DANIEL CALEM, BA
MARK KURD, MD
Spine surgery has historically relied on the routine use of opioids, with spine surgery patients often being exposed to opioids as conservative management for their pain preoperatively.
Preoperative opioid use is associated with negative outcomes postoperatively after spine surgery. These include higher rates of postoperative opioid use, worker absenteeism, hospital length of stay, wound complications, hospital readmission, risk of revision surgery, and overall healthcare costs.
The perioperative use of epidural or intrathecal injections of steroids, local anesthesia, gabapentin, pregabalin, ketamine, and alpha-2 agonists has been shown to reduce pain and opioid consumption after spine surgery.
A growing body of evidence supports the use of multimodal analgesia regimens with spine surgery to decrease the need for opioids postoperatively.
Spine surgery is a surgical specialty performed by orthopaedic surgeons and neurosurgeons. Patients with pain due to acute or chronic spinal pathologies are frequently treated with opioids; in fact, opioids are the most commonly used analgesics to treat low back pain.1 There was a 660% rise in opioid prescriptions from 1997 to 2006 for back and neck pain,2 despite little evidence that suggests their effectiveness.3,4 Thus, patients scheduled to undergo spine surgery are often taking opioids as conservative management for their pain. Moreover, spine surgeries, particularly lumbar procedures, often result in high levels of postoperative pain that historically have relied on opioids for treatment. There is an urgent and unmet need for extensive perioperative solutions to combat opioid use, particularly in spine patients. This Research Brief will outline modern treatment strategies designed to effectively manage pain in spine surgery while minimizing narcotic utilization. Evidence-based recommendations will be divided into preoperative, perioperative, and postoperative pain management strategies.
Preoperative opioid use prior to spine surgery has been reported to range from 20% to over 70%5–7, and nearly 20% of patients in this population are opioid dependent.8 However, preoperative opioid use has been shown to be overwhelmingly associated with negative outcomes.9–11 In a recent systematic review of 45 articles, Yerneni et al showed that a vast majority of published literature found preoperative opioid use to be associated with negative outcomes in patients undergoing spine surgery compared to those who were opioid naïve, including higher rates of postoperative opioid use, worker absenteeism, length of stay, healthcare cost, wound complications, hospital readmission within 90 days, and risk of revision surgery.12 In a prospective cohort study, Armaghani et al showed that for every 100 morphine equivalents a patient is taking preoperatively, their hospital stay is extended by 1.1 days postoperatively.13
Healthcare providers must screen patients for preoperative opioid use and dependence. If a patient is being treated with opioids before surgery, his or her medications should be tapered and ideally discontinued as a means to reduce postoperative opioid usage and reduce other complications. Spine surgeons should also screen patients for risk factors that can predispose patients to opioid-related morbidity or mortality. These include catastrophic thinking, anxiety, posttraumatic stress disorder, depression, other psychiatric diagnoses, family history of substance abuse, nicotine dependency, young age, and lower education level.14,15 Patients should receive preoperative counseling on the inherent risks of opioid analgesics that emphasizes minimizing opioid use prior to and rapid cessation after surgery. Additionally, patients with underlying psychiatric diagnoses may benefit from cognitive behavioral therapy.16
Spine surgeons have multiple analgesic and anesthetic techniques available perioperatively in addition to general anesthesia. These include epidural or intrathecal injections, local anesthesia, intraoperative intravenous medications, as well as oral medications taken shortly before surgery. The choice of perioperative anesthesia and analgesia can have a significant effect on postoperative pain and opioid consumption.
