Effects of a multimodal analgesic pathway with transversus abdominis plane block for lumbar spine fusion: a prospective feasibility trial

Opioid-sparing Anesthesia Decreases In-hospital and 1-year Postoperative Opioid Consumption Compared With Traditional Anesthesia: A Propensity-matched Cohort Study

STUDY DESIGN

Propensity-matched cohort.

OBJECTIVE

The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption.

SUMMARY OF BACKGROUND DATA

The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure.

MATERIALS AND METHODS

Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared.

RESULTS

Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients.

CONCLUSIONS

OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.

Transversus Abdominis Plane Block for Anterior Lumbar Interbody Fusion: a randomized controlled trial

BACKGROUND CONTEXT

ALIF (Anterior Lumbar Interbody Fusion) is a lumbar arthrodesis technique via an anterior approach that is less invasive than the posterior approaches. However, it is associated with specific pain in the abdominal wall.

PURPOSE

The objective of this study was to determine whether performing a bilateral ultrasound-guided TAP (Transversus Abdominis Plane) block allows a reduction in morphine consumption in the first 24 hours after surgery.

STUDY DESIGN

This study is a prospective single-centre, randomized, double-blind study.

PATIENT SAMPLE

Patients undergoing ALIF surgery were included and randomized into two groups. Both groups received a TAP block performed at the end of surgery with either ropivacaine or placebo.

OUTCOME MEASURES

The primary outcome measure was morphine consumption in the first 24 hours. The main secondary outcomes were immediate postoperative pain and opioid-related side effects METHODS: Intra- and postoperative anaesthesia and analgesia protocols where standardized. A bilateral ultrasound-guided TAP block was performed with 75 mg (in 15 ml) of ropivacaine per side or isotonic saline serum depending on their assignment group.

RESULTS

Forty-two patients were included in the study (21 per group). Morphine consumption at 24 hours (28 mg [18 - 35] in the ropivacaine group vs 25 mg [19 - 37] in the placebo group (p=0.503)) were not significantly different between the 2 groups.

CONCLUSION

TAP block with ropivacaine or placebo provided a similar postoperative analgesia when associated with a multimodal analgesia protocol for ALIF.

Utility of the transversus abdominis plane and rectus sheath blocks in patients undergoing anterior lumbar interbody fusions

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery.

PURPOSE

Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control.

STUDY DESIGN/SETTING

Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital.

PATIENT SAMPLE

Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021.

OUTCOME MEASURES

Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room.

METHODS

Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups.

RESULTS

The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups.

CONCLUSIONS

The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Ultrasound-guided fascial plane blocks for spine surgery

PURPOSE OF REVIEW

The development of truncal and fascial plane blocks has created novel opportunities to apply regional analgesic techniques to patients undergoing spine surgery. This review will summarize recent literature devoted to evaluating candidate blocks for spine surgery, including erector spinae plane block, thoracolumbar interfascial plane block, midpoint transverse process to pleura block, and transversus abdominis plane block. Procedure-specific effects of blocks on patient and healthcare system outcomes will be presented and gaps in care and knowledge will be highlighted.

RECENT FINDINGS

The most studied paradigm was bilateral erector spinae plane block for lumbar spine surgery. The most common outcomes assessed were early postoperative pain scores, opioid consumption and related side effects, and length of hospital stay. All candidate blocks were associated with mixed evidence for analgesic and opioid-sparing benefits, and/or reductions in length of hospital stay. The magnitude of these effects was overall small, with many studies showing statistically but not clinically significant differences on outcomes of interest. This may reflect, at least in part, the current state of the (emerging) evidence base on this topic.

SUMMARY

Our understanding of the risks, benefits, and value of truncal and fascial plane blocks for spine surgery cohorts is evolving. Although the results derived from this body of literature are encouraging, further research is required before the widespread adoption of specified blocks into spine care can be recommended.

Regional Anesthesia for Spine Surgery

Current advancements in spine surgery have led to a recent interest in regional anesthesia for spine surgery. Spinal anesthesia, epidural anesthesia, and their combination are commonly used modalities for regional anesthesia in spine surgeries. The successful use of regional anesthesia has led to the emergence of several new concepts such as awake spinal fusion and outpatient spinal surgery. Regarding analgesic techniques, several new modalities have been described recently such as erector spinae and thoracolumbar interfascial plane blocks. These regional analgesic modalities are aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. This narrative review focuses on the techniques, indications and contraindications, benefits, and complications of regional anesthesia in the context of spine surgery.

Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review

BACKGROUND

Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery.

METHODS

This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy.

RESULTS

Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017.

CONCLUSIONS

Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

OBJECTIVE

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion.

METHODS

The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses.

RESULTS

In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001).

