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Perioperative Analgesia for a Patient Going for Spine Surgery 275
•
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are another commonly used anal-
gesic for the treatment of mild to moderate pain. This class of medication acts
by inhibiting the COX 1 and 2 enzymes centrally and peripherally, preventing the
production of prostaglandins and decreasing the inflammatory response. Contraindi-
cations to NSAIDs include renal dysfunction, gastrointestinal inflammation or
bleeding, coagulopathy and heart failure.
NSAID use has been shown to be an effective opioid sparing technique in spinal
surgery. A meta-analysis of 8 RCTs of NSAID use in lumbar spine surgery concluded
that NSAIDs were effective in reducing visual analogue scores compared to placebo,
particularly in the COX-2 selective group [15]. Another meta-analysis of 17 double-
blinded RCTs found that patients who were administered NSAIDs in spinal surgery
had significantly lower pain scores and less opioid consumption [16].
•
Opioids
Opioids are the most common analgesic treatment for the treatment of spinal surgery
pain in the perioperative phase of care. This class of analgesics targets µ opioid
receptors both peripherally and centrally. Side effects of opioid administration
include nausea and vomiting, respiratory depression, constipation, sedation, dizzi-
ness, pruritus, dependency and tolerance. Opioid metabolism is primarily by the
CYP450 system in the liver with subsequent renal excretion of metabolites. Preop-
erative opioid use is associated with an increased incidence of prolonged postop-
erative opioid requirements and worsened surgical outcomes [17]. There has been
a movement to reduce or eliminate pre-operative opioid administration to improve
perioperative µ opioid receptor sensitivity and improve efforts at pain management
[18]. However, care must be taken to avoid withdrawal and these dose alterations may
be challenging to implement without the guidance of a dedicated healthcare clini-
cian, especially in the community setting. The use of buprenorphine is becoming
an increasingly common component of medication treatment of opioid use disorder
(MOUD). It is a partial mu-receptor agonist that acts centrally and is used as a substi-
tute for full opioid agonists with the aim of safely reducing opioid cravings and
withdrawal symptoms. Guidelines that detail the management of patients on preex-
isting buprenorphine recommend the continuation of the same dose of buprenorphine
preoperatively, although the dosage postoperatively can be divided into twice or three
times per day to maximize analgesic efficacy [19]. Patients on buprenorphine can
be prescribed additional opioid postoperatively for optimal pain control and these
patients often require robust multimodal analgesia regimens, especially if the spine
surgery is complex.
Similar to buprenorphine use, patients on preoperative methadone should continue
their normal prescription throughout their perioperative experience. Methadone is a
potent mu-receptor agonist with secondary N-methyl-D-aspartate (NMDA) receptor
inhibition that inhibits ascending pain pathways. Methadone dosing can be compli-
cated by a long elimination half-life of 33–46 h. Methadone also has a prolonged
duration of action, as such, the practicalities of its regular use with regards to titration
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276 M. L. Ma and V. Ip
for acute postoperative pain maybe challenging. Despite this, a 2017 RCT of 120
patients undergoing spinal fusion surgery were either administered methadone or
hydromorphone intraoperatively [20]. The patients in the methadone group required
less opioids, had lower pain scores and displayed improved patient satisfaction [20].
All patients with an opioid-use-disorder will be expected to require an increased
amount of opioid postoperatively and experience prolonged hospital admissions
secondary to difficulties associated with analgesic management. The opioid dose at
discharge should be returned to baseline or a weaning plan should be made available
that details a gradual opioid reduction back to baseline. Therefore, institutions with
transitional pain services will be advantageous for patients with significant baseline
opioid requirements [21].
•
Gabapentinoids
Gabapentinoids were originally indicated as anticonvulsants but have now become
a component of neuropathic and chronic pain management regimens. Their use has
crept into the acute postoperative pain realm; however, this is an off-label indication.
The mechanism of action of these medications is central binding to the alpha-2-delta
subunits of voltage dependent calcium channels leading to inhibition of excitatory
neurotransmitter release. Gabapentin is dosed enterally 900–2400 mg per day divided
into 3 doses. Pregabalin is first dosed at 75–150 mg 2 times per day or 50–100 mg
3 times per day, titrated as needed to a maximum of 600 mg per day. Common side
effects seen in this group of medications include dizziness, drowsiness, ataxia, weight
gain, abuse, and respiratory depression in the setting of overdose. Particular caution
should be used in the elderly and patients with renal dysfunction. Concurrent use of
opioids and benzodiazepines may also be associated with an increased incidence of
significant sedation and respiratory depression.
