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).

Laminectomy-specific evidence

Data table: Gabapentinoids for pain management after laminectomy

Arguments for…

• Three RCTs showed reduced pain scores and opioid use with pregabalin versus placebo (Yadav 2018; Kumar 2013; Choi 2013).
  • Pregabalin 300 mg (n=20) and pregabalin 150 mg (n=20) were associated with significantly reduced pain scores and IV-PCA fentanyl use compared to placebo (n=20), when administered 2 h before surgery (Yadav 2018). There was no significant difference between the two different doses of pregabalin. Rescue analgesia included oral NSAIDs and IV-PCA fentanyl.
  • A second study showed that oral pregabalin 150 mg (n=25), administered 1 h before induction, and oral tramadol 100 mg (n=25) were associated with significantly lower pain scores and fentanyl use postoperatively compared with placebo (n=25) (Kumar 2013). Post hoc analysis significantly favoured the tramadol group. Rescue analgesia included intermittent IV fentanyl and IV diclofenac.
  • Another study demonstrated that oral pregabalin 150 mg (administered twice daily, total 8 doses) (n=36) and the combination of oral pregabalin 150 mg plus IV dexamethasone 5 mg (n=36) were associated with significantly lower pain scores than placebo (n=36). The use of fentanyl was reduced in the pregabalin and dexamethasone combination group (n=36) (Choi 2013). Rescue analgesia included continuous IV fentanyl; basic analgesia was IV ketorolac.
• Four studies found reduced pain scores and opioid consumption with gabapentin versus placebo (Javaherforooshzadeh 2018; Khan 2011; Vasigh 2016b; Ozgencil 2011); a fifth study found analgesic benefit with the combination of oral gabapentin and oral celecoxib (Vasigh 2016a). None reported administration of basic analgesics.
  • Javaherforooshzadeh 2018 showed oral gabapentin 600 mg, administered 100 min before surgery (n=30), was associated with significantly lower pain scores and opioid consumption than placebo (n=30). A group that received melatonin 6 mg (n=30) also had lower opioid consumption than the placebo group. Rescue analgesia included IV morphine and IV pethidine.
  • Another study compared different doses of oral gabapentin at different administration times: 600 mg (2 h before surgery, n=25; end of surgery, n=25), 900 mg (2 h before surgery, n=25; end of surgery, n=25) and 1200 mg (2 h before surgery, n=25; end of surgery, n=25) versus placebo (n=25). Pain scores and morphine use were significantly lower in the gabapentin 900 mg and 1200 mg treatment groups (Khan 2011). The time of administration did not impact the analgesic effect. Rescue analgesia included IV-PCA morphine.
  • Another RCT found lower pain scores in patients receiving oral gabapentin (600 mg administered 2 h before surgery and 300 mg 6 h after surgery) (n=38) compared with patients receiving oral celecoxib (400 mg administered 2 h before surgery and 200 mg 6 h after surgery) (n=38) or placebo (n=38) (Vasigh 2016b). Opioid consumption was significantly lower in both intervention groups.
  • Ozgencil 2011 demonstated that both oral pregabalin 150 mg (n=30) and oral gabapentin 1200 mg (n=30) (twice before surgery and twice after surgery) were associated with reduced pain scores at 1h, 2h, 4h and 6h after surgery compared with placebo. Opioid consumption was significantly lower with pregabalin and gabapentin at all time points except at 6 h after surgery, when opioid consumption was lower with pregabalin.
  • In one RCT, the combination of oral gabapentin 300 mg and oral celecoxib 200 mg (administered 2 h before surgery and 6 h after surgery) (n=38) was associated with significantly lower pain scores and opioid consumption compared with oral gabapentin alone (600 mg administered 2 h before surgery and 300 mg 6 h after surgery) (n=38) and placebo (n=38) (Vasigh 2016a). 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, pregabalin 300 mg (n=20), administered 2 h before surgery, was associated with a higher incidence of dizziness and blurred vision when compared with placebo (Yadav 2018).

PROSPECT Recommendations

• Gabapentinoids are not recommended as the first line of treatment in lumbar laminectomy despite proven efficacy in this patient population due to a significant risk of important side effects (including, but not limited to sedation, dizziness, visual blurring).
• The FDA recently published an advisory emphasising the concerns of gabapentin and pregabalin (FDA 2019).

Laminectomy-specific evidence

Data table: Corticosteroids for pain management in laminectomy

Arguments for…

• One trial found that pain scores were not significantly different between IV dexamethasone 0.2 mg/kg before surgery (n=40) and placebo (n=40), although rescue IV-PCA morphine use was significantly lower in the dexamethasone group (Wittayapairoj 2017). No basic analgesia was reported.

