Recommendations for Postoperative pain management after complex spine surgery

Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.

A group of European researchers performed a systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.

The results of the study are as follows:

• Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria.
• Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids.
• Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.

 Main recommendations:

1. Systemic analgesia should include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase (COX)-2 specific inhibitors administered pre-operatively or intra-operatively and continued postoperatively.

2. Intra-operative intravenous low-dose ketamine infusion is recommended.

3. Epidural analgesia with local anaesthetics alone or combined with opioids are recommended.

4. Opioids should be reserved as rescue analgesics in the postoperative period.

Thus, the researchers concluded that the analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs continued postoperatively with opioids used as rescue analgesics.

Reference:

Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations by Piet W et. al. published in the European Journal of Anaesthesiology.

doi: 10.1097/EJA.0000000000001448