Abstract
Background: High-volume local infiltration analgesia is effective in knee arthroplasty, but the analgesic efficacy of systematic infiltration with high-volume local anesthetic in major lumbar spine surgery in L3 to S1 has not been clarified. We conducted a trial to evaluate the analgesic efficacy of intraoperative Local Infiltration Analgesia (LIA) administration and postoperatively via injections through intraoperatively placed wound catheters. Methods: In a randomized, double-blind, placebo-controlled trial in 48 patients undergoing major lumbar spine fusion surgery, 70 mL saline (n=24) or ropivacaine 0.5% with adrenaline (n=24) was infiltrated using a systematic technique to all tissue incised, handled or instrumented during surgery and with repeated injections at 6, 12 and 24 h postoperatively with 10, 10 and 20 mL. Twenty-two patients in each group were used for analysis. Allocation was determined by using a computer generated random sequence concealed in consecutively numbered sealed envelopes, which were opened on the morning of surgery. For postoperative analgesia 2 multi-hole catheters were placed under the fascia of the m. erector spinae and subcutaneously in accordance with the randomization. The primary end-point was postoperative pain at rest, during leg elevation and walking for 48 hours postoperatively. Secondary end-point was the amount of administered opioid in the same period. Results: VAS pain scores were only significantly lower at 3 hours postoperatively in the ropivacaine group with straight leg elevation (p=0.0169) and at 7 hours in the ropivacaine group during walking (p=0.0133). At 25 hours postoperatively, there was a slightly significant reduction in pain scores from repeated injection of ropivacaine vs. saline in the catheters both during elevated straight leg test (p=0.0495) and during walking (p=0.0192). Rescue opioid requirements (24 h) were about 30 % lower in the ropivacaine group (p<0.05). No local anesthetic side effects were observed. Conclusion: Intraoperative high-volume wound infiltration with ropivacaine in major lumbar spine fusion surgery may only have a small analgesic effect in early postoperative pain management and after local anesthetic administration through multiholed wound catheters 24 hours postoperatively.
Highlights
Major lumbar spine surgery usually causes severe pain, which challenges effective pain management, a prerequisite for early recovery and rehabilitation [1]
A renewed interest in the concept comes from the recent observations from Kerr and Kohan in Australia where high-volume, low concentration, multilocal infiltration analgesia has been administered in hip and knee replacement and with subsequent intermittent administration through a wound catheter [6,7,8]
Only one study has examined the effect of local anesthetic infiltration analgesia after major spine surgery followed by continuous wound infusion through a multiholed 16-gauge catheter placed between the muscle fascia and the subcutaneous tissues along the wound [9]
Summary
Major lumbar spine surgery usually causes severe pain, which challenges effective pain management, a prerequisite for early recovery and rehabilitation [1]. A systematic review on single administration of local infiltration analgesia with relatively small volumes in different types of lumbar spine surgery concluded that there were only minor and transient analgesic effects [5]. Only one study has examined the effect of local anesthetic infiltration analgesia after major spine surgery followed by continuous wound infusion through a multiholed 16-gauge catheter placed between the muscle fascia and the subcutaneous tissues along the wound [9]. This approach led to reduced pain scores and rescue medication requirements. We conducted a trial to evaluate the analgesic efficacy of intraoperative Local Infiltration Analgesia (LIA) administration and postoperatively via injections through intraoperatively placed wound catheters
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