Abstract
Postoperative pain control following posterior spinal fusion surgery remains a struggle for providing physicians. Poorly controlled pain can result in physiological dysfunction and emotional distress with undesired outcomes, and has been tied to poor patient satisfaction with their treatment. Additionally, there is a demand to decrease opioid prescription and utilization in the acute postoperative period as a means of preventing addiction/chronic use and opioid-related adverse events that may prolong hospital stay. Multimodal pain treatment regimens have been well-demonstrated in other surgical disciplines to improve pain outcomes and decrease opiate requirements.
The goal of the study was to objectively evaluate the change in outcomes that occurs with the usage of a multimodal pain treatment plan. We hypothesized that standardized application would improve postoperative pain control in lumbar spinal fusion patients.
Single-institution retrospective comparative cohort study.
All patients receiving open, posterior, lumbar fusion surgery at our institution between July 2016 and June 2017 were eligible. Patients treated for degenerative conditions were included, and large operations for the treatment of scoliosis or adult spinal deformity were not included. Patients treated with minimally invasive surgery, or anterior-posterior operations were excluded. Patients receiving surgery for traumatic, infections or neoplastic etiologies were also excluded.
Patient-reported, postoperative NRS pain scores were used to determine pain metrics, including mean pain score, highest pain score and time until pain satisfactorily managed. Opioid consumption was measured for patients in the first 72 hours after surgery. Hospital length of stay and opioid-related adverse events were secondary outcome measures.
An evidence-based, multidisciplinary quality improvement initiative was implemented to standardize pain treatment following neurosurgical procedures at our institution. A retrospective chart review was conducted to evaluate pain-related outcomes during the last six months before and the first six months after implementation of the multimodal treatment regimen. The protocol included scheduled dosing of acetaminophen, NSAIDs (ibuprofen or ketorolac), muscle relaxants (methocarbamol), topical lidocaine patches, as needed dosing of gabapentinoids, and opioid delivery as needed for rescue.
A total of 115 pre- and 126 postimplementation patients were identified. The cohorts were well-matched with no differences in sex, age, surgical duration, number of segments fused, preoperative pain level or baseline physical status (all p>.05). Average patient-reported pain scores significantly improved in the first 24 hours postoperatively (5.8 vs. 4.6, p<.001) and 24 to 72 hours postoperatively (4.9 vs. 4.0, p<.001) following use of the pain protocols. Likewise, maximum pain scores during these periods, as well as time to achieving appropriate pain control were also significantly improved (p<.05). Opioid consumption significantly decreased during the first 72 hours (128 vs. 97 morphine milligram equivalents, p<.001). Patients in the postimplementation cohort had a significantly decreased length of hospital stay (4.7 vs. 3.9 days, p<.001). Of opioid-related adverse events, there was a reduction in the incidence of constipation (58% vs. 44%, p<.001).
Implementation of an evidence-based, standardized multi-modal pain protocol led to a reduction in pain scores, opioid consumption, opioid-related adverse events, and length of hospital stay after posterior lumbar fusion.
This abstract does not discuss or include any applicable devices or drugs.