Managing pain following a complex Spinal Surgery
Thoracolumbar spine surgery that involves instrumentation, laminectomy at three or more levels, or scoliosis surgery is classified as complex spine surgery. Undergoing complex spine surgery may enhance the long-term pain relief and overall quality of life for individuals dealing with symptomatic back conditions, such as idiopathic scoliosis.
Nevertheless, significant postoperative pain is a common association with complex spine surgery. Optimal management of pain can have an impact on both early postoperative rehabilitation and long-term outcomes.
Analgesic Pre-operative Interventions
In patients undergoing multilevel posterior lumbar interbody fusion (PLIF) surgery, those who received intravenous (i.v.) ibuprofen 30 minutes before incision showed significantly lower VAS scores and required less morphine in the first 48 hours after surgery, compared to those who received a placebo.
Similarly, patients who were administered parecoxib 30 minutes before the induction of anesthesia and then every 12 hours for 48 hours showed a significant decrease in postoperative pain scores and total morphine consumption during the first 48 hours following surgery.
Previous literature has examined the efficacy of NSAIDs compared to a placebo in managing pain after lumbar spine surgery, with significant differences observed in the mean pain scores between the two groups during the initial 24-hour period. In comparison to a placebo, both gabapentin and pregabalin have been found to significantly decrease postoperative narcotic usage and alleviate postoperative pain scores.
Literature has demonstrated that methadone administered at the beginning of spinal fusion surgery and multilevel thoracolumbar spine surgery has a beneficial analgesic effect, in comparison to hydromorphone given at surgical closure. Methadone administration shows reduction in median hydromorphone consumption, reduced postoperative opioid requirement and lower pain scores.
Administration of a lidocaine infusion results in decreased morphine requirements during the initial 48 hours after surgery, lower pain scores, and an increased duration before patients requested additional analgesia.
High-dose intraoperative ketamine has been shown to reduce morphine usage in patients undergoing major lumbar spinal surgery. Additionally, patients who received ketamine reported lower pain scores both immediately following surgery and at the 6-week follow-up.
Literature has demonstrated that high-dose ketamine can reduce opioid usage in chronic pain patients undergoing major spine surgery, leading to less sedation caused by opioid medication. Administering ketamine during complex spinal surgery has been found to significantly reduce opioid usage, particularly in chronic pain patients, thereby providing opioid-sparing effects.
Administration of Dexmedetomidine during and after surgery has been associated with decreased pain levels and reduced hydromorphone and opioids requirements for up to 48 hours after surgery, with the exception being at the time of discharge.
When magnesium is added to ketamine treatment, patients demonstrate a significantly lower average cumulative morphine consumption compared to those who receive ketamine alone, up to 48 hours after surgery, as well as better quality of sleep and higher levels of satisfaction during the first postoperative night.
Implementation of a multimodal analgesia protocol that includes celecoxib, pregabalin, extended-release oxycodone, acetaminophen, and IV-PCA morphine has been found to effectively reduce pain levels at all time points until seven days postoperatively. Additionally, opioid consumption was found to be reduced for up to 48 hours following spinal fusion surgery.
Regional Analgesic Interventions
Administration of epidural infusions has been shown to significantly reduce pain levels and decrease the amount of postoperative opioids required.
Patients with degenerative or idiopathic scoliosis who undergo multilevel spinal fusion surgery and receive bupivacaine have been shown to experience lower VAS scores during mobilization. The use of intraoperative epidural infusion of bupivacaine and sufentanil has been shown to significantly decrease pain levels in patients undergoing surgery.
Local anesthetic techniques such as ropivacaine local wound infusion through a catheter with normal saline after posterior spinal fusion surgery have shown positive effects. Continuous wound infiltration eliminates the need for additional analgesia or opioid reduction.