Steroids and opioids can be given as epidural or intrathecal injections, which place them directly adjacent to the spinal cord and nerves. Epidural steroid injections are often used as an adjunct to other methods of pain management. A systematic review by Jamjoom & Jamjoom demonstrated strong evidence that intraoperative epidural steroid injection reduces early postoperative pain and opioid consumption.17 Neuraxial opioids may decrease postoperative pain and result in fewer systematic adverse effects than intravenous or oral opioids, and evidence shows lower pain scores and postoperative opioid use in patients who received intrathecal fentanyl compared to control.18,19 Additionally, local anesthetics such as lidocaine and bupivacaine can be injected in the soft tissues near the surgical site. Their ability to provide substantial pain relief after orthopaedic procedures requiring extensive soft-tissue dissection and retraction have been well described.20,21 In a randomized prospective double-blind placebo-controlled trial, Loftus et al showed that a continuous infusion of ketamine intraoperatively reduced pain intensity and postoperative opioid consumption in opiate-dependent patients with chronic pain without an increase in side effects.22 Perioperative systemic alpha 2-agonists such as dexmedetomidine and clonidine have also been shown to decrease postoperative opioid consumption, pain intensity, and nausea.23
High-quality evidence supports the use of gabapentin or pregabalin in perioperative pain management. Specifically, multiple randomized-controlled trials have showed that patients who took gabapentin or pregabalin 1 hour before incision had significantly less pain and consumed less opioids after surgery than placebo.24,25 In a systematic review, Yu et al demonstrated significant pain reduction and decreased narcotic consumption with either gabapentin or pregabalin, without notable adverse effects.26 In a recent metanalysis of 10 randomized controlled trials, Han et al indicated that preoperative gabapentin reduces postoperative opioid use, pain scores, vomiting, and urinary retention.27
Spine surgery is often associated with high levels of postoperative pain. Pain control after spine surgery can be challenging, and inadequate pain control can lead to increased morbidity, worse outcomes, delayed recovery and return to normal daily living, decreased patient satisfaction, and chronic persistent pain, which can further lead to opioid dependence.28 There is a growing body of evidence arguing for the use of multimodal analgesia (MMA) regimens to improve postoperative pain management and reduce opioid consumption. These regimens rely on the synergism of nonopioid agents given in lower doses to improve the continuity of pain control, reduce adverse effects, and facilitate rehabilitation. MMA regimens in joint arthroplasty have gained acceptance,20,29 but evidence supporting their use after spine surgery is limited but promising.
Many MMA regimens include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat postoperative pain. Traditionally, spine surgeons have been reluctant to adopt routine NSAID use for postoperative pain management because of concerns of nonunion, pseudarthrosis, and increased postoperative bleeding.30,31 However, recent evidence supports the use of NSAIDs and indicates that these agents do not affect fusion rates. In a meta-analysis published by Li et al, high-dose ketorolac was associated with increased risk of nonunion, but no detrimental effects were seen with short-term NSAIDs at normal doses.32 In another met-aanalysis, Jirarattanaphochai & Jung showed that patients who received NSAIDs and opioids had lower pain scores and reduced opioid use than patients who received opioids alone.33 In a randomized controlled trial, Jirarattanaphochai et al showed that patients receiving parecoxib had a 39% reduction in morphine use, reduced pain at rest, and greater satisfaction.34 Evidence thus supports the use of short-term, low-dose nonselective COX inhibitors or selective COX-2 inhibitors in spine surgery.
Multiple MMA regimens, encompassing agents such as NSAIDs, gabapentin, pregabalin, acetaminophen, ketamine, ondansetron, and opioids, delivered preoperatively, intraoperatively, and postoperatively have been proposed. Specific studies by Garcia et al, Kim et al, Mathiesen et al, and Rajpal et al are depicted in Table 1.35–38 Evidence supports the superiority of these MMA regimens compared to opioid regimens alone. More research is needed to determine optimal agents, dosages, and regimen length to clarify their effect on postoperative pain management, complication rate, length of stay, and long-term outcomes.
Table 1: Studies of MMA regimens for pain management in patients undergoing spine surgery.
