Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption

Ogura, Yoji; Gum, Jeffrey L.; Steele, Portia; Crawford, Charles H.; Djurasovic, Mladen; Owens, R. Kirk; Laratta, Joseph L.; Davis, Eric M.; Brown, Morgan; Daniels, Christy L.; Dimar, John R.; Glassman, Steven D.; Carreon, Leah Y.

doi:10.21037/jss-20-629

Cited by 12 publications

(14 citation statements)

References 40 publications

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“…The paradigm is not simply "opioid avoidance," and requires balancing the risks of both over-and under-utilization of these high-risk agents. To this end, postoperative opioid minimization should be pursued only in the greater context of optimizing acute pain management, reducing adverse events, and preventing persistent postoperative pain through comprehensive multimodal analgesia [19,33,[55][56][57][58][59][60][61]. Multimodal analgesia, or the use of multiple modalities of differing mechanisms of action, is key to decreasing surgical recovery times and complications, and so is also a fundamental component of the enhanced recovery paradigm promoted by the international Enhanced Recovery After Surgery (ERAS ® ) Society [19,24,[62][63][64][65].…”

Section: Opioid Stewardship Multimodal Analgesia and Equianalgesic mentioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Section: Opioid Stewardship Multimodal Analgesia and Equianalgesic mentioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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“…Numerous strategies have been employed to decrease postoperative opioid use, including careful preoperative assessment and patient selection, preoperative counseling, nonopioid analgesia, nerve blocks, the use of neuro-modulating medications, and the introduction of state prescription drug monitoring programs. Ogura et al [ 25 ]found that a multimodal pain regimen that included flexeril, gabapentin, tylenol, metadone, and a transversus abdominis block with ropivacaine decreased hospital opioid consumption after anterior lumbar instrumented fusion. The patients receiving the multimodal pain regimen had a final cumulative opioid requirement 62% lower than the control group.…”

Section: Discussionmentioning

confidence: 99%

The impact of the Florida law HB21 on opioid prescribing patterns after spine surgery

Geller

Milner

Pandya

et al. 2023

North American Spine Society Journal (NASSJ)

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“…11 Utilization of the TAP block in spine surgery in the setting of ALIF and lateral lumbar interbody fusion, however, is a relatively novel application with limited evidence in the literature. 3,12 Previous studies have investigated local anesthetic infiltration with TAP block in the setting of lower abdominal surgery and found lower pain scores at 24 hours postoperatively and increased patient satisfaction. 13,14 A small retrospective study found no difference between TAP block and thoracic epidural injection in pain scores with the only reported complications (hypotension and ineffective coverage) occurring in the TAP group.…”

Section: Discussionmentioning

confidence: 99%

“…2 Regional anesthesia in the form of fascial plane blocks has recently gained attention in the spine surgery literature as part of these MMA protocols. [3][4][5] Transversus abdominis plane (TAP) blocks are a form of regional anesthesia that may be useful in controlling pain for surgeries involving abdominal-based incisions, although its use in lumbar spine surgery is not yet well established. TAP blocks have been traditionally reserved to provide regional anesthesia in general, gynecologic, and urologic specialty procedures involving the anterior and lateral abdominal wall.…”

Section: Introductionmentioning

confidence: 99%

Transversus Abdominis Plane Block as Part of a Multimodal Analgesic Regimen in Patients Undergoing Anterior Lumbar Interbody Fusion: A Retrospective Cohort Study

et al. 2023

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Background: Opioids are a mainstay for pain control in patients undergoing lumbar spine surgery but are associated with a high risk of dependence and significant adverse effects. Efforts continue to be made to utilize non-narcotic agents such as regional nerve block for pain control as part of a multimodal analgesia regimen. Recently, transversus abdominis plane (TAP) blocks have proven beneficial for patients undergoing lumbar fusion procedures. The purpose of this study is to evaluate the efficacy of TAP blocks for postoperative pain control and the effect on opioid consumption and hospital length of stay (LOS) in patients undergoing anterior lumbar interbody fusion (ALIF).Methods: A retrospective review of patients undergoing elective ALIF included collection of data on demographics, LOS, pain scores using visual analog scale (VAS), opioid consumption using morphine milligram equivalents (MME) from postoperative day (POD) 0 to 5, and any complications. Patients who underwent primary ALIF or ALIF with concomitant posterolateral lumbar fusion were included.Results: A total of 99 patients met inclusion criteria; 47 had a preoperative TAP block and 52 did not. Demographic data and number of levels fused were equally distributed between the groups. The TAP group had significantly lower MME consumption postoperatively during POD 0 to 2 and 0 to 5. VAS pain scores were lower for TAP block patients on POD 3 and 4; otherwise, there was no significant difference. LOS and complication rates were not significantly different. A multiple regression analysis found male sex to be a predictor of increased postoperative MME, while age and TAP block were significant predictors of decreased MME.Conclusions: The use of TAP block for patients undergoing ALIF was associated with less cumulative MME consumption in the immediate postoperative period. TAP block may be an effective tool for reducing postoperative opioid consumption in patients undergoing ALIF.Clinical Relevance: The data in this study provide clinical relevance supporting the use of TAP blocks for patients undergoing ALIF procedures.

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Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption

Cited by 12 publications

References 40 publications

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

The impact of the Florida law HB21 on opioid prescribing patterns after spine surgery

Transversus Abdominis Plane Block as Part of a Multimodal Analgesic Regimen in Patients Undergoing Anterior Lumbar Interbody Fusion: A Retrospective Cohort Study

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