Optimizing Preemptive and Perioperative Analgesia in Spine Surgery to Reduce Postoperative Opioid Use

North American Spine Society 34th Annual Meeting Highlight

Peer Reviewed

With the goal of reducing the risk for long-term opioid use after spine surgery, Gregory Grabowski, MD, FAOA, discussed his strategy for optimizing preemptive and perioperative pain management at the North American Spine Society 34th Annual Meeting in Chicago, IL. Dr. Grabowski is Clinical Associate Professor, Orthopedic Surgery at the University of South Carolina School of Medicine and in practice at Palmetto Health-USC Orthopedic Center in Columbia, SC

Dr. Grabowski’s interest in preemptive analgesic began after the governor of South Carolina issued an executive order on December 18, 2017, that the Department of Health and Human Service would develop and publish a policy with a 5-day prescription limitation on initial opioid prescriptions for acute and postoperative pain management.

opioids and the prescription bottleDr. Grabowsky stated, "The paradigm used to be pain is bad, opioids are worse. Now it is pain is bad, but opioids may be worse." Photo Source: iStock.com.

“As a physician who is practicing at a tertiary referral center in the center of the state that has people driving in from long distances, who I perform significant surgeries on, this is going to significantly alter my practice,” said Dr. Grabowski. “There was a period where I had to make some significant changes to my practice, and the first thing I said was, why?”

A 2018 study by Shah et al found that the likelihood of long-term opioid use was based on the length of initial opioid prescription for acute pain in opioid-naïve patients.1

“This is the most important article that you can read relative to the opioid crisis,” Dr. Grabowski said. “What they found was that if a patient was given a prescription for 1 to 4 days, 6% of opioid-naïve patients were still on opioids at one year. When that initial prescription was for 8 days, that number jumped to 13.5%.”1

“And then came the really scary numbers: among opioid-naïve patients who received a one-month prescription for opioids for an episode of acute pain, 30% were still on opioids a year later,” Dr. Grabowski explained. “This is the reason that the legislators selected 5 days as the number, because of that significant inflection point after 5 days for long-term use.”

Preemptive Analgesia

“The nice part about elective surgery is that we know when we are going to inflict pain onto a person when they get to the operating room,” Dr. Grabowski said. “And we are able to preempt that process.”

The definition of preemptive analgesia is the “antinociceptive treatment that prevents establishment of altered central processes of afferent input from sites of injury,” Dr. Grabowski told NASS attendees. “So that means you are stopping hyperalgesia before it starts. Important considerations are establishment of an effective level of antinociception before injury and understanding that multimodal therapy is going to be more effective than high-dose, single-agent therapy.”

Multimodal, preemptive analgesia involves a series of classes of pain medications that cross multiple pathways of the pain spectrum, including gabapentinoids, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants, he explained. The literature supporting use of preemptive analgesia shows that this practice results in lower pain scores and opioid requirements postoperatively, with multimodal strategies having the greatest effect, Dr. Grabowski said.

NSAIDs and Bone Healing

The most common question that I receive during presentations on preemptive analgesia is on bone healing and NSAIDs,” Dr. Grabowski said, highlighting a review article by Pountos et al as a good summary of current knowledge on this topic. Evidence in the literature can be found to either support or refute potential negative effects of NSAIDs on bone healing.2

“But what I will also tell you with 100% certainty is that all of the literature will support the fact that NSAIDs prescribed, in and around the time of surgery, will decrease pain levels and decrease opioid requirements, Dr. Grabowski said. “And for that reason, I include NSAIDs in my perioperative pain regimen.”

Dr. Grabowski’s current preoperative cocktail includes the following:

  • Pregabalin 150 mg PO
  • Metaxalone 800 mg PO
  • Acetaminophen 1000 mg PO
  • Celecoxib 200 mg PO

Pregabalin and metaxalone were selected because they have fewer sedative properties relative to other agents in the same class, and celecoxib was chosen for its gastrointestinal profile, he explained.

Dr. Grabowski also uses a transversus abdominis plane block preoperatively for ALIFs or high-level interbody fusions. While transversus abdominis plane block is not researched well in the spine literature, Dr. Grabowski believes that future research will support use of this technique, which he said is a safe and effective block in the general surgery group.

