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 ERAS protocols are associated with a decreased rate of perioperative complications.[6,8]

ERAS protocols have shown meaningful reductions in narcotics usage following spine surgery.[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 management group reported continued use as opposed to 24% in the ERAS 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 ERAS 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 fusion.[14–20] Similar results were found in a systematic review relating to the use of ERAS in pediatric patients undergoing deformity correction with decreased postoperative pain scores and length of stay.[21] In addition to the clinical benefits, MMA/ ERAS protocols have been noted as effective cost saving measures across several types of spine surgery, even despite their upfront costs of implementation.[22,23]

Protocol Update

Preoperative

Adequate education and counseling has been shown to reduce postoperative VAS scores and LOS after spine surgery.[24] Preoperative analgesia protocols vary but are generally aimed at mitigating the effects of imminent painful stimuli. Preoperative administration of 600–1200 mg gabapentin or 100–150 mg pregabalin has been shown to reduce postoperative pain and narcotic consumption.[25-27] Utilization of a combination of pregabalin, acetaminophen, celecoxib, and extended release oxycodone has also demonstrated reduced postoperative pain in comparison to an equivalent intravenous morphine dosage.[28]

Intraoperative

Pain produced during spinal surgery is localized to the operative field; therefore, regional and local anesthetic administration is an attractive option. Erector spinae (ESP) blocks, thoracolumbar interfascial plane blocks (TLIP), and quadratus lumborum blocks have all been described. In a cohort of single level lumbar fusion patients, ESP blocks were found to result in lower immediate postoperative VAS pain scores, less postoperative opioid consumption, and higher patient satisfaction.[29] Similarly, TLIP blocks were found in a meta-analysis to lower first postoperative day pain scores and overall use of patient-controlled analgesia.[30] Local infiltration of the wound and incisional site is also frequently used to decrease postoperative pain. Administration of lidocaine with epinephrine into the incisional area followed by wound closure with 30-40 mL of 0.5% ropivacaine has been found to decrease postoperative pain and opioid consumption.[31] The addition of alpha-2 agonists, including clonidine or dexmedetomidine, to these anesthetics has been found to enhance their duration and effectiveness.[32] Finally, end-of-case epidural analgesia has demonstrated decreases in postoperative pain and opioid consumption.[33]

Adjunctive ketamine has been used in pain management since the discovery of the N-methyl-D-aspartate (NMDA) receptor’s role in opioid-induced hyperalgesia.[34] A recent systematic review and meta-analysis of 30 randomized controlled trials found that perioperative low dose ketamine resulted in lower visual analog scale pain scores and opioid requirements in the immediate postoperative period while also decreasing the incidence of nausea and vomiting in this period.[35] Similarly, magnesium has been found to act on the NMDA receptor, and intraoperative administration was found to reduce immediate postoperative opioid consumption.[36]

Intraoperative dexamethasone is commonly used to decrease postoperative nausea, and one study found that a dose of at least 0.11-0.2 mg/kg intraoperatively decreased postoperative opioid requirements in lumbar spine surgery patients without increasing the incidence of wound issues.[37]

Postoperative

Adequate postoperative pain control is integral in improving functional outcomes, facilitating early mobilization, and preventing the development of chronic pain.[38] From a medication standpoint, acetaminophen, nonsteroidal anti-inflammatory drugs (or selective COX-2 inhibitors), muscle relaxers, and gabapentinoids remain the mainstays of opioid-limiting treatment.[39] In addition to medical treatments, early mobilization remains a pillar of postoperative care. Multiple studies have shown that early mobilization reduces length of stay and morbidity.[40] Literature review reveals a multitude of different specific MMA protocols used by surgeons, and the best practice remains a topic of ongoing research.

References

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29. Goel VK, Chandramohan M, Murugan C, et al. Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study. Spine J. 2021;21(11):1873-1880.

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37. Wittayapairoj A, Wittayapairoj K, Kulawong A, Huntula Y. Effect of intermediate dose dexamethasone on post-operative pain in lumbar spine surgery: a randomized, triple-blind, placebo-controlled trial. Asian J Anesthesiol. 2017;55(3):73-77.

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39. Walker CT, Gullotti DM, Prendergast V, et al. Implementation of a standardized multimodal postoperative analgesia protocol improves pain control, reduces opioid consumption, and shortens length of hospital stay after posterior lumbar spinal fusion. Neurosurgery. 2020;87(1):130-136.

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Authors: William Conaway, MD, and Arash Sayari, MD

From Midwest Orthopaedic at Rush, Rush University Medical Center, in Chicago, Illinois.