The evidence supporting the analgesic benefit of gabapentinoids in postopera-
tive patients has been inconsistent [22, 23]. A meta-analysis of 16 clinical trials
found that gabapentinoids were associated with decreased pain scores and cumula-
tive morphine use up to 48 h following surgery [24]. Contrary to this, other recent
studies have found that gabapentinoids in other surgical cohorts lack opioid sparing
effects and are associated with an increased risk of opioid overdose and opioid-related
adverse effects, especially postoperative pulmonary complications [25, 26]. The use
of gabapentinoids for postoperative analgesia in spinal surgery requires a careful
benefit risk analysis, especially in elderly patients who are susceptible to side effects
such as drowsiness. The PROSPECT working group do not recommend routine use
in complex spinal surgical patients [7].
•
Ketamine
Ketamine is a valuable and potent addition to multimodal analgesic armamentariums
that can be utilized throughout the perioperative continuum. It is a NMDA receptor
antagonist and dissociative anesthetic that might be particularly useful in opioid
tolerant patients. Side effects of this medication include nausea and vomiting, disori-
entation, confusion, sedation, dysphoria, dizziness, hallucinations, hypertension and
tachycardia. Subanesthetic bolus doses of 0.1–0.3 mg/kg can be given either intra or
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Perioperative Analgesia for a Patient Going for Spine Surgery 277
postoperatively to augment analgesia and minimize opioid requirements. Ketamine
can also be delivered as an intraoperative infusion of 0.1–1 mg/kg/h with many insti-
tutions implementing protocols that allow for infusions on the ward postoperatively.
An example of our institutional protocol for postoperative ward infusions can be
found in Table 1.
The evidence supporting the perioperative analgesic use of ketamine for patients
undergoing spine surgery is reassuring. A recent systematic review and meta-analysis
of 30 RCTs which included 1865 elective spine surgery patients found significantly
lower opioid consumption and pain intensity with no increased adverse events expe-
rienced by patients who were administered low-dose ketamine perioperatively up
to48h[27]. These positive results were not observed for the pediatric cohort in
this meta-analysis [27]. Despite this finding, a 2022 meta-analysis of 5 RCTs exam-
ining ketamine use in adolescent idiopathic scoliosis patients undergoing fusion
surgery concluded that intra and postoperative use of continuous low dose ketamine
significantly decreased opioid requirements within the first 48 h after surgery [28].
Ketamine is often an analgesic included in multimodal strategies to combat pain in
opioid-dependent patients. A RCT of the analgesic effects of intraoperative ketamine
use on opiate-dependent patients with a history of chronic pain showed a significant
reduction in morphine consumption up to 48 h and at 6 weeks postoperatively [29].
It was also found that pain intensity was significantly lower in t he PACU and at 6
weeks with no differences in opioid related adverse events [29]. There is evidence
Table 1 An example of a ketamine infusion protocol for adults
Ketamine 250 mg in NaCl 0.9% 250 mL (1 mg/mL) infusion
0.1 mg/kg/h × Weight in kg, intravenous, continuous
Use the actual body weight up to a maximum weight of 100 kg
Maximum 0.4mg/kg/hr
Notify Most responsible Health Practitioner
Respiratory Rate less than 8 breaths per minute
Other: Sedation level of 4
Vital Signs—Protocol for duration of infusion and 8 h post discontinuation of Low-Dose
Ketamine Infusion for Analgesia
Monitorasfollows:Every15minfor1h,every2hfor4h,thenevery4hfordurationof
infusion and 8 h post discontinuation of infusion. Repeat monitoring sequence with any rate
increase of the low-dose ketamine infusion for analgesia
Nursing Communication—Notify Pain
Notify Acute Pain Service/Pain Consultant for all problems and orders related to pain, sedation,
nausea and vomiting, and pruritus
Nursing Communication—Notify Agitation
Notify Acute Pain Service/Pain Consultant if patient continues to experience agitation/
psychotomimetic effects despite administration of benzodiazepine and reduction of ketamine
infusion
Maintain IV Access
Maintain Intravenous Access for duration of therapy and for 8–12 h post discontinuation of
Low-Dose Ketamine Infusion for Analgesia
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278 M. L. Ma and V. Ip
that ketamine administration may not be as efficacious in opiate-naïve spinal surgery
patients [8]. A RCT of adults undergoing multilevel spine surgery in a mixed cohort
of opioid naïve and dependent patients either given multimodal analgesia, including
ketamine, compared to opioid only analgesia showed no difference in Quality of
Recovery scores up to 48 h postoperatively [22].
