Advertisement

The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial

  • Stephen Choi
  • Y. Raja Rampersaud
  • Vincent W. S. Chan
  • Oma Persaud
  • Arkadiy Koshkin
  • Paul Tumber
  • Richard BrullEmail author
Reports of Original Investigations

Abstract

Purpose

This randomized trial aimed to evaluate the effects of adding continuous epidural analgesia with a bupivacaine and hydromorphone solution to systemic multimodal analgesia following one- or two-level lumbar spinal fusion.

Methods

Thirty-nine patients undergoing lumbar spinal fusion, stratified for sex and one- or two-level fusion, were randomized to receive a continuous postoperative epidural infusion of either 0.1% bupivacaine with 15 μg·mL−1 hydromorphone (LA group) or 0.9% saline (NS group) at 6 mL·hr−1 for 48 hr through an epidural catheter placed intraoperatively. All patients received a standardized postoperative multimodal analgesia regimen. Patients, healthcare providers, and research staff were blinded. The primary outcome measure was cumulative opioid consumption (oral morphine equivalent) during the first 48 hr postoperatively.

Results

The mean (SD) cumulative opioid consumption 48 hours postoperatively was 249.3 (143.3) mg in the NS group and 184.7 (208.1) mg in the LA group (mean difference 64.6 mg; 95% confidence interval −54.3 to 183.5; P = 0.27). There were no adverse events in either group.

Conclusion

Continuous epidural infusion combined with systemic multimodal analgesia resulted in a mean reduction in 48-hr cumulative opioid consumption of 64.6 mg (95% confidence interval −54.3 to 183.5) following one- or two-level lumbar spinal fusion. This estimate of effect is imprecise, and the routine use of continuous epidural analgesia in this surgical population is not yet warranted. This trial was registered at www.clinicaltrials.gov: NCT00644111.

Keywords

Epidural Analgesia Hydromorphone Transforaminal Lumbar Interbody Fusion Opioid Consumption Epidural Infusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

L’ajout d’un anesthésique local en péridural à une analgésie multimodale systémique après une fusion lombaire: une étude randomisée contrôlée

Résumé

Objectif

Cette étude randomisée avait pour but d’évaluer les effets de l’adjonction d’une analgésie péridurale continue avec une solution de bupivacaïne et d’hydromorphone à une analgésie multimodale systémique après une fusion lombaire à un ou deux niveaux.

Méthode

Trente-neuf patients subissant une fusion lombaire, stratifiés selon leur sexe et leur fusion lombaire (à un ou deux niveaux), ont été randomisés à recevoir une perfusion péridurale postopératoire continue avec soit 0,1 % de bupivacaïne et 15 μg·mL−1 d’hydromorphone (groupe LA) ou 0,9 % de normal salin (groupe NS) à 6 mL·h−1 via un cathéter péridural placé en période peropératoire. Tous les patients ont reçu un régime d’analgésie multimodale postopératoire standardisé. Les patients, les professionnels de la santé et le personnel de recherche étaient tous en aveugle. La principale mesure d’évaluation était la consommation cumulative d’opioïdes (équivalent morphine orale) pendant les premières 48 h postopératoires.

Résultats

La consommation cumulée moyenne (ÉT) d’opioïdes à 48 h postopératoires était de 249,3 (143,3) mg dans le groupe NS et de 184,7 (208,1) mg dans le groupe LA (différence moyenne 64,6 mg; intervalle de confiance 95 % −54,3 à 183,5; P = 0,27). Aucun effet secondaire néfaste n’a été observé dans les deux groupes.

Conclusion

La combinaison d’une perfusion péridurale continue à une analgésie multimodale systémique a entraîné une réduction moyenne de la consommation cumulative d’opioïdes pendant les 48 h suivant l’opération de 64,6 mg (intervalle de confiance 95 % −54,3 à 183,5) suivant une fusion lombaire à un ou deux niveaux. L’estimation de l’effet est imprécise, et l’utilisation de routine d’une analgésie péridurale continue chez cette population chirurgicale n’est pas encore justifiée. Cette étude a été enregistrée au www.clinicaltrials.gov: NCT00644111.

Notes

Acknowledgement

The authors sincerely thank Mr. Michael Yang (BSc) for his help with data collection.

Funding

PSI Foundation resident research grant (S.C. and R.B.); Toronto General and Western Hospital Foundation Educational Grant (Y.R.R. and O.P.); R.B. is supported by the Merit Award Program, Department of Anesthesia, University of Toronto.

