Evaluation of the Optimal Preemptive Dose of Gabapentin for Postoperative Pain Relief After Lumbar Diskectomy

Antineuropathic Pain Management After Orthopedic Surgery: A Systematic Review

Background

The opioid crisis has become a present concern in the medical field. In an effort to address these complications, antineuropathic pain medications have been considered as alternatives to prescribed opioids.

Objective

This review focuses on the analgesic effects of neuromodulators, such as gabapentin, duloxetine, and pregabalin, that provide room for less dependence on narcotic analgesics following orthopedic surgery.

Methods

During the database searches, 1,033 records were identified as a preliminary result. After duplicates were removed, an initial screen of each article was completed which identified records to be removed due to absence of a full-text article. Articles were excluded if they were not either prospective or retrospective, showcased an irrelevant medication (such as tricyclic antidepressants) which are not pertinent to this review, or deemed to be unrelated to the topic.

Results

Ultimately, 19 articles were selected. Three different drugs, gabapentin, pregabalin, and duloxetine, were analyzed to compile data on the effectiveness of preventing opioid overuse and addiction following hand surgery. This review identifies potential evidence that peri-operative gabapentin, pregabalin, and duloxetine administration decreases post-operative pain and lowers opioid dependency.

Conclusion

Gabapentin, pregabalin, and duloxetine have potential to further decrease post-operative pain and lower opioid dependency. This review creates an opening for further research in hand surgery to assess an updated protocol for pain management to reduce opioid dependency.

Gabapentin and postoperative pain and opioid consumption: A double-blind randomized controlled trial of perioperative pain management for sinus surgery

BACKGROUND

The link between post-operative narcotic prescription and opioid misuse has spurred a nationwide effort to reduce perioperative opioid use. Previous work has suggested that perioperative gabapentin may reduce post-operative pain and opioid consumption across different procedures, although the optimal regimen remains to be defined.

METHODS

Chronic rhinosinusitis (CRS) patients undergoing functional endoscopic sinus surgery (FESS) with or without septoplasty were randomized to receive a 7-day pre- and post-operative course of placebo or gabapentin, starting at 300 mg daily and titrated to 300 mg three times daily, in a double-blind fashion. Primary endpoint was pain level using a validated visual analog scale (VAS). Secondary endpoints included post-operative opioid consumption and side effects, as well as modified Lund-Kennedy endoscopy, Lund-Mackay, and SNOT-22 scores.

RESULTS

Analysis of 35 patients (20 gabapentin, 15 control) showed no significant difference in mean postoperative VAS (p = 0.18) or postoperative opioid consumption between the placebo and gabapentin groups (2.3 and 4.8 oxycodone tablets respectively, p = 0.18). 15 of 35 patients did not require any post-operative oxycodone tablets, and only two patients required more than six tablets.

CONCLUSION

Preliminary results show no significant change in pain after FESS with or without septoplasty in patients taking 7-day pre- and post-operative gabapentin versus placebo. Results also showed no significant difference in opioid consumption between the treatment and placebo groups. Post-operative pain scores and opioid requirements are both quite low following FESS. Many patients do not need opioids at all, suggesting that routine initial post-operative opioid prescriptions can be limited accordingly.

The Preoperative Use of Gabapentinoids for the Treatment of Acute Postoperative Pain Following Lumbar Spine Fixation Surgery

BACKGROUND

Postoperative pain following posterior fixation is caused not only by tissue injury during surgery and is related to inflammatory, neuropathic, and visceral pain. This study aims to answer the question, "Is there a role for gabapentinoids in reducing postoperative pain?" In addition, it demonstrates which gabapentinoids may be used, for how long, and at what dose.

METHODS

The study was planned as a prospective, randomized, double-blind study. Lumbar posterior fixation was included and patients were divided into 9 groups. Gabapentinoids and a placebo were administered. Postoperative pain at hours 1, 6, 12, and 24 was evaluated by visual analog scale (VAS).

RESULTS

This study included 252 patients (141 women, 111 men). The median age was 51.62 years. A statistically significant difference was found when VAS-1, VAS-6, VAS-12, and VAS-24 scores were compared between all groups (P ˂ 0.001). Single and low doses of gabapentinoids were found to be ineffective (P > 0.05). Long-term and high-dose gabapentinoids had complications (P ˂ 0.001). Single and high doses of gabapentinoids were effective and safe (P ˂ 0.001).

CONCLUSIONS

Postoperative use of gabapentin for controlling early and late-stage pain is safe and effective. Single and high-dose gabapentin was the first choice. A single and high dose of pregabalin is the second choice.

Perioperative role of oral gabapentin as an analgesic in paediatric patients: A randomised controlled trial

Background and Aims

Surgical procedure commonly performed in the advanced pediatric age group includes urogenital surgery, adenotonsillectomy, etc., Aim: The aim of this study is to determine the effect of single-dose gabapentin 15 mg/kg on acute pain in the immediate postoperative period in patients aged 8-14 years undergoing surgeries under general anesthesia.