CONCLUSIONS

A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Thoracolumbar Interfascial Plane Block and Transversus Abdominis Plane Block for Postoperative Analgesia: 2-Dimensional Operative Video

While spinal fusion in properly selected patients has been shown to be effective in improving pain, function, and quality of life, many patients continue to have reservations regarding the historical morbidity associated with surgical intervention.1 Open lumbar fusion surgery traditionally is perceived as an intervention that is associated with significant pain, recovery time, and risk. Even though most patients ultimately recover from this procedure, they are often left scarred with the psychological, economic, and social costs.2  To combat these negative associations with spinal fusion, neurosurgeons have begun to adopt adjunctive treatment modalities, including thoracolumbar interfascial plane (TLIP) blocks and transversus abdominis plane (TAP) blocks to improve pain control and reduce postoperative opiate consumption.3,4 The TLIP block is done after the patient is intubated and prior to skin incision for our posterior lumbar cases. Recently, we have also begun placing TAP blocks for patients undergoing anterior lumbar interbody fusion (ALIF) using exclusively liposomal bupivacaine, as commonly practiced for other abdominopelvic surgeries, to lengthen the duration of analgesia.5 We have found that these blocks have ameliorated both intraoperative and postoperative pain management.6  In this video, we present a case of a 65-yr-old female who presented with a grade 1 spondylolisthesis and neuroforaminal compression from L4 to S1, who was treated with combined TAP and TLIP block followed by a L4 to S1 ALIF with posterolateral instrumentation.  Informed written consent was obtained from the patient and her family.

The association of transversus abdominis plane block with length of stay, pain and opioid consumption after anterior or lateral lumbar fusion: a retrospective study

PURPOSE

Anterior (ALIF) and lateral (LLIF) lumbar interbody fusion is associated with significant postoperative pain, opioid consumption and length of stay. Transversus abdominis plane (TAP) blocks improve these outcomes in other surgical subtypes but have not been applied to spine surgery. A retrospective study of 250 patients was performed to describe associations between TAP block and outcomes after ALIF/LLIF.

METHODS

The electronic medical records of 129 patients who underwent ALIF or LLIF with TAP block were compared to 121 patients who did not. All patients were cared for under a standardized perioperative care pathway with comprehensive multimodal analgesia. Differences in patent demographics, surgical factors, length of stay (LOS), opioid consumption, opioid-related side effects and pain scores were compared in bivariable and multivariable regression analyses.

RESULTS

In bivariable analyses, TAP block was associated with a significantly shorter LOS, less postoperative nausea/vomiting and lower opioid consumption in the post-anesthesia care unit (PACU). In multivariable analyses, TAP block was associated with significantly shorter LOS (β - 12 h, 95% CI (- 22, - 2 h); p = 0.021). Preoperative opioid use was a strong predictive factor for higher opioid consumption in the PACU, opioid use in the first 24 h after surgery and longer LOS. We did not find significant differences in pain scores at any times between the groups.

CONCLUSION

TAP block may represent an effective addition to pain management and opioid-reducing strategies and improve outcomes after ALIF/LLIF. Prospective trials are warranted to further explore these associations.

Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption

Background

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).

Methods

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).

Results

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 vs. 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 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs.

Conclusions

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%.

Hemodynamically significant cardiac arrhythmias during general anesthesia for spine surgery: A case series and literature review

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Although multiple factors have been implicated, our case series highlights SSEP stimulation as a common etiology of arrhythmia.

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Significant bradycardia and CA during spine surgery does not always require termination of the surgical procedure.

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Decision making should be undertaken in each case individually based on patient condition and circumstances of each event.

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Surgeons and anesthesiologists should be aware of and prepared to treat significant cardiac arrhythmias during spine surgery even in otherwise healthy patients without known risk factors.

Background context

Hemodynamically significant bradycardia and cardiac arrest (CA) are rare under general anesthesia (GA) for spine surgery. Although patient risks are well defined, emerging data implicate surgical, anesthetic and neurologic factors which should be considered in the immediate management and decision to continue or terminate surgery.

Purpose

To characterize causes and contributors to significant arrhythmias during spine surgery. We also provide an updated literature review to inform spine care teams and aid in the management of intraoperative bradycardia and CA.

Study design

Case series and literature review

Patient sample

Six patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia

Outcome measures

Our primary outcome was to identify potential risk factors of interest for significant arrhythmia during spine surgery.

Methods

Medical records of patients who underwent spine surgery from 03/2016 to 01/2020 at a single institution and developed unexpected hemodynamically significant arrhythmia during spine surgery were identified from a departmental Quality Assurance Database. We evaluated the presence/absence of patient, surgical, anesthetic and neurologic risk factors and estimated the most likely etiology of the event, immediate and subsequent management, whether surgery was postponed or continued and outcomes.

Results

We found a temporal relationship of bradyarrhythmia and CA after somatosensory evoked potential (SSEP) stimulation in 4/6 cases and pharmacy/polypharmacy in 2/6. Surgery was completed in 4/6 patients, and terminated in 2/6 (subsequently completed in both). We found no adverse outcomes in any patients. Our literature review predominately identified case reports for guidance to support decision making. New literaure suggests peripheral nerve blocks and opioid-sparing anesthetic agents should also be considered.

Conclusions

Significant bradycardia and CA during spine surgery does not always require termination of the surgical procedure. Decision making should be undertaken in each case individually, with an updated awareness of potential causes. The study also suggests the need for large prospective studies to adequately assess incidence, risk factors and outcomes.