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: Ketamine for pain management after complex spine surgery

• The efficacy of ketamine was investigated in six studies (Hadi 2009; Loftus 2010; Nielsen 2017; Subramaniam 2011; Pacreu 2012; Urban 2008):
  • None of the studies had adequate basic analgesia (Joshi 2019).
  • Bolus doses ranged from high (0.5 mg/kg) (Nielsen 2017; Loftus 2010; Pacreu 2012; Subramaniam 2011) to low (0.1 to 0.2 mg/kg) (Hadi 2009; Urban 2008) and continuous infusion doses ranged from high (up to 10 mg/kg/min) (Hadi 2009; Loftus 2010; Nielsen 2017) to low (1 to 2 mg/kg/min) (Hadi 2009; Subramaniam 2011; Pacreu 2012; Urban 2008).

Arguments for…

• In patients undergoing major lumbar spinal surgery, intra-operative high-dose ketamine had morphine-sparing effects, with decreased pain scores postoperatively and at 6 weeks (Loftus 2010).
• In patients undergoing lumbar posterior fusions, low-dose ketamine continued for 24 h postoperatively had analgesic, but not opioid-sparing effects (Urban 2008).
• Two studies found analgesic effects of ketamine against the backdrop of intra-operative remifentanil-based analgesia:
  • In one study, patients undergoing scoliosis surgery under remifentanil maintenance benefited from ketamine with lower pain scores, reduced morphine consumption and prolonged time to first rescue analgesic (Hadi 2009).
  • Another study demonstrated methadone-sparing effects when ketamine infusion was superimposed on a remifentanil maintenance regimen (Pacreu 2012).
• In chronic pain patients undergoing major spine surgery, high-dose ketamine was associated with opioid-sparing effects, and reduced opioid-induced sedation (Nielsen 2017).
• Side effects were described by three studies (Loftus 2010; Nielsen 2017; Subramaniam 2011): two of these studies found no increase in side effects with ketamine (Loftus 2010; Subramaniam 2011) and one study found decreased sedation in the ketamine group (Nielsen 2017).

Arguments against…

• No additional analgesic benefit of ketamine was observed in patients with pre-operative opioid intake when epidural bupivacaine was used as basic analgesia (Subramaniam 2011).

PROSPECT Recommendations

• 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).

Complex spine surgery-specific evidence

• No procedure-specific evidence was identified that met the inclusion criteria.

PROSPECT Recommendations

• IV glucocorticoid is not recommended due to lack of procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: Gabapentinoids for pain management after complex spine surgery

Arguments for…

• One study compared placebo with two doses of oral pregabalin (75 or 150 mg), 1 h before and 12 h after surgery (Kim 2011). Differences in pain scores were not significant, but cumulative morphine IV PCA consumption was reduced in the pregabalin 150 mg group after 24 h.
• A meta-analysis demonstrated that, compared with placebo, both gabapentin and pregabalin significantly reduced postoperative narcotic consumption and postoperative pain scores (Yu 2013).

PROSPECT Recommendations

• Oral gabapentinoids are not recommended due to significant risk of adverse effects.

Complex spine surgery-specific evidence

Data table: Methadone for pain management after complex spine surgery

Arguments for…

• One study found a positive analgesic effect of methadone 0.2 mg/kg at the start of surgery compared to hydromorphone 2 mg at surgical closure for spinal fusions (Murphy 2017). Median hydromorphone consumption was significantly reduced in the methadone group and pain scores were lower.
• Another study found reduced opioid consumption and pain scores when methadone 0.2 mg/kg before surgical incision was compared with a sufentanil bolus and continuous infusion in patients undergoing multi-level thoracolumbar spine surgery (Gottschalk 2011). Following methadone, postoperative opioid requirement was reduced by 50% at 48 and 72 h after surgery. Pain sores were also lower by approximately 50% in the methadone group at 48 h postsurgery.

PROSPECT Recommendations

• IV methadone is not recommended due to significant risk of adverse effects.

Complex spine surgery-specific evidence

Data table: IV lidocaine for pain management after complex spine surgery

Arguments for…

• One study found that IV lidocaine (2 mg/kg loading and 3 mg/kg/h infusion) significantly reduced pain scores in the first 48 h postsurgery, morphine consumption in the first 24 h and the time to the first request for additional analgesia, compared with placebo (Ibrahim 2018).
• A placebo-controlled trial showed that IV lidocaine infusion (2 mg/kg/h) reduced morphine requirements in the first 48 h, but the differences in mean VRS pain scores between the two groups were less than 10% (Farag 2013).

