Efficacy of perioperative pharmacological and regional pain interventions in adult spine surgery: a network meta-analysis and systematic review of randomised controlled trials

Abstract

Background: Development of a widely accepted standardised analgesic pathway for adult spine surgery has been hampered by the lack of quantitative analysis. We conducted a systematic review and network meta-analysis (NMA) to compare, rank, and grade all pharmacological and regional interventions used in adult spine surgery. Methods: A systematic search was performed in January 2021. We performed double study screening, selection, and data extraction. The co-primary outcomes were cumulative morphine consumption (mg) and visual analogue pain score (range 0e10) at postoperative 24 h. An NMA was performed using the Bayesian approach (random effects model). We also ranked and graded all analgesic interventions using the Grading of Recommendations Assessment, Development and Evaluation approach for NMA. Results: We screened 5908 studies and included 86 randomised controlled studies, which comprised 6284 participants. Of 20 pharmacological and 10 regional interventions, the most effective intervention was triple-drug therapy, consisting of paracetamol, nonsteroidal anti-inflammatory drugs, and adjunct. The pooled mean reduction in morphine consumption and pain score at postoperative 24 h were e26 (95% credible interval [CrI]: e39 to e12) mg and e2.3 (95% CrI: e3.1 to e1.4), respectively. Double-drug therapy was less effective, but showed moderate morphine reduction in a range of e15 to e17 mg and pain score reduction in a range of e1 to e1.6. Single-agent interventions were largely ineffective. Conclusions: Triple-drug therapy is the most effective pain intervention in adult spine surgery with moderate-to-high certainty of evidence. We have also identified a graded analgesic effect, in which analgesic efficacy increased with the number of multimodal drugs used. Systematic review registration: PROSPERO (CRD42020171326).

Multimodal Analgesia

“…These researchers also found the efficacy of analgesia to increase in a graded manner with additional multimodal drugs used. 27 Similarly, Cozowicz et al 37 found use of NSAIDs and COX-2 inhibitors in the perioperative period to be associated with significantly reduced prescriptions of opioid, decreased LOS, and decreased cost for patients undergoing posterior lumbar fusion surgery. Additional studies identified preoperative celecoxib in addition to gabapentin to result in significant decreases in postoperative pain and opioid consumption in elective spinal fusion 34 and laminectomy 35 patients, which was not seen with gabapentin alone.…”

“…Regardless of mechanism, acetaminophen is reported to be safe and effective as a single agent or combination agent with opioids at a dose of less than 4 g per day in patients not contraindicated due to severe hepatic impairment or previous sensitivity 26. Studies of MMA protocols within spine surgery have routinely isolated acetaminophen as one of the active agents in successful MMA protocols 2,27–29…”

“…A systematic review and meta-analysis of 86 RCTs performed by Bae et al27 sought to identify highly effective MMA protocols, finding a triple-drug therapy involving acetaminophen, NSAIDs, and an adjunct medication to be the most effective in reduction of patient-reported pain scores and correlating decreased opioid consumption. These researchers also found the efficacy of analgesia to increase in a graded manner with additional multimodal drugs used 27.…”

“…A systematic review and meta-analysis of 86 RCTs performed by Bae et al27 sought to identify highly effective MMA protocols, finding a triple-drug therapy involving acetaminophen, NSAIDs, and an adjunct medication to be the most effective in reduction of patient-reported pain scores and correlating decreased opioid consumption. These researchers also found the efficacy of analgesia to increase in a graded manner with additional multimodal drugs used 27. Similarly, Cozowicz et al37 found use of NSAIDs and COX-2 inhibitors in the perioperative period to be associated with significantly reduced prescriptions of opioid, decreased LOS, and decreased cost for patients undergoing posterior lumbar fusion surgery.…”

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial

“…Moreover, in a large, observational, multicenter study, spine surgery induced severe postoperative pain and was ranked the second (spinal fusion one to two segments) and third (dorsal spinal fusion, three or more segments) most painful surgical act among 179 procedures 5. In this context, a multimodal analgesic approach has recently been recommended to enhance postoperative rehabilitation and pain relief after spine surgery 6–8…”