Financial support

This project was supported by a Physicians’ Services Incorporated Resident Research Grant awarded to the first author (S.C., supervisor R.B. $19,500). Funding was also received from the Minimal Access Ambulatory Spine Surgery (MAASS) Research and Education Project, Toronto General and Western Hospital Foundation (Y.R.R., $6,000). The funding agencies had no role in protocol development, data collection/analysis, or preparation of the manuscript.

Conflicts of interest

None declared.

References

  1. 1.
    Sharma S, Balireddy RK, Vorenkamp KE, Durieux ME. Beyond opioid patient-controlled analgesia: a systematic review of analgesia after major spine surgery. Reg Anesth Pain Med 2012; 37: 79-98.PubMedCrossRefGoogle Scholar
  2. 2.
    Blumenthal S, Min K, Nadig M, Borgeat A. Double epidural catheter with ropivacaine versus intravenous morphine: a comparison for postoperative analgesia after scoliosis correction surgery. Anesthesiology 2005; 102: 175-80.PubMedCrossRefGoogle Scholar
  3. 3.
    Gottschalk A, Freitag M, Tank S, et al. Quality of postoperative pain using an intraoperatively placed epidural catheter after major lumbar spinal surgery. Anesthesiology 2004; 101: 175-80.PubMedCrossRefGoogle Scholar
  4. 4.
    Schenk MR, Putzier M, Kugler B, et al. Postoperative analgesia after major spine surgery: patient-controlled epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg 2006; 103: 1311-7.PubMedCrossRefGoogle Scholar
  5. 5.
    Cata JP, Noguera EM, Parke E, et al. Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery. J Neurosurg Anesthesiol 2008; 20: 256-60.PubMedCrossRefGoogle Scholar
  6. 6.
    Joshi GP, McCarroll SM, O’Rourke K. Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine. Anesth Analg 1995; 80: 511-4.PubMedGoogle Scholar
  7. 7.
    Cassady JF Jr, Lederhaas G, Cancel DD, Cummings RJ, Loveless EA. A randomized comparison of the effects of continuous thoracic epidural analgesia and intravenous patient-controlled analgesia after posterior spinal fusion in adolescents. Reg Anesth Pain Med 2000; 25: 246-53.PubMedGoogle Scholar
  8. 8.
    Cohen BE, Hartman MB, Wade JT, Miller JS, Gilbert R, Chapman TM. Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. Spine (Phila Pa 1976) 1997; 22: 1892-6; discussion 1896-7.Google Scholar
  9. 9.
    Fisher CG, Belanger L, Gofton EG, et al. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Spine (Phila Pa 1976) 2003; 28: 739-43.Google Scholar
  10. 10.
    Kluba T, Hofmann F, Bredanger S, Blumenstock G, Niemeyer T. Efficacy of post-operative analgesia after posterior lumbar instrumented fusion for degenerative disc disease: a prospective randomized comparison of epidural catheter and intravenous administration of analgesics. Orthop Rev (Pavia) 2010; 2: e9.CrossRefGoogle Scholar
  11. 11.
    O’Hara JF Jr, Cywinski JB, Tetzlaff JE, Xu M, Gurd AR, Andrish JT. The effect of epidural vs intravenous analgesia for posterior spinal fusion surgery. Pediatr Anesth 2004; 14: 1009-15.CrossRefGoogle Scholar
  12. 12.
    Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 1993; 77: 1048-56.PubMedCrossRefGoogle Scholar
  13. 13.
    Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR. The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine (Phila Pa 1976) 1998; 23: 834-8.Google Scholar
  14. 14.
    Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999; 88: 83-90.PubMedGoogle Scholar
  15. 15.
    Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther 2001; 81: 776-88.PubMedGoogle Scholar
  16. 16.
    Brasher PM, Brant RF. Sample size calculations in randomized trials: common pitfalls. Can J Anesth 2007; 54: 103-6.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2014

Authors and Affiliations

  • Stephen Choi
    • 1
  • Y. Raja Rampersaud
    • 2
  • Vincent W. S. Chan
    • 3
  • Oma Persaud
    • 2
  • Arkadiy Koshkin
    • 3
  • Paul Tumber
    • 3
  • Richard Brull
    • 3
    Email author
  1. 1.Department of AnesthesiaSunnybrook Health Sciences CentreTorontoCanada
  2. 2.Division of Orthopedic Surgery, Toronto Western HospitalUniversity Health NetworkTorontoCanada
  3. 3.Department of Anesthesia and Pain ManagementToronto Western HospitalTorontoCanada

Personalised recommendations