Complex Spine Surgery 2020

Complex spine surgery-specific evidence

Data table: NSAIDs/COX-2-selective inhibitors for pain management after complex spine surgery

Arguments for…

• Three studies found that NSAIDs and COX-2-specific inhibitors were associated with lower pain scores and/or opioid consumption compared with placebo/control:
  • One study found VAS scores and morphine consumption were significantly lower with 800 mg of IV ibuprofen 30 min prior to incision versus placebo in the first 48 h postsurgery, in patients undergoing multilevel PLIF surgery (Pinar 2017).
  • One study found that total morphine requirements over the first 48 h and postoperative pain scores were significantly reduced with 40 mg parecoxib 30 min before induction of anaesthesia and then every 12 h for 48 h, compared with placebo, in patients who underwent PLIF surgery (Jirarattanaphochai 2008).
  • A third RCT compared PCA morphine 1 mg/ml versus PCA morphine 1 mg/ml plus tenoxicam 0.6 mg/ml versus a loading dose of 20 mg tenoxicam 30 min before wound closure and a morphine plus tenoxicam PCA (Chang 2013). The PCA devices were programmed to deliver a loading dose of 0.05 ml/kg, a continuous infusion of 0.005 ml/kg/h and a bolus dose of 0.02 ml/kg with a 10 min lock-out period. The pain scores were not significantly different, but morphine consumption was reduced in both tenoxicam groups.
• Two meta-analyses support the use of NSAIDs:
  • Zhang 2017 included eight studies in a meta-analysis, with a total of 408 patients, comparing NSAIDs with placebo after lumbar spine surgery. The mean difference of pain scores between NSAIDs and placebo groups was significant during the first 24 h.
  • The meta-analysis by Jirarattanaphochai 2008 included 17 RCTs and 789 patients, and compared pain scores in patients who underwent lumbar spine surgery and received either NSAIDs in addition to opioids, or opioids alone. The NSAIDs group experienced significantly less pain and had lower morphine consumption. No significant difference was found regarding side effects.

PROSPECT Recommendations

• 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.
  • The analgesic benefits and opioid-sparing effects of simple analgesics such as paracetamol and NSAIDs are well described (Joshi 2014; Martinez 2017; Ong 2010; Chidambaran 2018).
  • Short-term use of low-dose NSAIDs around the time of spinal fusion is well tolerated and does not interfere with osteogenesis or increase the rate of non-union (Sivaganesan 2017; Dodwell 2010; Mathieson 2013).
  • Patients undergoing spine surgery in association with peri-operative NSAIDs do not have an increased risk of bleeding (Zhang 2017; Mikhail 2020; Chin 2007).
  • Fixed-time interval analgesia has been shown to provide superior pain relief in comparison with on-demand analgesia (Atkinson 2015; Yefet 2017).

Complex spine surgery-specific evidence

Data table: Epidural analgesia for pain management after complex spine surgery

Arguments for…

• Two RCTs (Park 2016; Gessler 2016) compared the epidural infusion of 0.2% ropivacaine with IV-PCA opioids. Pain scores were significantly lower in the epidural groups and lower doses of postoperative opioids were required.
• One of two studies found a benefit of the combined effects of neuraxial local anaesthetics and opioids compared with IV-PCA opioid:
  • One study found that VAS scores in the epidural groups were less than in the IV morphine group up to 48 h postoperatively (Prasartritha 2010).
  • Another study concluded that epidural 0.2% ropivacaine and sufentanil did not lower postoperative pain scores and IV sufentanil rescue doses compared with an IV-PCA with piritramide (Kluba 2010).
• Epidural bupivacaine 0.125% infusion was compared with 0.2% ropivacaine infusion in patients with degenerative or idiopathic scoliosis undergoing multi-level spinal fusion surgery. The VAS scores on mobilisation were lower within the bupivacaine group (Pham Dang 2008).
• One study compared an intra-operative epidural infusion of 0.175% bupivacaine and sufentanil 0.5 mg/kg with an epidural infusion started after neurological examination on the PACU (Wenk 2018). They found significantly decreased pain scores in the intra-operative group. Patients in the postoperative group received more intra-operative opioids and postoperative piritramide rescue doses. Early postoperative neurological examination was feasible in all patients in both groups.

Arguments against…

• One placebo-controlled trial compared PCEA with 0.1% bupivacaine and hydromorphone with a PCEA 0.9% saline infusion (Choi 2014). The mean cumulative opioid consumption was less in the active treatment group, but the difference was statistically not significant.

PROSPECT Recommendations

• 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.