PROSPECT Recommendations

• IV lidocaine is not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: IV dexmedetomidine for pain management after complex spine surgery

Arguments for…

• Dexmedetomidine infusion (0.01 to 0.02 mg/kg/min) was compared with remifentanil infusion (0.01 to 0.2 mg/kg/min) in patients undergoing PLIF surgery (Hwang 2015). The pain scores in the dexmedetomidine group were significantly lower than those in the remifentanil group at the immediate and late postoperative periods (48 h after surgery). The dexmedetomidine group had lower hydromorphone requirements for 48 h after surgery except at time of discharge from PACU.
• One study reported that dexmedetomidine (1 mg/kg loading dose followed by 0.5 mg/kg/h infusion) reduced intra-operative, but not postoperative, opioid consumption when compared with placebo in patients undergoing thoracic and/or lumbar spine surgery at three levels or more (Naik 2016). There were no differences in pain scores at 24 h postoperatively.
• A systematic review with 913 patients included, showed that dexmedetomidine was sedative and allowed an opioid-sparing effect intra-operatively (Tsaousi 2018). No definite conclusion could be drawn due to the considerable heterogeneity of the available data.

PROSPECT Recommendations

• IV dexmedetomidine is not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: IV magnesium for pain management after complex spine surgery

Arguments for…

• In one study, patients given magnesium (50 mg/kg) and ketamine (0.2 mg/kg bolus with an infusion of 0.15 mg/kg/h) showed a significantly lower average cumulative morphine consumption compared with ketamine alone until 48 h postsurgery (Jabbour 2014). VAS scores were not significantly different, but quality of sleep and patient satisfaction were better in the magnesium group during the first postoperative night.

PROSPECT Recommendations

• IV magnesium is not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: Multimodal technique for pain management after complex spine surgery

Arguments for…

• One study compared a multimodal analgesia protocol with celecoxib 200 mg, pregabalin 75 mg, extended-release oxycodone 10 mg, acetaminophen 500 mg and IV-PCA morphine with IV-PCA morphine alone (Kim 2016). Pain scores were lower in the multimodal pain management group at all time points (until seven days postoperatively) and opioid consumption was reduced for 48 h after spinal fusion surgery.

Arguments against…

• One RCT investigated the use of a multimodal analgesic pathway in patients at high risk of postoperative pain undergoing multilevel spine surgery (Maheshwari 2020). The study compared pre-operative acetaminophen and gabapentin, combined with intra-operative infusions of lidocaine and ketamine, with placebo. All patients received epidural analgesia or local wound infiltration. Pain scores, quality of recovery and opioid consumption in the multimodal analgesic group were not superior to the placebo group.

PROSPECT Recommendations

• Multimodal pain management is recommended using the protocol described in the Summary Recommendations.

Complex spine surgery-specific evidence

• No procedure-specific evidence was identified that met the inclusion criteria at the time of the search. However, recent data are promising (Singh 2020).

PROSPECT Recommendations

• Erector spinae plane block is not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: Thoraco-lumbar interfascial plane (TLIP) block for pain management after complex spine surgery

Arguments for…

• One study compared the pre-operative placement of a bilateral single shot, ultrasound-guided, lateral thoracolumbar interfascial plane (TLIP) block with a 30 ml bolus of 0.375% ropivacaine at each side versus placebo in patients undergoing lumbar spinal fusion surgery (Chen 2019). Opioid and anaesthetic consumption in the peri-operative period decreased significantly in the TLIP group compared with the control group. The VAS scores in the TLIP group were lower at 12, 24 and 36 h postoperatively.

PROSPECT Recommendations

• Thoracolumbar interfascial plane block is not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data table: Epidural anaesthesia with opioids alone for pain management after complex spine surgery

Arguments against…

• In one RCT, low (10 mg) and high (15 mg) doses of extended-release epidural morphine were compared (Offley 2013). Pain scores in the first 48 h were not significantly different, neither was the total postoperative analgesic consumption.

PROSPECT Recommendations

• Epidural opioids are not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data Table: Intrathecal anaesthesia with opioids for pain management after complex spine surgery

Arguments for…

• One study compared the effect of 0.4 mg intrathecal morphine versus placebo after posterior lumbar interbody surgery (Ziegeler 2008). There was a significantly lower cumulative piritramide requirement in the intrathecal morphine group without any serious increase of opioid-associated side effects. VAS scores were only significantly lower in the morphine group at 4 and 8 h after surgery.

PROSPECT Recommendations

• Intrathecal opioids are not recommended due to limited procedure-specific evidence.

Complex spine surgery-specific evidence

Data Table: Local anaesthetics infiltration/infusion for pain management after complex spine surgery

Arguments against…

• A placebo-controlled trial compared 0.2% ropivacaine (8 ml/h) local wound infusion through a catheter with normal saline after posterior spinal fusion surgery (Greze 2017). No additional analgesia or opioid reduction was provided with continuous wound infiltration.
• One study compared a continuous local wound infusion of 0.33% ropivacaine with flurbiprofen and pentazocine infusion following thoracolumbar spinal surgery (Xu 2017). There were no differences in pain scores and rescue analgesia.

PROSPECT Recommendations

• Local anaesthetic wound infusion is not recommended due to limited and inconsistent procedure-specific evidence.