“Even though we aren't thinking about blocks much in the spine literature, blocks have been proven to be very effective in lots of other places in the surgical world. And so, this is an opportunity for us to venture into that space,” he said.

Intraoperative Considerations

“What happens in that short amount of time in the operating room makes a difference in the long term,” Dr. Grabowski said.

  • For example, in a randomized controlled trial involving 116 patients undergoing complex spine surgery, patients randomized to perioperative intravenous lidocaine had lower pain scores (P<0.001), less opioid use (P=0.011), and improved SF-12 physical composite scores at both 1- and 3-months post-surgery (P=0.002) compared with patients who received placebo during surgery.2
  • In a double-blind study in which 50 patients were randomized to perioperative IV ketamine (bolus injection plus continuous infusion), patients in the ketamine arm had a 37% reduction in morphine in the acute postoperative period (P=0.029), and a 27% reduction in pain scores in the PACU and at 6 weeks (P=0.033 and 0.026, respectively).3

Dr. Grabowski also uses magnesium as a muscle relaxant (10 mg/kg/h) when a paralytic is contraindicated. Magnesium is a non-narcotic, non-opioid alternative to a paralytic that is contraindicated, he explained. Thus, after standard induction, as determined by an anesthesiologist, Dr. Grabowski requests IV lidocaine, IV ketamine, and IV magnesium as well as paralytics and fentanyl as needed.

While implementing this intraoperative cocktail may be difficult given the added work required by the anesthesia team, the end result of improved outcomes is worth overcoming potential roadblocks, Dr. Grabowski noted. It is important for spine surgeons to “take control of that process,” he said.

“What happens in that period of time, can dictate what their [the patients’] final outcomes are going to be,” Dr. Grabowski told the NASS attendees. “Postoperatively, for optimal results from preemptive anesthesia, we need to continue that effective analgesic level as well through the post-injury period and ultimately through what is called the inflammatory phase, which is the continuing period of time where hypersensitization can occur.”

Postsurgical Analgesia

For the first 24 hours, Dr. Grabowski uses the same agents given preoperatively in the following dosages:

  • Acetaminophen 650 mg PO q6h
  • Pregabalin 75 mg PO q12h
  • Metaxalone 800mg PO q8h
  • Celecoxib 200 mg BID
  • Tramadol 50 mg PO q4
  • Breakthrough pain
    • 5 mg q4h PO prn pain q4-6h
    • 10 mg q4h PO prn pain q7-10h

“This use of tramadol postoperatively is the first time patients undergoing spine surgery receive opioids from me,” Dr. Grabowski said. “We also use oxycodone for breakthrough pain.”

After the first 24 hours, patients are switched to celecoxib 200 mg on a daily basis and cyclobenzaprine 10 mg every 8 hours as needed. They are also given hydrocodone bitartrate 5 mg (1 tab for pain scores of 1-5 and 2 tabs for pain scores 6-10) and acetaminophen 650 mg for patients with temperatures greater than 101.4°F.

“The reason for the switch to cyclobenzaprine is that metaxalone is not available as a generic,” Dr. Grabowski explained. “Thus, if you are sending people out of the hospital with a metaxalone prescription, they’ll often not be able to pay for it.”

Dr. Grabowski presented a quick retrospective evaluation of patients in his practice who underwent 1 and 2-level anterior cervical discectomy and fusion (ACDFs) before (n=183) and after adoption of this protocol (n=23). He found that the protocol resulted in a 25% decrease in inpatient opioid administration—from 105 to 81 morphine milligram equivalents.

“The ultimate goal here is to make sure that people are off of opioids by the time they get to their 2-week postoperative visit. Today, most of my patients fit that bill—or certainly by the time they get to their 6-week postoperative visit, because you don’t want them on opioids for a month-long period.”

Conclusion

“The paradigm used to be pain is bad, opioids are good,” Dr. Grabowski. “Now it is pain is bad, but opioids may be worse. Multimodal analgesia is going to be the key to reducing opioid use after spine surgery.”

“For the surgeon, taking control of the process preoperatively, intraoperatively, and postoperatively is going to be particularly important,” he concluded.

Disclosures
Dr. Grabowski has no relevant disclosures.

Updated on: 12/20/19
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Gregory Grabowski, MD
Clinical Associate Professor, Orthopedic Surgery
University of South Carolina School of Medicine
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