Administering a bilateral single-shot, ultrasound-guided, lateral thoracolumbar interfascial plane (TLIP) block with ropivacaine on each side before lumbar spinal fusion surgery leads to significant reductions in opioid and anesthetic consumption during the perioperative period. Additionally, VAS scores are lower at 12, 24, and 36 hours postoperatively.
It is recommended to use a combination of paracetamol and an NSAID or a COX-2 specific inhibitor prior to or during surgery, and to continue their use after surgery unless there are any contraindications.
Fixed-time interval administration of analgesia is more effective at managing pain than on-demand administration. A low-dose intravenous ketamine infusion is recommended for the intraoperative period.
To manage pain during and after surgery, it is recommended to use epidural infusion of local anesthetic alone or in combination with opioids. Opioids can also be used as rescue analgesics after surgery.
The pain-relieving advantages and reduced need for opioids provided by common pain relievers such as paracetamol and NSAIDs have been extensively documented. The effect of NSAIDs on fusion rates appears to depend on the dose and duration of use, and short-term use after surgery is generally well tolerated.
It is recommended to use low-dose NSAIDs for a short period of time around the time of spinal fusion, as it has a dose-dependent and duration-dependent effect on fusion rates and does not interfere with osteogenesis or increase the rate of nonunion. Patients who receive perioperative NSAIDs during spinal surgery do not exhibit a higher risk of bleeding.
To reduce the need for opioids, especially in patients with chronic pain who are dependent on opioids, it is recommended to use an intraoperative ketamine infusion. To the elderly, higher doses of ketamine compared to placebo can lead to negative psychotropic side effects like postoperative hallucinations and nightmares.
It can be reasonably assumed that administering ketamine infusion after surgery may increase the likelihood of adverse drug effects associated with ketamine. Administration of low doses of ketamine during surgery has demonstrated improved pain control in the perioperative phase. Nonetheless, extending ketamine infusions to the postoperative period is not recommended due to the risk of adverse events
Incorporating epidural analgesia using local anesthetic with or without opioids is recommended as a part of multimodal analgesia, whereas the use of epidural analgesia with opioids alone is not recommended. Our doctors at Complete Orthopedic place the epidural catheter at the end of the surgery.
Literature has raised a concern about the use of epidural catheters and potential loss of sensory function and motor weakness, as well as the risk of delayed diagnosis of neurological complications, meaning low doses of local anesthesia should be administered, and it should be individualized.
Intraoperative administration of methadone is more effective than hydromorphone and sufentanil in reducing postoperative pain scores and the need for opioids. The advantages of methadone might be linked to its length of effectiveness (shorter-acting opioids).
Nonopioid analgesics should be the first choice of analgesics to decrease the overall requirement of opioids, including methadone. The administration of a one-time dose of methadone to patients undergoing elective spinal fusion of two or more levels can lead to moderate respiratory depressions, characterized by less than eight breaths per minute. As a result, the use of i.v. methadone is presently not recommended.
Although intraoperative dexmedetomidine infusion has been shown to reduce perioperative opioid use and lower postoperative pain scores, it is not recommended for routine use due to limited procedure-specific evidence. Dexmedetomidine has exhibited a decreased incidence of adverse effects such as low blood pressure, tremors, post-surgery queasiness, and slow heart rate.
Presently available literature does not endorse the habitual use of gabapentinoids as a component of a multi-faceted pain relief plan in intricate spinal operations, and there are apprehensions about undesirable outcomes, including drowsiness and breathing difficulties.
In outline, substantial opioid intake is necessary to manage the pain caused by major spinal surgery that involves multiple levels of instrumentation. It is recommended to adopt a multimodal approach to pain management, which involves administering paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2 specific inhibitors before or during the operation and continuing their use in the postoperative period.
During the operation, it is advised to use a ketamine infusion at a low dosage. Additionally, it is suggested to use an epidural catheter that is inserted under our doctors direct observation, followed by a postoperative infusion of local anesthesia alone or in conjunction with opioids. As a backup pain relief option after the operation, the use of opioids is recommended.
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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