•
Lidocaine Infusions
Intravenous (IV) lidocaine infusions have been used perioperatively as an opioid
sparing analgesic. This amide local anesthetic (LA) mainly acts by blocking voltage
gated sodium channels. Secondary target sites of action include inhibiting calcium
and potassium channels. Lidocaine is metabolised the P450 enzyme system in the
liver. It would be prudent to caution use or reduce dosage in patients with cardiac,
liver or renal dysfunction as well as in the elderly. Regular monitoring for local anes-
thetic systemic toxicity should be observed, especially during infusions continuing
more than 24 h [30, 31]. Lidocaine infusions should not concurrently be used with
other local anesthetic infusions such as nerve block catheter infusions and 20% lipid
emulsion should be easily accessible [31].
There is a wide variability in IV lidocaine dosing administration reported in the
literature. Various protocols outline bolus doses of 1–2 mg/kg over 10 min with
or without a continuous infusion at 1–3 mg/kg/h intraoperatively and/or postop-
eratively. The proposed mechanism of lidocaine analgesia is through reductions in
inflammation supports delivery at various timepoints within the perioperative period.
The efficacy of intravenous lidocaine administration beyond 24 h postoperatively,
however, is questionable.
A 2021 international consensus statement on the use of intravenous lidocaine for
postoperative pain considers this form of analgesia as “high risk” [31]. Some of
the recommendations listed as best practice safety considerations include informed
patient consent before use, considering toxic plasma lidocaine concentrations as >
5 mcg/ml, utilizing ideal body weight for dosing calculations, avoiding use in patients
< 40 kg, avoiding doses in excess of 120 mg/h, limiting loading bolus dosing to no
more than 1.5 mg/kg, and limiting ongoing infusions to a maximum of 1.5 mg/kg/h
and less than 24 h use [31].
A 2022 systematic review and meta-analysis of 8 RCTs examining the effective-
ness of perioperative intravenous lidocaine administration in patients undergoing
spine surgery found pain scores were significantly decreased up to 24 h in adult
and pediatric cohorts but up to 48 h specifically in adult populations [32]. Opioid
requirements and hospital length of stay were also reduced in the same review [32].
In all 8 studies, an initial bolus was administered along with an occasional continuous
infusion running into the postoperative period [32].
Interventional
•
Neuraxial
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Perioperative Analgesia for a Patient Going for Spine Surgery 279
Spinal surgery is still preferentially performed under general anesthesia; however,
with advancements in minimally invasive and endoscopic spine surgery, neuraxial
techniques have become increasingly feasible. There are many advantages associated
with the use of neuraxial anesthesia as a sole technique or as an analgesic adjunct to
general anesthesia. These advantages include shorter operative times, cost savings,
and superior analgesia. In addition, decreased pulmonary complications, cognitive
dysfunction, thrombotic events, and intraoperative blood loss have all been reported
with the use of neuraxial anesthesia [8, 33].
When compared to general anesthesia, the benefits of a neuraxial anesthetic for
lumbar and some lower thoracic spine surgeries are that the patient experiences less
nausea and vomiting, has improved hemodynamic stability, experiences decreased
surgical bleeding and need for transfusion, is able to position themselves comfort-
ably intraoperatively (theoretically reducing the risk of stretch/pressure injuries),
realizes improved perioperative pain control, and avoids the risks associated with
airway instrumentation and general anesthesia [8, 34]. Disadvantages of neuraxial
anesthesia for spine surgery include limited anesthetic duration of non-catheter based
techniques, non-ubiquitous availability, lack of airway protection in a prone patient,
the frequent need for sedation in a prone patient, and coughing/patient movement
that might be substantially magnified under the surgical microscope [34]. A recent
scoping review of the literature studying regional anesthetic techniques for spinal
surgery found that bupivacaine was the most frequently utilized local anesthetic [33].
Advantages of isobaric bupivacaine administration include decreased cephalad local
anesthetic spread and block extension while in the prone position [8]. Spinal anes-
thetic adjuncts including fentanyl and epinephrine may be useful when prolongation
of surgical anesthesia is required [8].
Epidural techniques in spinal surgery have been used less as a replacement for
general anesthesia for a number of reasons. Despite the benefits outlined above, it’s
analgesic effects can be inconsistent and large volumes of local anesthetic in the
epidural space obstructs the surgical field [34]. In addition, inadvertent dural punc-
tures can produce difficult postdural puncture headache management conundrums
in patients recovering from recent spinal surgery. Epidural and combined spinal-
epidural placements for spinal surgeries were observed to use a range of amide local
anaesthetics including lidocaine, bupivacaine or ropivacaine [33]. Adjuncts ranged
from a variety of opioids to dexmedetomidine and methylprednisolone [33]. It should
be noted that surgically placed epidural catheters have been utilized for the provision
of postoperative analgesia although practice has not been widespread [35].
