Wound Infiltration with Levobupivacaine, Ketorolac, and Adrenaline for Postoperative Pain Control after Spinal Fusion Surgery

Abstract

This study enrolled patients in from a single center who underwent primary spinal fusion procedure and divided them into two groups (group-control study). Purpose: Good local infiltration can reduce postoperative analgesic requirements and enable expedited discharge. Administration of a combination of levobupivacaine (200 mg/100 mL, 0.9% N-Saline), ketorolac (30 mg), and adrenaline (0.5 mg) as a wound infiltrate is recommended at an optimum combination. Overview of Literature: There is currently no consensus on the optimum intraoperative local infiltration of spinal surgery patients undergoing operative fusion. Methods: Patients who were enrolled in two spinal centers (over 24 months) undergoing primary spinal fusion procedures were allocated into two groups, comparing the type of local infiltration used at the time of the procedure. Group 1 received the combination of levobupivacaine (200 mg), ketorolac (30 mg), and adrenaline (0.5 mg), while group 2 received other types of local anesthetics. Primary outcome measures include patient-controlled analgesia (PCA) use, morphine consumption, and length of hospital stay. Secondary outcome measure are as follows: days of physiotherapy, pain score, side effects, and complications. Results: There are a total of 140 patients enrolled. Seventy-five patients enrolled were allocated to group 1, receiving the study combination, and 65 patients were assigned in group 2, receiving other local infiltrations. All primary outcome measures (consumption of morphine, use of PCA, and length of stay) were significantly higher in group 2 than the study combination (p<0.05). The secondary outcomes of pain scores and days of physiotherapy values were also significantly higher in group 2 (p<0.05). Patient satisfaction questionnaires gave significantly better results in group 1 (p<0.05). There were no significant statistical differences with regard to any postoperative complications between the two groups. Conclusions: Our data suggest that the studied wound infiltration is a safe and feasible option that could provide good postoperative pain control without significant side effects. It also allowed to reduce dependence of opioids and PCA, earlier postoperative mobilization, lower pain scores postoperatively, and reduced hospital stay.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

“…Other medications used off-label for CWI, alone or as adjuncts to LA include alpha-2agonists [47,48], tramadol [49], nonsteroidal anti-inflammatory drugs (NSAIDs) [50][51][52][53] and NMDA antagonist [54]. Of note, studies using adjuvants rarely compare the adjuvant given intravenously in the same dose in order to assess the systemic vs. local effect of the adjuvant [48,50].…”

“…Novel studies suggest improved WI efficacy by adding NSAIDs or epinephrine or combining single WI and CWI [53], resulting in improved analgesia during early mobilization. Although these are off-label uses of NSAIDs, side effects were not reported in any of these studies; WI with ketorolac, levobupivacaine and epinephrine enabled better mobilization, shorter duration of physical therapy, reduced PCA-IV opioid use, and reduced LOS compared to WI with local anesthetic chosen by surgeon after spine surgery [53].…”

A Novel Approach to Treat a Rare Case of Interprosthetic Humeral Fracture with Osteosynthesis and Combined Grafting: A Case Report and Review of the Literature

“…Being surface-bound, all cellular activity resulting from the P-15 Osteogenic Cell Binding Peptide attachment is restricted to the implant surface, so the bone cannot grow where it does not belong (ectopic bone growth). The outcomes in spinal surgery showed high safety and effectiveness and similar results to those of the cases where autografts were used [ 24 , 25 , 26 ]. Moreover, it provides more benefit/cost rather than the association of allograft and growth factor.…”

Study protocol for a randomised controlled trial on the effect of local analgesia for pain relief after minimal invasive sacroiliac joint fusion: the ARTEMIS study

“…5 In several orthopaedic procedures, intraoperative infiltration of the wound bed results in decreased consumption of analgesics, earlier mobilisation and shorter hospitalisation time. [6][7][8] As the implants are inserted laterally through the gluteal musculature during MISJF, and the SIJ is punctured to place the implants, pain is expected on loading the operated side. In the first 3 weeks after surgery patients mobilise with crutches, as 50% weight-bearing is allowed.…”