Preemptive Multimodal Analgesia Regimens Control Pain Following Spine Surgery

Mark F. Kurd, MD, and Lali Sekhon, MD, PhD, FACS, FAANS comment

Peer Reviewed

The efficacy of preemptive multimodal analgesia in controlling postoperative pain and reducing opioid consumption is well documented in studies involving orthopaedic surgery of the lower extremities. Now, emerging evidence also supports preemptive multimodal analgesia in controlling pain following spine surgery, according to a review in the Journal of the American Academy of Orthopaedic Surgeons.

IV drip against a blurry hospital roomEmerging evidence supports preemptive multimodal analgesia in controlling pain following spine surgery,The Importance of Postoperative Pain Control in Spine Surgery
“Postoperative pain control is critical because it directly correlates with postoperative recovery and outcomes,” said lead author Mark F. Kurd, MD, Assistant Professor of Orthopaedic Surgery at Thomas Jefferson University and spine surgeon at the Rothman Institute, Philadelphia, PA. “Patients who have well-controlled postoperative pain are able to work with physical therapy, ambulate, and become more functional more quickly. This leads to a quicker recovery, less postoperative complications and better outcomes,” Dr. Kurd said.

Which Multimodal Analgesia Regimens Are Best Following Spine Surgery?
“Although the data on this is emerging, the regimens that are most successful are those that adhere to 2 main principles,” Dr. Kurd explained. “First, the regimen must include a preoperative, intraoperative, and postoperative component. Data shows it is important to begin the medications preoperatively to reduce the formation of pain pathways that can plague patients postoperatively.”

“Second, the regimen must use medicines with multiple different mechanisms of action,” Dr. Kurd continued. “This effectively controls pain while minimizing the side effects of the medications as each medicine can be used in lower doses. Side effects from pain medications is generally dose dependent.”

Regimens include use of preemptive analgesia, nonsteroidal anti-inflammatory drugs, gabapentin and pregabalin, acetaminophen, and extended-release local anesthesia.

The researchers noted findings from two retrospective studies showing that patients treated with multimodal analgesia regimens after spine surgery had improved pain control, reduced opioid consumption, earlier mobilization, along with a reduced incidence of opioid-related side effects compared with patients who received standard patient-controlled analgesia. Efficacy of these regimens also is found in randomized controlled trials.

Findings Also Support Efficacy of Perioperative Multimodal Analgesia
In addition, Dr. Kurd and colleagues also found Level II evidence supporting the superiority of perioperative multimodal regimens over standard opioid treatments for controlling pain during spine surgery. These regimens are not linked to an increased risk of nonunion in spine procedures, the researchers noted.

Dr. Kurd emphasized that “Perioperative pain management using MMA will be one of the great advances in spine surgery over the next 5 to 10 years. It will not only lead to better patient outcomes, but will also influence the landscape of spine surgery as many surgeries currently performed in the inpatient setting will be able to be performed on an outpatient basis. This has tremendous implications for the delivery of spine care in the U.S.”

The Future of Multimodal Analgesia Regimens
In looking to the future of postoperative pain control in spine surgery, Dr. Kurd said that “We need to continue to explore new medicines that address the pain receptors in different ways. We also need to better understand the impact of NSAIDs on fusion as this has been a major limiting factor in multimodal analgesia in spine surgery. Finally, we need to better understand other factors that impact pain: body temperature, hydration, etc.”

Commentary
Lali Sekhon, MD, PhD, FACS, FAANS
Partner at Sierra Neurosurgery Group
Adjunct Associate Professor
Department of Physiology and Cell Biology
University of Nevada, School of Medicine
Reno, NV

Overall MMA is beneficial in spine surgery. The sticking point for most spine surgeons is the preoperative use of nonsteroidal anti-inflammatory drugs (NSAIDs). There are numerous studies for and against the use of NSAIDs and, apart from potential bleeding, most spine surgeons worry about NSAID usage and potential pseudoarthrosis. Kurd et al point out that there are studies confirming that pseudoarthrosis is a risk with NSAID use.

There is no question about the efficacy of NSAIDs in postoperative pain management. In my own practice, I use ketorolac judiciously in the postoperative period for posterior lumbar and cervical cases. These encompass simple decompressions as well as arthrodeses. I weigh several important factors before prescribing this agent, such as blood loss during surgery, kidney function, and likelihood of developing a pseudoarthrosis.

There is no class I data that establishes the safety of COX-2 inhibitors with respect to potential fusion failure. The morbidity and expense of pseudoarthrosis are not small and, in general, clinical outcomes worsen for revision procedures. Thus, most surgeons do what they can to avoid NSAIDs perioperatively and for 6-12 weeks postoperatively, given the aforementioned facts.

Overall, Kurd et al have given a thorough and informative overview of MMA and should be commended. I am glad they mentioned elastomeric pumps with local anesthesia infusions into paraspinal muscles, which in my own practice dropped length of stay for fusions to a little over 2 days. Narcotic usage is a bane of society and all we can do to reduce its usage is a good thing.

Updated on: 03/20/18
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