• Kamal Maheshwari, Rafi Avitsian, Daniel I Sessler, Natalya Makarova, Marianne Tanios, Syed Raza, David Traul, Shobana Rajan, Mariel Manlapaz, Sandra Machado, Ajit Krishnaney, Andre Machado, Richard Rosenquist, and Andrea Kurz.
• From the Department of General Anesthesiology (K.M., R.A., D.T., S.R., M.M., S.M., A. Kurz) Department of Quantitative Health Sciences (N.M.) Department of Neurosurgery (A. Krishnaney, A.M.) Department of Pain Management (R.R.) Department of Outcomes Research (K.M., D.I.S., N.M., M.T., S.R., A. Kurz), Cleveland Clinic, Cleveland, Ohio.
• Anesthesiology. 2020 May 1; 132 (5): 992-1002.

BackgroundVarious multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores.MethodsAdults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h.ResultsThe trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, -6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being -9 (97.5% CI, -23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being -0.4 (97.5% CI; -0.8, 0.1, P = 0.094).ConclusionsAn analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery.

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