•
Nerve Blocks
Multiple regional anesthetic blocks have been shown to decrease opioid requirements
and pain scores following spinal surgery. These blocks are frequently placed prior
to surgery and are generally used as an analgesic adjunct and not as a replacement
for general anesthesia.
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280 M. L. Ma and V. Ip
•
Erector Spinae Plane Blocks
The use of erector spinae plane blocks for postoperative analgesia following spine
surgery makes conceptual sense as this block has a well-defined mechanism for
anesthetizing the dorsal rami of the thoracolumbar spinal nerves [33]. Advantages of
erector spinae plane blocks include surgical procedural versatility and relative ease
associated with block placement. Erector spinae place blocks can be performed as
a single injection or as a continuous catheter insertion, although the latter may be
logistically challenging given the proximity to the surgical field. Under ultrasound
guidance, the paraspinal fascial plane block is typically carried out using an in-plane
technique, targeting the plane between the erector spinae muscle and the transverse
process. A large volume (15–20 ml) of local anesthetic is deposited bilaterally and
spread in a cranial to caudal direction achieves a multi-dermatomal block (Fig. 1).
•
Thoracolumbar Interfascial Plane Block
The thoracolumbar interfascial plane (TLIP) block targets the medial branch of
the thoracolumbar dorsal rami as it passes between the multifidus and longissimus
thoracis fascial plane components of the erector spinae muscle (Fig. 2)[36]. Needle
insertion is typically with an in-plane technique and 20 ml of local anesthetic is
Fig. 1 Erector spinae plane block—TP (Transverse Process)
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Perioperative Analgesia for a Patient Going for Spine Surgery 281
deposited between these planes with cranial to caudal spread, blocking 2–3 spinal
levels in either direction from the point of injection. The block is performed bilat-
erally for a complete block covering the midline either as a single-shot or contin-
uous block. A recent meta-analysis of 17 RCTs for lumbar spine surgeries showed
moderate quality evidence that TLIP blocks reduce PONV, total analgesic consump-
tion and pain scores up to 24 h [37]. However, further robust RCTs are warranted to
examine its efficacy.
•
Multifidus Cervices Plane block
A block aimed at supplying analgesia for the cervical spine is the multifidus cervices
plane block (Fig. 3). This block was first described in a 2017 case report where it was
described as an analgesic strategy for patients undergoing a cervical laminoplasty
[38]. It is similar to the TLIP block, however it targets the cervical dorsal rami via
local anesthetic deposition within the fascial plane between the multifidus cervicis
and semispinalis cervicis muscles at the C5 level. Ohgoshi et al. described using 20ml
of 0.375% ropivacaine [38]. Further high quality research is required to recommend
regular use.
•
Superficial Cervical Plexus Block
Patients undergoing cervical surgery with an anterior approach may benefit from
administration of a superficial cervical plexus (SCP) block (Fig. 4). This nerve block
targets the SCP formed by the ventral rami of C1–4 and can be performed under
ultrasound guidance or landmark technique to provide analgesia to the anterolateral
Fig. 2 Thoracolumbar Interfascial Plane block—SP (Spinous Process), SAP (Superior Articular
Process), MF (Multifidus), LT (Longissimus Thoracis)
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282 M. L. Ma and V. Ip
Fig. 3 Multifidus Cervices
Plane block—SP (Spinous
Process), MS (Multifidus
Cervicis Muscle), SCE
(Semispinalis Cervicis
Muscles), SCA
(Semispinalis Capitis
Muscle)
aspect of the neck. The aim is to deposit 10–15 ml of local anesthetic in the fascial
layer under the posterior/lateral border of sternocleidomastoid at the C5 level, above
the pre-vertebral fascia. A common complication of this procedure is phrenic nerve
blockade, especially if local anesthetic is deposited below the pre-vertebral fascia,
causing unilateral diaphragmatic paralysis. A RCT of patients undergoing anterior
cervical discectomy and fusion surgery found that patients who had SCP blocks
performed after induction compared to those who had not been blocked, had a higher
global quality of recovery questionnaire (QoR) score, but failed to show a difference
in 24 h opioid consumption or realize earlier discharge [39]. Mulcahy et al. are in the
process of carrying out a randomized placebo-controlled trial investigating the use
of bilateral SCP blocks on patients undergoing anterior cervical spine surgery [40].
