Multimodal pain management can provide appropriate pain control for spine surgery
Use of a multimodal pain management regimen before, during and after spine surgery may provide appropriate pain control and reduce complications, opioid use and improve patient satisfaction, according to a presenter.
In his presentation at the Lumbar Spine Research Society Annual Instructional Course, Shah-Nawaz Dodwad, MD, noted use of gabapentinoids preoperatively can have a significant effect on patients’ pain management postoperatively by reducing postoperative pain, total morphine consumption and morphine-related complications.
NSAIDs, which can be used preoperatively and postoperatively, have been shown to reduce opioid use and improve VAS scores, according to Dodwad.
“We have used Tylenol on our patients, and it has been shown to reduce morphine consumption by 22% to 46% in patients undergoing major orthopedic surgery or spinal fusion,” Dodwad said in his presentation.
Although logistically difficult to perform prior to a large surgery, Dodwad noted epidural injections have also been found to be safe and effective with high patient satisfaction and a decrease in overall opioid consumption.
Intraoperatively, Dodwad noted use of epidural morphine soaked on a gel foam improved analgesic consumption for 48 hours, time of first analgesic request, time of ambulation, time of discharge from a post-anesthesia care unit and hospital, and had no adverse effects. He added epidural opioids and intrathecal morphine may lead to early transition to oral medication, mobilization, lower pain scores and discharge, while dexamethasone reduced pain scores, opioid use and delayed time from first postoperative analgesic intake.
In the postoperative setting, Dodwad noted the literature has shown multimodal pain medications to be superior to patient-controlled analgesia.
“Unfortunately, long-acting liposomal local anesthetics have not borne out in the literature to show a statistical benefit in narcotic usage, length of stay and complications, but that is controversial,” Dodwad said. “Also, many surgeons do not use [muscle relaxants and ketamine] for pain control. There is insufficient or conflicting evidence here that shows that this provides any pain control or decrease in narcotic consumption.”
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Dodwad SN. Multimodal pain management. Presented at: Lumbar Spine Research Society Annual Instructional Course; Jan. 12, 19, 26, 2021 (virtual meeting).
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