Newly Published
Perioperative Medicine  |   January 2020
Multimodal Analgesic Regimen for Spine Surgery: A Randomized Placebo-controlled Trial
Author Notes
  • From the Department of General Anesthesiology (K.M., R.A., D.T., S.R., M.M., S.M., A. Kurz), Department of Quantitative Health Sciences (N.M.), Department of Neurosurgery (A. Krishnaney, A.M.), Department of Pain Management (R.R.), and Department of Outcomes Research (K.M., D.I.S., N.M., M.T., S.R., A. Kurz), Cleveland Clinic, Cleveland, Ohio.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication July 16, 2019. Accepted for publication December 18, 2019.
    Submitted for publication July 16, 2019. Accepted for publication December 18, 2019.×
  • Correspondence: Address correspondence to Dr. Maheshwari: Departments of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue/E-31, Cleveland, Ohio 44195. maheshk@ccf.org. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Neurosurgical Anesthesia / Pain Medicine / Pharmacology
Perioperative Medicine   |   January 2020
Multimodal Analgesic Regimen for Spine Surgery: A Randomized Placebo-controlled Trial
Anesthesiology Newly Published on January 28, 2020. doi:https://doi.org/10.1097/ALN.0000000000003143
Anesthesiology Newly Published on January 28, 2020. doi:https://doi.org/10.1097/ALN.0000000000003143
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • Multimodal analgesia is a strongly advocated approach for perioperative pain management

  • Multimodal analgesia has not been carefully evaluated for spine surgery

What This Article Tells Us That Is New:

  • Adult spine surgery patients were randomized to placebo or to the combination of acetaminophen, gabapentin, ketamine, and lidocaine

  • The Quality of Recovery was similar in each group, as were pain scores and opioid consumption

Background: Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores.

Methods: Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h.

Results: The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, –6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being –9 (97.5% CI, –23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being –0.4 (97.5% CI; –0.8, 0.1, P = 0.094).

Conclusions: An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery.