61. Multi-modal analgesia protocol significantly decreased opioid requirements following lumbar spine surgery: results from a feasibility trial

Abstract

BACKGROUND CONTEXT Over the past decade, opioid use in the United States has increased rapidly. However, patient satisfaction with pain management has not improved. Instead, with growing number of overdose deaths, over- and misuse of opioids has been declared a public health crisis. Patients presenting for lumbar spine surgery frequently present with pain related to their spine condition, are frequently consuming opioids to treat this pain and, following surgery, this is exacerbated due to disruption of skin, muscle tissue, vertebrae, intervertebral discs, and facet joints. Proper pain management is necessary to reduce pain-related and medication side effects and to promote recovery. While this pain is often treated with opioids, roughly 40% of patient experience suboptimal pain management. Multimodal pain management strategies have been proposed to (1) control preoperative pain; (2) employ nonopioid medication to pre-empt surgical pain; and (3) monitor and control pain intensity before and after surgery. PURPOSE We provide critical evidence that a multi-modal pain management plan for patients undergoing lumbar spine surgery leads to reduction in opioid requirements following surgery and superior pain relief. STUDY DESIGN/SETTING A randomized clinical trial to determine feasibility of comparing two pain management plans. Multimodal Pain Management (MPM): acetaminophen plus gabapentin in the preparation area prior to surgery; preinduction opioid titration with fentanyl until pain is relieved and/or respiratory depression ensues; volatile anesthetic, intravenous ketamine and nitrous oxide during surgery; acetaminophen, valium plus gabapentin during hospitalization; and prescription for acetaminophen, valium plus gabapentin at discharge. Standard postoperative analgesia (SPA) is a protocol directed and clinically appropriate for postoperative analgesia. In this study, standard postoperative analgesia is defined as: oxygen, fentanyl, hydromorphone preceded by an intraoperative general anesthetic of propofol and remifentanil which is often recommended to facilitate intraoperative monitoring (IOM). PATIENT SAMPLE We enrolled 51 participants (2 canceled surgery) and randomized 49 (24 MPM; 25 SPA). Patient sample was 63% white, 55% female, and 60% over the age of 65 years. A majority of patients underwent fusion procedures (70%). There were no demographic or clinical differences between groups. OUTCOME MEASURES The primary outcome measures were postoperative pain scores and analgesic use. METHODS Postoperative pain score (numeric rating scale, 0-10) and narcotic use (total morphine equivalent units [TME] in milligrams) were compared between groups in the post-anesthesia care unit (PACU), postoperative day (POD) 0, POD 1, and following discharge (tablets used). RESULTS Patients in MPM had significantly lower mean pain rating in the PACU, POD 0, and POD 1 compared to SPA (4.1 vs 8.3; 2.7 vs 5.1; and 2.3 vs 4.2; p CONCLUSIONS In our feasibility trial, we were able to demonstrate that patients in MPM experienced significantly less pain following surgery and required less opioid in hospital compared to patients in SPA. These patients may also use less opioid following discharge. It may be important that the intraoperative anesthetic SPA group is typically what is recommended for patients undergoing IOM. A larger, multicenter trial is needed to further examine the impact of MPM on patient outcomes beyond pain and on postoperative opioid use. FDA DEVICE/DRUG STATUS fentanyl (Approved for this indication), acetaminophen (Approved for this indication), valium (Approved for this indication), gabapentin (Approved for this indication), propofol (Approved for this indication), hydromorphone (Approved for this indication), remifentanil (Approved for this indication).