Multimodal Pain Management and Postoperative Outcomes in Lumbar Spine Fusion Surgery: A Population-Based Cohort Study.

November 28, 2019

STUDY DESIGN:

retrospective population-based cohort analysis.

OBJECTIVE:

Given the lack of population-based data on the use and efficacy of multimodal analgesia in spine fusion surgery, we conducted a population-based analysis utilizing the nationwide claims-based Premier Healthcare database.

SUMMARY OF BACKGROUND DATA:

Multimodal analgesia, combining different pain signaling pathways to achieve additive and synergistic effects is increasingly emerging as the standard of care.

METHODS:

Cases of posterior lumbar fusion were extracted (2006-2016). Opioid-only analgesia was compared to multimodal analgesia, i.e. systemic opioid analgesia + either acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, or neuraxial anesthesia (categorized into 1, 2, or >2 additional analgesic modes). Mixed-effects models measured associations between multimodal analgesia categories and outcomes, including opioid prescription dose, cost/length of hospitalization, and opioid-related complications. Odds ratios (OR, or % change) and 95% confidence intervals (CI) are reported.

RESULTS:

Among 265,538 patients the incidence of multimodal analgesia was 61.1% (162,156); multimodal pain management -specifically when adding NSAIDs/COX-2 inhibitors to opioids- was associated with reduced opioid prescription (-13.3% CI -16.7;-9.7%), cost (-2.9% CI -3.9;-1.8%) and length of hospitalization (-7.3% CI -8.5;-6.1%). Multimodal analgesia in general was associated with decreased odds for gastrointestinal complications (OR 0.95 CI 0.88-1.04;OR 0.84 CI 0.75-0.95;OR 0.78 CI 0.64-0.96), while odds were increased for postoperative delirium (OR 1.14 CI 1.00-1.32; OR 1.33 CI 1.11-1.59;OR 1.31 CI 0.99-1.74), and counterintuitively- naloxone administration (OR 1.25 CI 1.13-1.38;OR 1.56 CI 1.37-1.77;OR 1.84 CI 1.52-2.23) with increasing analgesic modes used: 1, 2, or >2 additional analgesic modes, respectively. Post-hoc analysis revealed that specifically gabapentinoid use increased odds of naloxone requirement by about 50%, regardless of concurrent opioid dose (p < 0.001).

CONCLUSIONS:

While multimodal analgesia was not consistently implemented in spine fusion surgery, particularly NSAIDs and COX-2 inhibitors demonstrated opioid sparing effects. Moreover, results suggest a synergistic interaction between gabapentinoids and opioids, the former potentiating opioid effects resulting in greater naloxone requirement.