Neuraxial Analgesia and Anesthesia in Chronic Opioid Users and Patients with Pre-existing Pain

Abstract

Neuraxial anesthesia and analgesia are effective modalities for surgery and perioperative pain management, respectively. These techniques may have nonanalgesic benefits as well, including improved 30-day mortality benefit, decreased risk of perioperative pneumonia, decreased risk of persistent postoperative pain, and attenuation of the stress response to surgery with improved survival in certain cancers. Post-operative pain control with epidural can be especially beneficial for opioid tolerant chronic pain patients compared to enteral or parenteral analgesics alone. In patients with previous back surgery or scoliosis, neuraxial techniques may be technically difficult. However, there is no evidence to suggest neuraxial approaches worsen pre-existing back pain. The exceptions are a pathology that reduces spinal canal cross-sectional area (e.g., severe spinal stenosis) and spinal infection. Neuraxial techniques should be avoided in these patients. Preprocedural labs and imaging are dictated by patient comorbidities, medication, and anatomy (e.g. scoliosis or spinal column pathology).