Skip to main content
SpringerLink
Log in

Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials

  • Review Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

Opioids are the primary analgesics used in patients undergoing spine surgery. Postoperative pain is common despite their liberal use and so are opioid-associated side effects. Non-opioid analgesics are gaining popularity as alternative to opioids in spine surgery.

Methods

This systematic review evaluated current evidence regarding opioid and non-opioid intraoperative analgesia and their influence on immediate postoperative pain and adverse events in spine surgery.

Results

A total of 10,459 records were obtained by searching Medline, EMBASE and Web of Science databases and six randomized controlled trials were included. Differences in postoperative pain scores between opioid and non-opioid groups were not significant at 1 h: 4 studies, mean difference (MD) = 0.65 units, 95% confidence intervals (CI) [−0.12 to 1.41], p = 0.10, but favored non-opioid at 24 h after surgery: 3 studies, MD = 0.75 units, 95%CI [0.03 to 1.46], p = 0.04. The time for first postoperative analgesic requirement was shorter (MD = −45.06 min, 95%CI [−72.50 to −17.62], p = 0.001), and morphine consumption during first 24 h after surgery was higher in opioid compared to non-opioid group (MD = 4.54 mg, 95%CI [3.26 to 5.82], p < 0.00001). Adverse effects of postoperative nausea and vomiting (Relative risk (RR) = 2.15, 95%CI [1.37 to 3.38], p = 0.0009) and shivering (RR = 2.52, 95%CI [1.08 to 5.89], p = 0.03) were higher and bradycardia was lower (RR = 0.35, 95%CI [0.17 to 0.71], p = 0.004) with opioid analgesia.

Conclusion

The certainty of evidence on GRADE assessment is low for studied outcomes. Available evidence supports intraoperative non-opioid analgesia for overall postoperative pain outcomes in spine surgery. More research is needed to find the best drug combination and dosing regimen.

Prospero Registration: CRD42020209042.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Rajan S, Devarajan J, Krishnaney A et al (2022) Opioid alternatives in spine surgery: a narrative review. J Neurosurg Anesthesiol 34:3–13. https://doi.org/10.1097/ANA.0000000000000708

    Article  Google Scholar 

  2. Sriganesh K, Bidkar PU, Krishnakumar M et al (2021) Perioperative Analgesia in Neurosurgery (PAIN): A national survey of pain assessment and management among neuroanesthesiologists of India. Int J Clin Pract 75:e13718. https://doi.org/10.1111/ijcp.13718

    Article  CAS  Google Scholar 

  3. Yerneni K, Nichols N, Abecassis ZA et al (2020) Preoperative opioid use and clinical outcomes in spine surgery: a systematic review. Neurosurgery 86:E490–E507. https://doi.org/10.1093/NEUROS/NYAA050

    Article  Google Scholar 

  4. Dunn LK, Durieux ME, Nemergut EC (2016) Non-opioid analgesics: novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol 30:79–89. https://doi.org/10.1016/J.BPA.2015.11.002

    Article  Google Scholar 

  5. Goyal A, Kalgudi P, Sriganesh K (2021) Ultrasound-guided erector spinae plane block for perioperative analgesia in cervical and thoracic spine surgeries - a case series. Neurol India 69:487–489. https://doi.org/10.4103/0028-3886.314568

    Article  Google Scholar 

  6. Waelkens P, Alsabbagh E, Sauter A et al (2021) Pain management after complex spine surgery: a systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol 38:985–994. https://doi.org/10.1097/EJA.0000000000001448

    Article  Google Scholar 

  7. Garg N, Panda NB, Gandhi KA et al (2016) Comparison of small dose ketamine and dexmedetomidine infusion for postoperative analgesia in spine surgery - a prospective randomized double-blind placebo controlled study. J Neurosurg Anesthesiol 28:27–31. https://doi.org/10.1097/ANA.0000000000000193

    Article  Google Scholar 

  8. Ma J, Bi Y, Zhang Y et al (2021) Erector spinae plane block for postoperative analgesia in spine surgery: a systematic review and meta-analysis. Eur Spine J 30:3137–3149. https://doi.org/10.1007/S00586-021-06853-W

