Multimodal Analgesia for Spinal Surgery – What Is the Gold Standard?

Abstract

Pain control for spine surgery has fundamentally changed in the last decade as new medications and pain techniques have been broadly adopted. Enhanced recovery protocols are the new standard of care, allowing for shorter hospital stays and more rapid patient recovery. Adequate analgesia in the perioperative setting is paramount in achieving these goals and the use of narcotics alone is inadequate. A multimodal approach to perioperative pain management in spinal surgery begins in the preoperative setting, with gabapentin or pregabalin, Celebrex, and acetaminophen. These medicines also play a large role in the multimodal approach for postoperative analgesia with suggested usage being continued while inpatient. Ketorolac remains a useful postoperative adjunctive medication with minimal downside for fusion. Local and intravenous (IV) steroid application also play an important role to decrease nerve irritation and pain related to local inflammation at the surgery site and should be utilized regularly. The use of local anesthetic must also be used at the surgery site in all cases with great improvement in immediate opiate needs and pain scores. Other techniques have had mixed results with both Ketamine and IV lidocaine showing some promise, but further research needs to be done to understand their exact role. To practice spine surgery requires the use of a multimodal approach including nonsteroidal anti-inflammatory drugs, local and IV steroid, local anesthetic, and neuromodulatory agents beginning prior to an incision and continued through the recovery process.