A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

Abstract

Purpose: Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population.

Methods: A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group.

Results: Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6.

Conclusions: In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Fig. 1

Box plot showing oral morphine (eq.) consumption on postoperative days (POD) 1–6. Data for POD 1 + 2 are without patients treated with patient controlled analgesia (PCA) devices. Plots demonstrate medians and IQR. Whiskers show 5 and 95 % percentiles. The 24-h morphine consumption was significantly reduced on postoperative day 1 (P = 0.024) and 2 (P = 0.048) in the post-intervention group receiving the new multimodal pain treatment protocol

Fig. 2

a–c Mobilization ability as the percentage of patients achieving a fixed endpoint: mobilization from bed, walking with a walking frame and walking without a walking frame. The ability to be mobilized from bed (P = 0.003), as well as walking with (P = 0.027) and without (P = 0.027) the help of a walking frame was significantly improved in the post-intervention group receiving the new multimodal pain treatment protocol