(Adopted with permission from Kurd et al39 – J Am Acad Orthop Surg 2017)
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6. Walid MS, Robinson ECM, Robinson JS. Higher comorbidity rates in unemployed patients may significantly impact the cost of spine surgery. J Clin Neurosci Off J Neurosurg Soc Australas. 2011;18(5):640-644. doi:10.1016/j.jocn.2010.08.029
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10. Lee D, Armaghani S, Archer KR, et al. Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. J Bone Joint Surg Am. 2014;96(11):e89. doi:10.2106/JBJS.M.00865
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13. Armaghani SJ, Lee DS, Bible JE, et al. Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery. Clin Spine Surg. 2016;29(2):E93-98. doi:10.1097/BSD.0000000000000109
14. Helmerhorst GTT, Vranceanu A-M, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014;96(6):495-499. doi:10.2106/JBJS.L.01406
15. Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015;23(5):267-271. doi:10.5435/JAAOS-D-14-00163
16. Archer KR, Motzny N, Abraham CM, et al. Cognitive-behavioral-based physical therapy to improve surgical spine outcomes: a case series. Phys Ther. 2013;93(8):1130-1139. doi:10.2522/ptj.20120426
17. Jamjoom BA, Jamjoom AB. Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskelet Disord. 2014;15:146. doi:10.1186/1471-2474-15-146
18. Chan JHH, Heilpern GNA, Packham I, Trehan RK, Marsh GDJ, Knibb AA. A prospective randomized double-blind trial of the use of intrathecal fentanyl in patients undergoing lumbar spinal surgery. Spine. 2006;31(22):2529-2533. doi:10.1097/01.brs.0000241135.79983.52
19. Guilfoyle MR, Mannion RJ, Mitchell P, Thomson S. Epidural fentanyl for postoperative analgesia after lumbar canal decompression: a randomized controlled trial. Spine J Off J North Am Spine Soc. 2012;12(8):646-651. doi:10.1016/j.spinee.2012.07.007
20. Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg Am. 2011;93(11):1075-1084. doi:10.2106/JBJS.J.01095
21. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg. 2006;203(6):914-932. doi:10.1016/j.jamcollsurg.2006.08.007
22. Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010;113(3):639-646. doi:10.1097/ALN.0b013e3181e90914
23. Blaudszun G, Lysakowski C, Elia N, Tramèr MR. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology. 2012;116(6):1312-1322. doi:10.1097/ALN.0b013e31825681cb
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25. Kim JC, Choi YS, Kim KN, Shim JK, Lee JY, Kwak YL. Effective dose of peri-operative oral pregabalin as an adjunct to multimodal analgesic regimen in lumbar spinal fusion surgery. Spine. 2011;36(6):428-433. doi:10.1097/BRS.0b013e3181d26708
26. Yu L, Ran B, Li M, Shi Z. Gabapentin and pregabalin in the management of postoperative pain after lumbar spinal surgery: a systematic review and meta-analysis. Spine. 2013;38(22):1947-1952. doi:10.1097/BRS.0b013e3182a69b90
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28. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin N Am. 2005;23(1):21-36. doi:10.1016/j.atc.2004.11.013
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30. Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR. The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine. 1998;23(7):834-838. doi:10.1097/00007632-199804010-00020
31. Martin GJ, Boden SD, Titus L. Recombinant human bone morphogenetic protein-2 overcomes the inhibitory effect of ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), on posterolateral lumbar intertransverse process spine fusion. Spine. 1999;24(21):2188-2193; discussion 2193-2194. doi:10.1097/00007632-199911010-00003
32. Li Q, Zhang Z, Cai Z. High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion. Spine. 2011;36(7):E461-468. doi:10.1097/BRS.0b013e3181dfd163
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34. Jirarattanaphochai K, Thienthong S, Sriraj W, et al. Effect of parecoxib on postoperative pain after lumbar spine surgery: a bicenter, randomized, double-blinded, placebo-controlled trial. Spine. 2008;33(2):132-139. doi:10.1097/BRS.0b013e3181604529
35. Garcia RM, Cassinelli EH, Messerschmitt PJ, Furey CG, Bohlman HH. A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study. J Spinal Disord Tech. 2013;26(6):291-297. doi:10.1097/BSD.0b013e318246b0a6
36. Kim S-I, Ha K-Y, Oh I-S. Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2016;25(5):1614-1619. doi:10.1007/s00586-015-4216-3
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38. Rajpal S, Gordon DB, Pellino TA, et al. Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech. 2010;23(2):139-145. doi:10.1097/BSD.0b013e3181cf07ee
39. Kurd MF, Kreitz T, Schroeder G, Vaccaro AR. The Role of Multimodal Analgesia in Spine Surgery. J Am Acad Orthop Surg. 2017;25(4):260-268. doi:10.5435/JAAOS-D-16-00049