3 Future Developments
Optimal analgesic management for patients undergoing spinal surgeries is rapidly
evolving. Secondary to multiple analgesic challenges encountered in the manage-
ment of these patients, innovative approaches are being continuously developed and
optimal analgesic management may not yet be determined. Cryotherapy and cryo-
compression may ultimately play a role in treating acute postoperative pain following
spine surgery [41, 42]. Neuromodulation might represent another significant area
which could be further explored. The individualized care package consisting of a
transitional pain service is an area for investigation, however, a lack of funding and
specialized healthcare allies forming a collaborative team may pose a challenge.
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Perioperative Analgesia for a Patient Going for Spine Surgery 283
Fig. 4 Superficial Cervical Plexus Block—SCM (Sternocleidomastoid Muscle), SCP (Superficial
Cervical Plexus), CA (Carotid Artery)
4 Conclusion
The nature of spinal surgery and the characteristics of those who require these surg-
eries frequently coalesce to produce challenges when attempting to deliver effective
postoperative analgesia. Multiple factors require consideration when balancing the
risks and benefits of analgesic requirements for this patient cohort. Multimodal phar-
macological regimens may not be a panacea for complex spinal patients but the peri-
operative implementation of individualized non-pharmacological, pharmacological
and regional anesthetic techniques can help multidisciplinary teams deliver the best
results for these patients.
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284 M. L. Ma and V. Ip
Key Takeaways of the Chapter
1. Pain control for patients undergoing spine surgery can be challenging as these
patients may have pre-existing chronic pain and/or opioid tolerance.
2. Preoperative education and alignment of goals of pain management is important
for successful postoperative course.
3. Multimodal individualized care involving multidisciplinary care is necessary.
4. Regional anesthesia techniques are good analgesic adjuncts to reduce opioid
consumption and should not be overlooked.
5. Alternative modalities such as acupuncture and behavioral interventions for pain
management should also be considered.
References
1. Cram P, Landon BE, Matelski J, Ling V, Perruccio AV, Paterson JM, et al. Utilization and
outcomes for spine surgery in the United States and Canada. Spine. 2019;44(19):1371–80.
2. Deyo RA, Hallvik SE, Hildebran C, Marino M, O’Kane N, Carson J, et al. Use of prescrip-
tion opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain.
2018;159(6):1147–54.
3. Davin SA, Savage J, Thompson NR, Schuster A, Darnall BD. Transforming standard of care
for spine surgery: integration of an online single-session behavioral pain management class for
perioperative optimization. Front Pain Res. 2022;3:1–8.
4. Mino DE, Munterich JE, Castel LD. Lumbar fusion surgery for degenerative conditions is asso-
ciated with significant resource and narcotic use 2 years postoperatively in the commercially
insured: a medical and pharmacy claims study. J Spine Surg. 2017;3(2):141–8.
5. Prout J, Jones T, Martin D. Advanced training in anaesthesia the essential curriculum. Oxford:
Oxford University Press; 2014.
6. Bajwa SJS, Haldar R. Pain management following spinal surgeries: an appraisal of the available
options. J Craniovertebral Junction Spine. 2015;6:105–10.
7. Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H. Pain management after complex
spine surgery: a systematic review and procedure-specific postoperative pain management
recommendations. Eur J Anaesthesiol. 2021;38:985–94.
8. Prabhakar NK, Chadwick AL, Nwaneshiudu C, Aggarwal A, Salmasi V, Lii TR, et al. Manage-
ment of postoperative pain in patients following spine surgery: a narrative review. Int J General
Med. 2022;15:4535–49.
9. Ip HYV, Abrishami A, Peng PWH, Wong J, Chung F. Predictors of postoperative pain and
analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111(3):657–77.
10. Horn A, Kaneshiro K, Tsui BCH. Preemptive and preventive pain psychoeducation and its
potential application as a multimodal perioperative pain control option: a systematic review.
Anesth Analg. 2020;130(3):559–73.
11. Cho YH, Kim CK, Heo KH, Lee MS, Ha IH, Son DW, et al. Acupuncture for acute postoperative
pain after back surgery: a systematic review and meta-analysis of randomized controlled trials.
Pain Pract: Official J World Inst Pain. 2015;15(3):279–91.
12. Chen BA, Deng WC, Chen MY. Acupuncture for pain control after degenerative lumbar spine
surgery. Eur J Med Res. 2022;27(1):167–75.
13. Bogaert L, Thys T,Depreitere B, Dankaerts W, Amerijckx C, Wambeke PV,et al. Rehabilitation
to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis. Eur
Spine J. 2022;31(6):1525–45.
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