Ogura Yoji, Gum Jeffrey L, Steele Portia, Crawford Charles H, Djurasovic Mladen, Owens R Kirk, Laratta Joseph L, Davis Eric, Brown Morgan, Daniels Christy, Dimar John R, Glassman Steven D, Carreon Leah Y
Norton Leatherman Spine Center, Louisville, KY, USA.
J Spine Surg. 2020 Dec;6(4):681-687. doi: 10.21037/jss-20-629.
The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF).
This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs).
In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs.
The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.
目前美国阿片类药物泛滥已达到极其严重的程度。手术中使用阿片类药物以及术后后续的疼痛管理是导致阿片类药物依赖的已知风险因素。此外，阿片类药物会对多个方面产生负面影响，包括临床结局、住院时间和总体护理成本。因此，必须尽最大努力减少围手术期阿片类药物的使用，多模式疼痛控制（MMPC）越来越受欢迎。然而，其在脊柱手术中的疗效尚不清楚。我们旨在评估MMPC方案在接受腰椎单节段前路腰椎椎间融合术（ALIF）患者中的疗效。
这是一项回顾性比较研究。从一个前瞻性、单术者的手术数据库中，在MMPC方案启动前后，确定连续接受单节段ALIF手术、伴有或不伴有后续后路融合术治疗退行性腰椎疾病的患者。MMPC方案包括术前口服环苯扎林（10毫克）、加巴喷丁（600毫克）、对乙酰氨基酚（1克）和美沙酮（10毫克）。术后在拔管前给予患者双侧腹横肌平面阻滞，使用0.5%罗哌卡因。我们比较了MMPC组和非MMPC组的院内阿片类药物消耗量，以及基线人口统计学资料、住院时间、费用和术后肠梗阻发生率。计算阿片类药物消耗量并将其换算为吗啡毫克当量（MME）。
共确定MMPC组68例患者和非MMPC组39例患者。两组在基线人口统计学资料方面无差异，包括性别、体重指数、吸烟状况或术前阿片类药物使用情况。虽然手术当天的MME无差异（58.5±66.9，P = 0.387），但MMPC组术后每天的累积MME显著更低，最终累积MME减少了62%（120.2±314.8，P < 0.001）。术后肠梗阻、住院时间和住院费用方面无差异。
在接受单节段ALIF手术治疗退行性疾病的患者中使用MMPC方案可从术后第一天起减少阿片类药物消耗，累积减少62%。
