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

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

Canadian Journal of Anesthesia/Journal canadien d'anesthésie volume 61, pages 330–339 (2014)Cite this article

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.

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.

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Notes

  1. Compendium of Pharmaceuticals and Specialties; 2011.

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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.

Author information

Authors and Affiliations

  1. Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Stephen Choi MD

  2. Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada

    Y. Raja Rampersaud MD & Oma Persaud MSc

  3. Department of Anesthesia and Pain Management, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada

    Vincent W. S. Chan MD, Arkadiy Koshkin MD, Paul Tumber MD & Richard Brull MD

Authors
  1. Stephen Choi MD
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  2. Y. Raja Rampersaud MD
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  3. Vincent W. S. Chan MD
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Corresponding author

Correspondence to Richard Brull MD.

Additional information

Author contributions

Stephen Choi, Y. Raja Rampersaud, Vincent W.S. Chan, Paul Tumber, and Richard Brull helped design the study. Stephen Choi, Y. Raja Rampersaud, Vincent W.S. Chan, Oma Persaud, Arkadiy Koshkin, and Richard Brull helped conduct the study. Stephen Choi, Y. Raja Rampersaud, Oma Persaud, and Arkadiy Koshkin helped analyze the data. Stephen Choi, Y. Raja Rampersaud, Vincent W.S. Chan, Paul Tumber, and Richard Brull helped write the manuscript. Richard Brull is responsible for archiving the study files.

Appendix- Standard preoperative questionnaire completed by patients in surgeon’s (Y.R.R.) clinic

Appendix- Standard preoperative questionnaire completed by patients in surgeon’s (Y.R.R.) clinic

  1. 1.

    What results do you expect from your treatment (Circle one response on each line)

      Not at all likely Slightly likely Somewhat likely Very likely Extremely likely Not applicable
    Relief from symptoms (pain, stiffness, swelling, numbness, weakness, instability) 1 2 3 4 5 6
    To do more everyday household activities or yard activities 1 2 3 4 5 6
    To sleep more comfortably 1 2 3 4 5 6
    To go back to my usual job 1 2 3 4 5 6
    To exercise and do recreational activities 1 2 3 4 5 6
    To prevent future disability 1 2 3 4 5 6
  2. 2.

    If you had to spend the rest of your life with the symptoms you have right now, how would you feel about it?

Very Dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Very satisfied

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Choi, S., Rampersaud, Y.R., Chan, V.W.S. et al. The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial. Can J Anesth/J Can Anesth 61, 330–339 (2014). https://doi.org/10.1007/s12630-014-0115-z

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Keywords

  • Epidural Analgesia
  • Hydromorphone
  • Transforaminal Lumbar Interbody Fusion
  • Opioid Consumption
  • Epidural Infusion