Devin Clinton J, McGirt Matthew J
Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Nashville, TN 37232, USA.
Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA.
J Clin Neurosci. 2015 Jun;22(6):930-8. doi: 10.1016/j.jocn.2015.01.003. Epub 2015 Mar 9.
Multimodal approaches to pain management have arisen with the goal of improving postoperative pain and reducing opioid analgesic use. We performed a comprehensive literature review to determine grades of recommendation for commonly used agents in multimodal pain management and provide a best practice guideline. To evaluate common drugs used in multimodal treatment of pain, a search was performed on English language publications on Medline (PubMed; National Library of Medicine, Bethesda, MD, USA). Manuscripts were rated as Level I-V according to the North American Spine Society's (NASS) standardized levels of evidence tables. Grades of recommendation were assigned for each drug based on the NASS Clinical Guidelines for Multidisciplinary Spine Care. There is good (Grade A) evidence gabapentinoids, acetaminophen, neuraxial blockade and extended-release local anesthetics reduce postoperative pain and narcotic requirements. There is fair (Grade B) evidence that preemptive analgesia and nonsteroidal anti-inflammatory drugs (NSAID) result in reduced postoperative pain. There is insufficient and/or conflicting (Grade I) evidence that muscle relaxants and ketamine provide a significant reduction in postoperative pain or narcotic usage. There is fair (Grade B) evidence that short-term use of NSAID result in no long-term reduction in bone healing or fusion rates. Comprehensive assessment of the effectiveness of perioperative pain control can be accomplished through the use of validated measures. Multimodal pain management protocols have consistently been demonstrated to allow for improved pain control with less reliance on opioids. There is good quality evidence that supports many of the common agents utilized in multimodal therapy, however, there is a lack of evidence regarding optimal postoperative protocols or pathways.
为了改善术后疼痛并减少阿片类镇痛药的使用，多模式疼痛管理方法应运而生。我们进行了一项全面的文献综述，以确定多模式疼痛管理中常用药物的推荐等级，并提供最佳实践指南。为了评估多模式疼痛治疗中使用的常见药物，我们在美国国立医学图书馆（位于马里兰州贝塞斯达）的Medline（PubMed）数据库中搜索了英文出版物。根据北美脊柱协会（NASS）的标准化证据水平表，将手稿评为I - V级。根据NASS多学科脊柱护理临床指南，为每种药物指定推荐等级。有充分（A级）证据表明，加巴喷丁类药物、对乙酰氨基酚、神经轴阻滞和缓释局部麻醉剂可减轻术后疼痛并减少麻醉剂需求。有中等（B级）证据表明，超前镇痛和非甾体抗炎药（NSAID）可减轻术后疼痛。关于肌肉松弛剂和氯胺酮能显著减轻术后疼痛或减少麻醉剂使用量，证据不足和/或相互矛盾（I级）。有中等（B级）证据表明，短期使用NSAID不会导致骨愈合或融合率长期降低。通过使用经过验证的措施，可以对围手术期疼痛控制的有效性进行全面评估。多模式疼痛管理方案一直被证明能够在减少对阿片类药物依赖的情况下改善疼痛控制。有高质量证据支持多模式治疗中使用的许多常见药物，然而，关于最佳术后方案或途径缺乏证据。
