neuraxial blockade, and extended-release local infiltrative anesthetics (10).Approximately 40% of patients who undergo major operations such as spine surgery have severe or extreme post-operative pain—and the majority are more concerned with pain than the whether the surgery improves their condition, said Dr. Kurd.1 Post-operative pain is the primary driver of inpatient length-of-stay after spine surgery, and fear avoidance behavior predicts negative outcome after spine surgery.2

While opioids are first-line agents for post-operative pain, these agents are associated with significant adverse effects, including tolerance and hyperalgesia as well as potentially abuse, Dr. Kurd said. In addition, he said confusion may occur over whether a side effect (eg, urinary retention) is opioid-related or is a surgical complication (eg, epidural hematoma).

Patients at highest risk for over-sedation and respiratory depression following spine surgery include those with sleep apnea or sleep disorder, morbid obesity, snoring, older age, no recent opioid use, abdominal or thoracic surgery, increased opioid dose requirement, longer time receiving general anesthesia during surgery, smoking status, and concomitant use of other sedating drugs.3

Safety measures, including education and monitoring, may reduce the risk of opioid-related adverse events in patients undergoing spine surgery. In addition, multimodal opioid-sparing approaches, including use of nonopioid pain medications, may be warranted in key patients, Dr. Kurd noted.3

In addition, pre-operative opioid use in patients undergoing spine surgery is linked to longer length of stay and worse outcomes, Dr. Kurd said. He cited a study showing that every 10-mg increase in daily morphine equivalent taken pre-operatively led to significantly decreased Oswestry Disability Index, Neck Disability Index, and 12-Item Short-Form Health Survey scores.4 These findings raise the question of how to manage patients who are taking opioids pre-operatively, Dr. Kurd said.

Multimodal Analgesia
Post-operative pain management should target all the components of acute pain following spine surgery, including nociceptive, visceral, neuropathic, inflammatory, and muscle spasms, Dr. Kurd said, adding that “no single drug can adequately treat each of these components.”

Thus, the concept of multimodal analgesic arose to allow for synergistic effects of different analgesics used at a lower dose to reduce side effects, Dr. Kurd explained. He said that adapting to the mentality that patients do not necessarily need opioids constantly in the post-anesthesia care unit (PACU) was the biggest challenge implementing a multimodal analgesia protocol at Thomas Jefferson University.

Nonopioid Analgesics Effective Post-Operatively for Spine Surgery
Dr. Kurd highlighted recent studies showing the efficacy of non-opioid analgesics used for surgery. In one study, patients given a long-acting liposomal bupivacaine incisional injection following single-level microdiscectomy required significantly fewer hours of intravenous opioid medication.5 A meta-analysis of 7 trials showed that gabapentin and pregabalin significantly reduce post-operative opioid use following lumbar spine surgery.6

Research on ketolorac suggests that this agent decreases pain and opioid use post-operatively following multilevel lumbar compression surgery;7 however, concerns have been raised on the potential negative impact of non-steroidal anti-inflammatory agents (NSAIDs) like ketolorac on fusion rates.8,9 Dr. Kurd said that his institution avoids use of high-dose ketolorac, and has concluded that use of normal dose NSAIDs for a few days post-operatively does not appear to affect fusion rates. 

A study examining best evidence in multimodal pain management in spine surgery found Grade A evidence (ie, good evidence, using the North American Spine Society grading system) for gabapentinoids, acetaminophen, neuraxial blockade, and extended-release local infiltrative anesthetics.10 Grade B evidence (fair evidence) was found for preemptive analgesia, NSAIDs, muscle relaxants, and ketamine.10

Analysis of Multimodal Studies
A retrospective analysis of 239 patients undergoing anterior cervical discectomy and fusion (ACDF) showed a lower rate of opioid consumption post-operatively and decreased post-operative nausea/vomiting, Dr. Kurd explained.11 In addition, hospital length of stay was reduced by approximately 20 hours, which Dr. Kurd said is “meaningful as patients are actually getting out of the hospital a day or two earlier, and that impacts cost and overall post-operative management.”

In a small prospective study (n=22) of patients undergoing multilevel lumbar decompression, patients who were randomized to a multimodal (celecoxib, pregabalin, extended-release oxycodone) analgesic regimen post-operatively had lower intravenous morphine requirements, better pain scores, and earlier time to solid food intake.12 In addition, a randomized prospective study of patients undergoing lumbar fusion (n=80) showed significantly less opioid use, less nausea/vomiting, and shorter hospital length of stay.13

Conclusion
Studies examining multimodal analgesia regimens for spine surgery in general show lower pain scores, shorter length of stay, faster recovery, and less opioid consumption, Dr. Kurd concluded. However, these studies are limited by lack of a consistent regimen, with some including opioids as part of the regimen and others not.

Physician-related barriers to implementation of multimodal regimens include “getting our minds around not giving opioids and using other protocols,” Dr. Kurd noted. He added that multimodal regimens are critical to the success of outpatient surgery, and that “we are starting to feel the pressure to head in that direction” for inpatient spine surgery as well.

View the other presentations in this symposium:

Disclosure
Dr. Kurd reported Speaking and/or Teaching Arrangements for Stryker Spine.

Updated on: 12/07/17
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