Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients

• Published in: The spine journal Vol. 19; no. 11; pp. 1753 - 1763
• Main Authors: Haffner, Max, Saiz, Augustine M., Nathe, Ryan, Hwang, Joshua, Migdal, Christopher, Klineberg, Eric, Roberto, Rolando
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2019
• Subjects: Adult; Aged; Analgesia - methods; Analgesics - therapeutic use; Analgesics, Opioid - therapeutic use; Celecoxib - administration & dosage; Drug Therapy, Combination; Elective spine surgery; Elective Surgical Procedures - adverse effects; Female; Gabapentin - therapeutic use; Humans; Male; Middle Aged; Morphine - therapeutic use; Multimodal analgesia; Opioid use; Pain Management - methods; Pain Measurement; Pain, Postoperative - drug therapy; Postoperative pain management; Postoperative physical therapy; Preoperative Care - methods; Retrospective Studies; Spinal fusion; Spinal Fusion - adverse effects; Young Adult; Postoperative pain management; Elective spine surgery; Multimodal analgesia; Postoperative physical therapy; Opioid use; Spinal fusion
• ISSN: 1529-9430; 1878-1632
• DOI: 10.1016/j.spinee.2019.07.005

Effective postoperative pain management in patients undergoing elective spinal fusion surgery has been associated with shorter hospital stays, reduced rates of hospital readmissions due to pain, and decreased cost of care. Furthermore, preoperative multimodal analgesia regimens have been shown to decrease postoperative subjective pain measurements and narcotic consumption in patients undergoing spinal fusion and total arthroplasty surgeries. Compare the difference in effects on 24-hour postoperative narcotic consumption, reported pain, and early mobility with administration of preoperative celecoxib plus gabapentin, gabapentin alone, and a nonstandardized analgesia regimen in patients undergoing elective spinal fusion surgery involving ≤5 levels. Retrospective review, Level of Evidence III. A total of 185 adult patients undergoing elective spinal fusion surgery involving ≤5 levels from 2013 to 2017 at one academic institution. Patients were excluded if the surgery was nonelective, for oncological purposes, or the patient was younger than 17 years old. Twenty-four-hour postoperative morphine equivalent consumption, 24-hour postoperative visual analogue scale (VAS) pain scores, postoperative day to ambulate, and postoperative day to clear physical therapy. A single-institution retrospective chart review was conducted. Patients meeting inclusion criteria were grouped by whether they had received preoperative celecoxib plus gabapentin, gabapentin alone, or neither of these medications. Opioid medication intake for the first 24 hours after the surgery end time was tabulated and converted to morphine equivalents. Visual analogue scale (VAS) pain scores were also averaged over the first 24 hours. Finally, physical therapy notes were reviewed to determine the time taken for the patient to first ambulate and to clear physical therapy. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work. Twenty-four-hour postoperative morphine equivalent consumption was significantly lower in the celecoxib plus gabapentin group compared with control (p=.004). Patients in the celecoxib plus gabapentin group had significantly lower mean VAS scores (p=.002) and had earlier mobility postoperatively (p=.012) than those in the control group. Early mobility and time to physical therapy clearance did differ between the celecoxib + gabapentin group compared with the gabapentin alone group. The gabapentin group had a significantly higher 24-hour morphine dose equivalent (p=.013) and a significantly higher VAS average (p=.009) compared with the celecoxib + gabapentin group. Gabapentin given alone compared with control did not show statistically significant improved outcomes in postoperative morphine equivalent consumption, pain scores or physical therapy goals. This study demonstrates that administering a selective COX-2 inhibitor and GABA-analogue preoperatively can significantly decrease 24-hour postoperative opioid consumption, VAS pain scores, and elapsed time to postoperative mobility in patients undergoing elective spine fusion surgery of ≤5 levels. Optimal standardized dosing and drug combination for preoperative multimodal analgesia remains to be elucidated.