The role of the perispinal route for postsurgical pain relief

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Summary Excellent postsurgical pain relief is no longer a privilege for patients nursed in the intensive care unit or the post anaesthetic care unit. The discovery of opioid receptors in the spinal cord has opened new horizons in the treatment of postoperative pain. Nevertheless, we still lack the ideal opiate to provide long-lasting pain relief of fast onset without the risk of life-threatening side-effects. This has resulted in more attention being focused in the first place on combined regimens with local anaesthetic drugs and also on other adjuvant agents allowing for significant dose reductions of both opioid and additives. The trend towards combinations of opioids with low concentrations of local anaesthetics has received growing interest due to the unanswered question of whether analgesia obtained with continuous administration of lipophilic opioids is a true spinal cord effect or the result of the drug being redistributed through the plasma to supraspinal levels. Nevertheless, continuous and PCA administration are the techniques of the future rather than the renewed interest in bolus injections of morphine. There should be no doubt that the perispinal route offers other beneficial effects besides pain relief, but that for these the use of local anaesthetics is essential. Most probably opioids have no effect on platelet aggregation, neither do they accelerate bowel motility. Local anaesthetics may induce a better quality of analgesia. However, future studies, making more distinction between pain at rest and pain during activity and stressing the site of operation, are mandatory to determine the optimal concentration and dose of local anaesthetic drugs required to improve the quality of opioid-induced analgesia. The definite place of α 2 -adrenergic agonist drugs in postsurgical pain relief, whether used alone or in combined regimens, still remains unclear. The increasing popularity of continuous spinal anaesthesia will undoubtedly promote the use of this route for prolonged analgesia into the postoperative period.