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.

Intraoperative Interventions

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.

If you are interested in knowing more about managing pain following a complex spinal surgery you have come to the right place!

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Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

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.

Please take a look at my profile page and don't hesitate to come in and talk.