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Analgesic therapy for major spine surgery

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Abstract

Pain following spine surgery is often difficult to control and can persist. Reduction of this pain requires a multidisciplinary approach that depends on contributions of both surgeons and anesthesiologists. The spine surgeon’s role involves limiting manipulation of structures contributing to pain sensation in the spine, which requires an in-depth understanding of the specific anatomic etiologies of pain originating along the spinal axis. Anesthesiologists, on the other hand, must focus on preemptive, multimodal analgesic treatment regimens. In this review, we first discuss anatomic sources of pain within the spine, before delving into a specific literature-supported pain management protocol intended for use with spinal surgery.

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Authors and Affiliations

  1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Varun Puvanesarajah, Jason A. Liauw, Sheng-fu Lo, Ioan A. Lina, Timothy F. Witham & Allan Gottschalk

  2. Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA

    Allan Gottschalk

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  1. Varun Puvanesarajah
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  2. Jason A. Liauw
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  3. Sheng-fu Lo
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  4. Ioan A. Lina
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  5. Timothy F. Witham
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  6. Allan Gottschalk
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Correspondence to Allan Gottschalk.

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Wolf Lüdemann, Hannover, Germany

The manuscript is very instructive for every surgeon dealing with major or minor spine surgery.

Concepts in pain management are described as well as different multimodal pain strategies. This includes a firework of possible treatment options as well as their side effects. Intravenous lidocaine is not used by the group. Oral gabapentine, injected rupivacaine before surgery and epidural as well as intradural morphine is used to reduce systemic opoid consumption and with it their side effects. Some of the presented methods, such as intrathecal morphine application, are not to be recommended for every department, because of the risks involved on the normal ward. Other issues as the consensus between neurosurgeons and anesthesiologists are still on our wishlist.

Renata Simm, Paulo Henrique Aguiar, Sao Paulo, Brazil

Puvanesarajah et cols wrote a very important article which shows the pain syndrome following spine surgery, its importance, mechanisms, and main methods of treatment. Multiple spine surgeries in a patient harboring of low back pain may cause long-term pain syndromes making worse the symptoms. The pain may caused by mechanical or inflammatory sources initially; however, if the pain is not controlled even with elimination of the known sources, certainly the pain memory involving central and spinal local mechanisms is the most important factor to be analyzed. In this case, multidisciplinary approach has to be employed. We meant also that, in many cases after spine surgery, complex regional pain syndrome may be present in inferior limbs worse than the low back pain, and the treatment is very complex. Central sensitization is an important mechanism in pain and reflects the increased sensitivity of spinal neurons, despite unchanged afferent input. As a result, the pains become chronic and non noxius stimuli become painful. The authors discussed very well all mechanisms involved in this type of pain and the difficult to treat it. They mentioned the risk factors including genetic susceptibility, psychosocial, and demographic factors, prior the surgical procedures as well as the intensity of uncontrolled postoperative pain. For us, it is clear that a bad result in the first spine surgery (iatrigenic tissue damage) due to CSF leak, persistence of radicular pain, ectopic screw with reduction of sensitive, or motor evoked potential of the nerve will cause other surgery or surgeries and the complication potential will increase in each surgery causing inflammatory, mechanical, and chronic pain for rupture of neural afferences or damage of sensitive ganglia. Autonomic phenomena can appear to complicate and intensify the pain memory. This way the treatment has to stop this circle of effects, and be strong with analgesic and anti-inflammatory therapy, and physical rehabilitation. For patients with autonomic manifestations, we can add lumbar sympathectomy [5], pulsed radiofrequency treatment [2], epiduroscopy with infusion of anesthetic solutions, corticoid, morphine, fentanyl, clonidine, and ozone therapy [3, 4]. Epiduroscopy is used to identify painful structures in the epidural space, which may stablish a diagnosis of conflict between the nerve root and screw and possibility to administrate therapy. The rationale consists in the use of an epiduroscope to deliver therapies such as adhesiolysis and targeted administration of epidural anesthetics, anti-inflammatory drugs, morphine, and corticoids. Also spinal cord stimulation may be take in concern with good results [1].

References

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Mehmet Zileli, Izmir, Turkey

It is a dilemma that most of the degenerative spine surgery are being done to relieve pain. But the surgery itself may increase the original pain or add some other pain which then can persist. The reasons of postoperative pain after major spine surgery are multiple. It is not just incisional pain; but discs, muscles, ligaments, facet joints, and bone may be sources of postoperative pain. If not managed well, postoperative pain may continue and even increase and chronicity can develop which would decrease the success of surgery.

I am afraid that postoperative pain in spine surgery is a neglected subject especially by most spine surgeons. I congratulate the authors of this paper for their nice review of an important subject. I also want to stress the necessity of a good cooperation of surgeons and anesthesiologist to manage postoperative pain after major spine surgery. There is a need for application of less known pain control techniques such as preemptive and multimodal analgesic treatments.

If the subject is realized and accepted by all disciplines involved in spine surgery, the new and more successful protocols may be developed which would improve surgical outcomes and increase the willingness of patients for spine surgery.

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Puvanesarajah, V., Liauw, J.A., Lo, Sf. et al. Analgesic therapy for major spine surgery. Neurosurg Rev 38, 407–419 (2015). https://doi.org/10.1007/s10143-015-0605-7

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