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Complex Spine Surgery 2020

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Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Grades of recommendation and levels of evidence

Grades of recommendation are assigned according to the overall level of evidence on which the recommendations are based, which is determined by the quality and source of evidence: Relationship between quality and source of evidence, levels of evidence and grades of recommendation.

Complex spine surgery can be defined as thoracolumbar spine surgery with instrumentation, laminectomy at three or more levels, or scoliosis surgery. Complex spine surgery is associated with intense postoperative pain, while adequate pain control can improve early postoperative rehabilitation and long-term outcomes (Lamperti 2017; Borgeat 2008).

The aim of this guideline is to provide clinicians with an evidence-based approach to pain management after complex spine surgery to improve postoperative outcomes such as early ambulation and discharge. The recommendations are based on a procedure-specific systematic review of randomised controlled trials and meta-analyses, with primary outcomes being postoperative pain scores and analgesic requirements. The methodology considers clinical practice, efficacy and adverse effects of analgesic techniques.

Recommended: Pre- and intra-operative interventions

  • ‘Pre-operative’ refers to interventions applied before surgical incision and ‘intra-operative’ refers to interventions applied after incision and before wound closure
  • Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Paracetamol and NSAIDs/COX-2-specific inhibitors Systemic analgesia should include oral or IV paracetamol (Grade D) and NSAIDs or COX-2 specific inhibitors (Grade A) administered pre-operatively or intra-operatively and continued postoperatively, unless contraindicated.
Ketamine Intra-operative IV low-dose ketamine infusion is recommended (Grade A) due to its significant opioid-sparing effect, especially in opiate-dependent chronic pain patients (Loftus 2010; Pacreu 2012; Urban 2008; Subramaniam 2011).

  • Ketamine infusions should not be continued in the postoperative period due to insufficient evidence and potential risk of side effects with increasing ketamine doses (Avidan 2017; Stoker 2019; Schwenk 2016).

COX, cyclooxygenase; IV, intravenous; NSAIDs, non-steroidal anti-inflammatory drugs.

Recommended: Postoperative interventions

  • ‘Postoperative’ refers to interventions applied at or after wound closure
  • Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Paracetamol and NSAIDs/COX-2-specific inhibitors Systemic analgesia should include oral or IV paracetamol (Grade D) and NSAIDs or COX-2 specific inhibitors (Grade A) administered pre-operatively or intra-operatively and continued postoperatively, unless contraindicated
Epidural analgesia Epidural analgesia with local anaesthetics alone or combined with opioids is recommended (Grade B) as a component of multimodal analgesia (Park 2016; Gessler 2016; Prasartritha 2010; Pham Dang 2008)

  • The epidural catheter should be placed under direct visualisation by the surgeon at the end of surgery.
  • Low concentrations of local anaesthetics should be used since concerns about the use of epidural catheters are loss of sensory function and motor weakness and the possibility of delayed diagnosis of neurological complications. No major adverse effects were reported in the literature (Wenk 2018).
  • Use of epidural analgesia should be individualised.
Opioids Opioids should be reserved as rescue analgesics in the postoperative period (Grade D)

COX, cyclooxygenase; IV, intravenous; NSAIDs, non-steroidal anti-inflammatory drugs.

Analgesic interventions that are not recommended for pain management in patients undergoing complex spine surgery.

Intervention

Reason for not recommending
Oral gabapentinoids Significant risk of adverse effects
IV methadone Significant risk of adverse effects
Erector spinae plane block Limited procedure-specific evidence
Thoracolumbar interfascial plane block Limited procedure-specific evidence
IV lidocaine Limited procedure-specific evidence
IV glucocorticoid Lack of procedure-specific evidence
IV dexmedetomidine Limited procedure-specific evidence
Epidural opioids Limited procedure-specific evidence
Intrathecal opioids Limited procedure-specific evidence
Local anaesthetic wound infusion Limited and inconsistent procedure-specific evidence
IV magnesium Limited procedure-specific evidence
Surgical interventions Limited procedure-specific evidence

 

Overall recommendations for peri-operative pain management in patients undergoing complex spine surgery
Pre-operative and intra-operative interventions
  • Oral or IV paracetamol (Grade D)
  • Oral or IV NSAIDs/COX-2 specific inhibitors (Grade A)
  • IV ketamine infusion (Grade A)
Postoperative interventions
  • Epidural analgesia with local anaesthetics with or without opioids (Grade B)
  • Oral or IV paracetamol (Grade D)
  • Oral or IV NSAIDs/COX-2 specific inhibitors (Grade A)
  • Opioids as rescue medication (Grade D)

COX, cyclooxygenase; IV, intravenous; NSAIDs, non-steroidal anti-inflammatory drugs.

PROSPECT recommendations for complex spine surgery – infographic