PROSPECT Recommendations

• Dexamethasone cannot be recommended as part of the standard analgesic regimen in patients undergoing lumbar laminectomy due to limited procedure-specific evidence.
• Nonetheless, it has an important role in the prevention of post-operative nausea and vomiting.

Laminectomy-specific evidence

Data table: Magnesium for pain management in laminectomy

Arguments against…

• One study found that IV magnesium, with a loading dose of 30 mg/kg at the start of surgery and a continuous infusion of 10 mg/kg/h during surgery (n=20) showed no significant difference from placebo (n=20) in terms of pain scores or opioid use (IV-PCA morphine) (Ghaffaripour 2016). No basic analgesia was reported.

PROSPECT Recommendations

• Magnesium is not recommended for use in lumbar laminectomy due to lack of supporting procedure-specific evidence.

Laminectomy-specific evidence

Data table: Intrathecal analgesia for pain management after laminectomy

Arguments for…

• Two studies showed a reduction in pain scores and/or opioid consumption with intrathecal opioid versus placebo/control (Chan 2006; Yen 2015). No basic analgesia was reported.
  • In one study, pain scores and opioid consumption were significantly lower with intrathecal fentanyl 15 µg (n=30) compared with control (n=30) (Chan 2006). Rescue analgesia included IV-PCA morphine. No significant differences in adverse effects were noted.
  • In one study, intrathecal morphine 3.5 µg/kg (maximum dose 350 µg) (n=16) and placebo (n=16) showed no significant difference in pain scores although total opioid consumption was significantly lower in patients receiving intrathecal morphine (Yen 2015). Rescue analgesia included IV-PCA morphine. No episodes of respiratory depression were observed in either group.
• In one further study, pain scores and opioid consumption were significantly lower with the combination of intrathecal morphine 200 µg and naloxone 20 µg (n=40) than with intrathecal morphine 200 µg (n=37) (Firouzian 2020). Rescue analgesia included IV-PCA morphine. No significant differences in adverse effects were seen.

PROSPECT Recommendations

• Intrathecal opioids are not recommended due to significant risk for adverse effects (including but not limited to respiratory depression, cardiovascular stress, cognitive dysfunction, delayed wound healing, urinary and gastrointestinal dysfunction, as well as the risk of acquired tolerance and long-term opioid use).
• It is unclear whether intrathecal opioids provide enhanced, clinically relevant pain relief over the use of basic analgesics combined with local anaesthetic instillation or infiltration.

Laminectomy-specific evidence

Data table: Epidural anaesthesia for pain management after laminectomy

Arguments for…

• Two studies favoured the use of epidural gelfoam soaked in morphine 5 mg for reduction of pain scores and opioid use compared with epidural instillation with morphine 5 mg (Kundra 2014, Hassanein 2016).
  • Epidural gelfoam soaked in morphine 5 mg (n=75) was associated with significantly lower pain scores and opioid consumption compared to the combination of epidural gelfoam soaked in saline and epidural instillation with morphine 5 mg (n=75) (Kundra 2014). Rescue analgesia included IV diclofenac and intermittent IV morphine. No significant differences in adverse effects were noted.
  • Another study demonstated that pain scores and opioid consumption were lower with epidural gelfoam soaked in morphine 5 mg (diluted either with crystalloid [n=25] or colloid [n=25]) compared to epidural instillation with morphine 5 mg (n=25) (Hassanein 2016). Rescue analgesia included IV diclofenac and intermittent IV morphine. No significant differences in adverse effects were noted.
• One study showed that epidural gelfoam soaked in levobupivacaine 10 mL 0.25% plus dexamethasone 10 mg (n=25) or epidural gelfoam soaked in levobupivacaine 10 mL 0.25% plus saline (n=25) were associated with significantly lower pain scores and opioid consumption compared to epidural gelfoam soaked in saline only (n=25) (Kumari 2018). Addition of dexamethasone did not result in significant differences. Rescue analgesia included IV tramadol. No significant differences in adverse effects were noted.
• One study found that pain scores were significantly reduced with epidural gelfoam soaked in ketamine 50 mg diluted with 5 mL saline (n=20) or epidural gelfoam soaked in nalbuphine 10 mg diluted with 5 mL saline (n=20) compared with epidural gelfoam soaked in 5 mL saline (n=20) (Giri 2018). Rescue analgesia included IV diclofenac. Total diclofenac consumption was significantly lower in patients receiving epidural gelfoam soaked in ketamine. No significant differences in adverse effects were noted.

