• Piet Waelkens, Emissia Alsabbagh, Axel Sauter, Girish P Joshi, Hélène Beloeil, and PROSPECT Working group∗∗ of the European Society of Regional Anaesthesia and Pain therapy (ESRA).
• From the Department of Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (PW), CHU Rennes, Anesthesia and Intensive Care Department, Rennes, France (EA), the Department of Anaesthesiology and Pain Management, University of Oslo, Oslo, Norway (AS), the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AS), the Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA (GPJ), the University Rennes, CHU Rennes, Inserm, INRA, CIC 1414 NuMeCan, Anesthesia and Intensive Care Department, Rennes, France (HB).
• Eur J Anaesthesiol. 2021 Sep 1; 38 (9): 985994985-994.

BackgroundComplex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.ObjectivesWe aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.Design And Data SourcesA systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.ResultsOut of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.ConclusionsThe analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.

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