Laminectomy 2020

Laminectomy-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after laminectomy

Arguments for…

• One RCT found that IV paracetamol 1000 mg (n=20) was associated with significantly lower pain scores at 12 h, 18 h and 24 h postoperatively versus placebo (n=20) (Cakan 2008). No basic analgesia or additional baseline analgesics were prescribed. There was no significant difference in rescue IV-PCA morphine use.
• Four studies found a reduction in pain scores and/or opioid consumption with NSAIDs or COX-2 selective inhibitors versus placebo (Kesimci 2011; Khajavikhan 2016; Attia 2017; Cassinelli 2008).
  • One trial using oral dexketoprofen 25 mg (n=25) 30 minutes before induction of anaesthesia showed no significant difference in pain scores compared with oral paracetamol (n=25) or placebo (n=25). However, there was a reduction in rescue IV-PCA morphine consumption at 2 h, 6 h and 24 h postoperatively with dexketoprofen versus placebo (Kesimci 2011).
  • Another trial found that celecoxib (n=38) was associated with significantly lower pain scores and total opioid consumption compared with placebo (n=38) when given 2 h before surgery (400 mg) and 6 h after surgery (200 mg) (Khajavikhan 2016). Rescue analgesia included intermittent IV morphine.
  • One trial compared etoricoxib 120 mg (n=30), duloxetine 60 mg (n=30), the combination of etoricoxib 120 mg and duloxetine 60 mg (n=30), and placebo (n=30) (Attia 2017). Pain scores were significantly lower at all times in patients receiving the combination of etoricoxib and duloxetine as well in patients receiving etoricoxib alone. Postoperative opioid consumption was lower in the combination group. Drugs were administered 1 h pre- and 24 h post-surgery. Rescue analgesia included IV paracetamol and intermittent IV morphine.
  • In another trial comparing ketorolac 30 mg (15 mg if patient age >65 years) (n=13) versus placebo (n=12), pain scores and opioid consumption at 0 h and 4 h after surgery were significantly lower in patients receiving ketorolac (Cassinelli 2008).
• One study found no significant difference in pain scores between diclofenac 100 mg suppository (n=51) and IV paracetamol 1000 mg (n=51), although opioid consumption was significantly lower in the diclofenac group (Nikooseresht 2016). Rescue analgesia included IV-PCA fentanyl.
• One trial compared IV ketorolac 30 mg (n=25) versus 15 mg (n=25), finding no significant difference in pain scores or postoperative opioid consumption (Duttchen 2017). Rescue analgesia included intermittent IV morphine.
• A single study found that pain scores and opioid consumption were significantly lower at all time points in patients receiving a multimodal analgesic regimen (celecoxib 100 mg twice a day, pregabalin 75 mg twice a day and oxycodone 10 mg twice a day) (n=12) versus control (n=10) (Garcia 2013). Rescue analgesia included intermittent IV morphine.

Arguments against…

• In one study, significantly lower pain scores were reported at all time points with IM pethidine 0.5 mg/kg (n=50) versus diclofenac 100 mg suppository (n=50) (Emamhadi 2016). Rescue analgesia was not reported.

PROSPECT Recommendations

• A combination of paracetamol (Grade D) and a nonsteroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2-selective inhibitor (Grade A), administered pre-operatively or intra-operatively and continued postoperatively, is recommended, unless there are contraindications.
• Although there is limited procedure-specific evidence for paracetamol, as only one trial investigated analgesic efficacy for lumbar laminectomy specifically, the PROSPECT methodology considers paracetamol a basic analgesic, with a favourable risk-benefit profile (Joshi 2019).