From Midwest Orthopaedic at Rush, Rush University Medical Center, in Chicago, Illinois.
PAIN MANAGEMENT
33
An Update on Multimodal Analgesia Are We Better at Managing Postoperative Pain?
Since its introduction in 1993, multimodal analgesia (MMA) has been used to provide a synergistic analgesic effect, therefore reducing the adverse effects of any individual drug used in isolation at higher doses.1 The use of MMA has subsequently been incorporated into the concept of Enhanced Recovery After Surgery (ERAS) and is used alongside preoperative patient education/ optimization, preemptive analgesia, standardized intraoperative anesthesia, early mobilization, and novel medication classes in order to enhance pain control and minimize the use of opioid analgesics.2 In hopes of mitigating the unwanted side effects of narcotics, MMA and ERAS protocols have been widely adapted across surgical subspecialties. 3-4 Given these successes, spine surgery centers have begun to adopt similar protocols in order to enhance patient outcomes and satisfaction. 5 With increasingly widespread implementation of MMA and ERAS protocols, a critical review of their implementation and outcomes is necessary.
Efficacy of MMA/ERAS protocols Multiple systematic reviews of spine operative MMA/ERAS protocols have shown that their use results in significant reduction in the length of hospital stay and reduced postoperative pain scores.6–9 Equally important, these reviews have found that the ER AS
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protocols are associated with a decreased rate of perioperative complications.6,8 ER AS protocols have shown meaningful reductions in narcotics usage following spine surWilliam Conaway, MD gery.10-12 In a prospective study, Flanders et al found their ERAS protocol patients took significantly fewer opioid medications after elective spine surgery at 1, 3, and 6 months postoperatively. At the 6 month assessment, 52% of the traditional pain manageArash Sayari, MD ment group reported continued use as opposed to 24% in the ER AS protocol group.11 In a randomized trial of 284 patients, the ERAS group utilized significantly less intravenous opioid and patient-controlled analgesia than the standard-of-care group.13 At 6-month follow-up, significantly fewer ERAS participants reported any opioid use (11.4% vs 20.6%). Additionally, mean VAS scores were lower (3.0 vs 4.0), Foley catheters were used less often, and patients were discharged home more often (91.1% vs 81.0%) in the ER AS group.13 This trend has continued in various spine surgical procedures, including anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, lumbar fusion, and transforaminal interbody
Vertebral Columns
Fall 2023