    Article  Google Scholar 

  9. Corley JA, Charalambous LT, Mehta VA et al (2022) Perioperative pain management for elective spine surgery: opioid use and multimodal strategies. World Neurosurg 162:118-125.e1. https://doi.org/10.1016/J.WNEU.2022.03.084

    Article  Google Scholar 

  10. Ward S, Guest C, Goodall I, Bantel C (2018) Practice and bias in intraoperative pain management: results of a cross-sectional patient study and a survey of anesthesiologists. J Pain Res 11:561–570. https://doi.org/10.2147/JPR.S153857

    Article  CAS  Google Scholar 

  11. Aveline C, Le HH, Vautier P et al (2006) Peroperative ketamine and morphine for postoperative pain control after lumbar disk surgery. Eur J Pain 10:653. https://doi.org/10.1016/j.ejpain.2005.10.005

    Article  CAS  Google Scholar 

  12. Turgut N, Turkmen A, Gökkaya S et al (2008) Dexmedetomidine-based versus fentanyl-based total intravenous anesthesia for lumbar laminectomy. Minerva Anestesiol 74:469–474

    CAS  Google Scholar 

  13. Hwang W, Lee J, Park J, Joo J (2015) Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol. https://doi.org/10.1186/S12871-015-0004-1

    Article  Google Scholar 

  14. Rahimzadeh P, Faiz SHR, Alimian M, Mohammadian Erdi A (2015) Remifentanil versus dexmedtomidine for posterior spinal fusion surgery. Med J Islam Repub Iran 29:215

    Google Scholar 

  15. Alansary AM, Elbeialy MAK (2019) Dexmedetomidine versus fentanyl added to bupivacaine for epidural analgesia in combination with general anesthesia for elective lumbar disc operations: A prospective, randomized double-blinded study. Saudi J Anaesth 13:119–125. https://doi.org/10.4103/SJA.SJA_600_18

    Article  Google Scholar 

  16. Jannatmakan F, Nassajian N, Jarirahmadi S et al (2021) Comparison of the effect of dexmedetomidine and remifentanil on pain control after spinal surgery: a double-blind. Randomized Clin Trial Anesthesiol pain Med. https://doi.org/10.5812/AAPM.111533

    Article  Google Scholar 

  17. Sriganesh K, Boris K, GS Umamaheswara R, et al (2022) Non-opioid intraoperative analgesia for perioperative pain management in neurosurgical patients: A systematic review and meta-analysis of randomized clinical trials. PROSPERO 2020 CRD42020209042

  18. McHugh ML (2012) Interrater reliability: The kappa statistic. Biochem Medica 22:276–282. https://doi.org/10.11613/bm.2012.031

  19. Sterne JAC, Savović J, Page MJ et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:14898. https://doi.org/10.1136/bmj.l4898

    Article  Google Scholar 

  20. Williamson A, Hoggart B (2005) Pain: a review of three commonly used pain rating scales. J Clin Nurs 14:798–804. https://doi.org/10.1111/j.1365-2702.2005.01121.x

    Article  Google Scholar 

  21. Schünemann H, Brożek J, Guyatt G, Oxman A E (2013) GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from guidelinedevelopment.org/handbook

  22. UNC Health Care Guideline Analgesic equivalent chart. In: https://www.med.unc.edu/aging/wp-content/uploads/sites/753/2018/06/Analgesic-Equivalent-Chart.pdf. https://www.med.unc.edu/aging/wp-content/uploads/sites/753/2018/06/Analgesic-Equivalent-Chart.pdf. Accessed 30 Apr 2022

  23. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University and Evidence Prime, 2022. Available from. gradepro.org

  24. Yang MMH, Riva-Cambrin J, Cunningham J et al (2020) Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery. J Neurosurg Spine 34:3–12. https://doi.org/10.3171/2020.5.SPINE20347

    Article  Google Scholar 

  25. Grape S, Kirkham KR, Frauenknecht J, Albrecht E (2019) Intra-operative analgesia with remifentanil vs. dexmedetomidine: a systematic review and meta-analysis with trial sequential analysis. Anaesthesia 74:793–800. https://doi.org/10.1111/ANAE.14657

    Article  CAS  Google Scholar 

  26. Rivosecchi RM, Rice MJ, Smithburger PL et al (2014) An evidence based systematic review of remifentanil associated opioid-induced hyperalgesia. Expert Opin Drug Saf 13:587–603. https://doi.org/10.1517/14740338.2014.902931