Arguments against…

• One study found that fentanyl 100 µg (n=29) administered through an epidural catheter was associated with significantly lower pain scores upon admission to recovery, but not afterwards, compared with control (no intervention) (n=31) (Guilfoyle 2012). Rescue analgesia was not reported. No significant differences in adverse effects were noted.

PROSPECT Recommendations

• Epidural anaesthesia is not recommended for use in lumar laminectomy due to limited procedure-specific evidence and risk of adverse effects.
• It is unclear whether epidural analgesia provides enhanced, clinically relevant pain relief over the use of basic analgesics combined with local anaesthetic instillation or infiltration.

Laminectomy-specific evidence

Data Table: Paravertebral block for pain management after laminectomy

Arguments for…

• A single study (n=100) found that pain scores and opioid consumption were significantly lower in patients who received a paravertebral block than in patients who received control (Ozbek 2009). Paravertebral block was performed with 5 mL levobupivacaine 0.5% for each nerve to upper dermatome of laminectomy level. Rescue analgesia included IV-PCA morphine.

PROSPECT Recommendations

• Paravertebral block is not recommended due to limited procedure-specific evidence.

Laminectomy-specific evidence

Data Table: Perineural infiltration for pain management after laminectomy

Arguments for…

• Two studies demonstrated significantly lower opioid consumption after surgery with perineural infiltration versus control (no intervention) (Mordeniz 2010; Torun 2010). Perineural infiltration was defined as the infiltration of local anaesthetics in the irritated neural root sheath, prior to root extraction. Both studies used IV tramadol as rescue analgesia.
  • The first study involved perineural infiltration with 2 mL bupivacaine 0.5% (Mordeniz 2010).
  • The second study evaluated perineural infiltration with 5 mL lidocaine 2% (Torun 2010).

Prospect Recommendations

• Surgical perineural infiltration is not recommended due to limited procedure-specific evidence.

Laminectomy-specific evidence

Data table: Surgical wound infiltration and instillation for pain management after laminectomy

Arguments for…

• Three of four studies found benefits of wound instillation or infiltration compared with placebo on pain relief and analgesia in laminectomy.
  • One study demonstrated that wound instillation with 20 mL ropivacaine 0.25% (n=20) was associated with significantly lower pain scores and total diclofenac consumption than placebo (n=20) (Saini 2018). Wound instillation was defined as the irrigation of the local analgesic into the surgical area for a dwell time of 60 seconds. Rescue analgesia included IV paracetamol and IV diclofenac.
  • Another study found significantly lower pain scores and total diclofenac consumption in patients who received wound instillation with 20 mL bupivacaine25% (n=16) than in those receiving placebo (n=16) (Jonnavithula 2015). Rescue analgesia included IM diclofenac.
  • Another study found significantly lower pain scores and opioid consumption in patients who received wound infiltration with 20 mL levobupivacaine 0.25% combined with methylprednisolone 40 mg (n=19) or wound infiltration with 20 mL bupivacaine 0.25% combined with methylprednisolone 40 mg (n=18) than in those who received placebo (n=19) (Gurbet 2014). Wound infiltration was defined as direct administration of the local analgesic along the line of the incision. Rescue analgesia included IV-PCA morphine.
  • One study found no significant difference in pain scores when surgical wound instillation with 30 mL bupivacaine 0.25% (n=30) was compared with placebo (n=30) (Rahmanian 2016). Rescue analgesia was not reported.

• One study comparing local wound infiltration with 20 mL bupivacaine 0.25% combined with magnesium sulphate 500 mg (n=30) versus 20 mL ropivacaine 0.25% combined with magnesium sulphate 500 mg (n=31) found no significant difference in pain scores after surgery; however, opioid consumption was significantly lower in patients that received local wound infiltration with bupivacaine (Hazarika 2017). Rescue analgesia included IV nalbuphine.

Prospect recommendations

• Wound instillation or infiltration with local anaesthetics, performed by the surgeon just before wound closure, is recommended (Grade A) based on procedure-specific evidence of analgesic efficacy.
• Wound instillation is defined as the irrigation of the local anaesthetics into the surgical area; wound infiltration is defined as the direct injection of local anaesthetics into the tissue along the line of incision.
• Surgical wound instillation or infiltration is a simple technique that can be rapidly performed, with limited risk for side effects including anaesthetic systemic toxicity.