    Article  CAS  Google Scholar 

  27. Olsen MF, Bjerre E, Hansen MD et al (2017) Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain. BMC Med. https://doi.org/10.1186/S12916-016-0775-3

    Article  Google Scholar 

  28. Kelly AM (2001) The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J 18:205–207. https://doi.org/10.1136/EMJ.18.3.205

    Article  CAS  Google Scholar 

  29. Tsaousi GG, Pourzitaki C, Aloisio S, Bilotta F (2018) Dexmedetomidine as a sedative and analgesic adjuvant in spine surgery: a systematic review and meta-analysis of randomized controlled trials. Eur J Clin Pharmacol 74:1377–1389. https://doi.org/10.1007/S00228-018-2520-7

    Article  CAS  Google Scholar 

  30. Zhou L, Yang H, Hai Y, Cheng Y (2022) perioperative low-dose ketamine for postoperative pain management in spine surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Res Manag 2022:1–20. https://doi.org/10.1155/2022/1507097

    Article  CAS  Google Scholar 

  31. Licina A, Silvers A (2022) Perioperative intravenous lidocaine infusion for postoperative analgesia in patients undergoing surgery of the spine: systematic review and meta-analysis. Pain Med 23:45–56. https://doi.org/10.1093/PM/PNAB210

    Article  Google Scholar 

  32. Yu L, Ran B, Li M, Shi Z (2013) Gabapentin and pregabalin in the management of postoperative pain after lumbar spinal surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976) 38:1947–1952. https://doi.org/10.1097/BRS.0B013E3182A69B90

  33. Peene L, Le Cacheux P, Sauter AR et al (2021) Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations. Eur Spine J 30:2925–2935. https://doi.org/10.1007/S00586-020-06661-8

    Article  Google Scholar 

  34. Vahedi HSM, Hajebi H, Vahidi E et al (2019) Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World J Emerg Med 10:27. https://doi.org/10.5847/wjem.j.1920-8642.2019.01.004

    Article  Google Scholar 

Download references

Acknowledgements

We thank Dr. Eduardo Villamor, Maastricht University, Netherlands, for his guidance and support during the conceptual phase of the review. We acknowledge Mr. George Franssen, Maastricht University, Netherlands, for his guidance in performing literature search for this review. We also thank the National Institute of Mental Health and Neurosciences, Bengaluru, India and the Maastricht University, Netherlands, for their administrative support.

Funding

Non-funded research.

Author information

Author notes

  1. Kamath Sriganesh and Boris W Kramer conceptualized the study.

Authors and Affiliations

  1. Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Neurosciences Faculty Block, 3rd Floor, Bengaluru, India

    Kamath Sriganesh, Suparna Bharadwaj, Ganne S. Umamaheswara Rao & Talakad N. Sathyaprabha

  2. Department of Anesthesia, McMaster University, Hamilton, ON, Canada

    Harsha Shanthanna

  3. Maastricht University Medical Center, The Netherlands, School of Women’s and Infants’ Health, University of Western Australia, Perth, Australia

    Boris W. Kramer

  4. Department of Neurophysiology, National Institute of Mental Health and Neurosciences, Bengaluru, India

    Talakad N. Sathyaprabha

Authors
  1. Kamath Sriganesh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Suparna Bharadwaj
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Harsha Shanthanna
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ganne S. Umamaheswara Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Boris W. Kramer
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Talakad N. Sathyaprabha
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KS, BWK and H.S. were involved in the study design. Title and Abstract and full-text screening, and data extraction were performed by KS and S.B. Manuscript preparation was done by K.S., S.B., H.S., G.S.U.M., B.W.K., T.N.S. reviewed the manuscript and approved the final draft before submission.

Corresponding author

Correspondence to Kamath Sriganesh.

Ethics declarations

Conflict of interest

Authors have nothing to declare with regards to competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sriganesh, K., Bharadwaj, S., Shanthanna, H. et al. Opioid versus non-opioid analgesia for spine surgery: a systematic review and meta-analysis of randomized controlled trials. Eur Spine J 32, 289–300 (2023). https://doi.org/10.1007/s00586-022-07469-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-022-07469-4

Keywords

Search

Navigation