Material and Methods

After the approval from the institutional ethical committee, 60 American Society of Anesthesiologists (ASA) I and II patients aged 8-14 years undergoing urogenital surgeries (orchidopexy/urethroplasty) under general anesthesia were included in this study. The patients were assigned into one of the two treatment groups. Patients in group I received oral gabapentin 15 mg/kg dissolved in 5 mL of honey 2 h before surgery, while patients in group II received 5 mL honey orally 2 h before surgery.

Results

A total of 60 patients participated. Patients in group I had lower consumption of fentanyl perioperatively (intraoperatively: 1.36 ± 0.70 mcg/kg; postoperatively: 2.36 ± 0.795 mcg/kg) than group II (intraoperatively: 1.8 ± 0.6 mcg/kg; postoperatively: 2.9 ± 0.47 mcg/kg). The differences in the two groups were significant. The time to first rescue analgesia was greater in group I (3.03 ± 0.60 h) than in group II (2.26 ± 0.57 h). There was an increase in sedation score in the treatment group.

Conclusion

Our clinical study demonstrates that a 15 mg/kg single preemptive oral dose of gabapentin might reduce the requirement of analgesics perioperatively in pediatric urogenital surgery but might also be associated with undesirable effects such as increased sedation.

Chronic pain after spine surgery: Insights into pathogenesis, new treatment, and preventive therapy

Chronic pain after spine surgery (CPSS) is often characterized by intractable low back pain and/or radiating leg pain, and has been reported in 8-40% of patients that received lumbar spine surgery. We conducted a literature search of PubMed, MEDLINE/OVID with a focus on studies about the etiology and treatments of CPSS and low back pain. Our aim was to provide a narrative review that would help us better understand the pathogenesis and current treatment options for CPSS. This knowledge will aid in the development of optimal strategies for managing postoperative pain symptoms and potentially curing the underlying etiologies. Firstly, we reviewed recent advances in the mechanistic study of CPSS, illustrated both structural (e.g., fibrosis and scaring) and non-structural factors (e.g., inflammation, neuronal sensitization, glial activation, psychological factor) causing CPSS, and highlighted those having not been given sufficient attention as the etiology of CPSS. Secondly, we summarized clinical evidence and therapeutic perspectives of CPSS. We also presented new insights about the treatments and etiology of CPSS, in order to raise awareness of medical staff in the identification and management of this complex painful disease. Finally, we discussed potential new targets for clinical interventions of CPSS and future perspectives of mechanistic and translational research. CPSS patients often have a mixed etiology. By reviewing recent findings, the authors advocate that clinicians shall comprehensively evaluate each case to formulate a patient-specific and multi-modal pain treatment, and importantly, consider an early intraoperative intervention that may decrease the risk or even prevent the onset of CPSS.

Translational potential statement

CPSS remains difficult to treat. This review broadens our understanding of clinical therapies and underlying mechanisms of CPSS, and provides new insights which will aid in the development of novel mechanism-based therapies for not only managing the established pain symptoms but also preventing the development of CPSS.

Different Gabapentin and Pregabalin Dosages for Perioperative Pain Control in Patients Undergoing Spine Surgery: A Systematic Review and Network Meta-Analysis

IMPORTANCE

Patients undergoing spine surgery often experience severe pain. The optimal dosage of pregabalin and gabapentin for pain control and safety in these patients has not been well established.

OBJECTIVE

To evaluate the associations of pain, opioid consumption, and adverse events with different dosages of pregabalin and gabapentin in patients undergoing spine surgery.

DATA SOURCES

PubMed/MEDLINE, Embase, Web of Science, Cochrane library, and Scopus databases were searched for articles until August 7, 2021.

STUDY SELECTION

Randomized clinical trials conducted among patients who received pregabalin or gabapentin while undergoing spine surgery were included.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently performed data extraction following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guideline. The network meta-analysis was conducted from August 2022 to February 2023 using a random-effects model.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity measured using the Visual Analog Scale (VAS), and secondary outcomes included opioid consumption and adverse events.

RESULTS

Twenty-seven randomized clinical trials with 1861 patients (median age, 45.99 years [range, 20.00-70.00 years]; 759 women [40.8%]) were included in the systematic review and network meta-analysis. Compared with placebo, the VAS pain score was lowest with gabapentin 900 mg per day, followed by gabapentin 1200 mg per day, gabapentin 600 mg per day, gabapentin 300 mg per day, pregabalin 300 mg per day, pregabalin 150 mg per day, and pregabalin 75 mg per day. Additionally, gabapentin 900 mg per day was found to be associated with the lowest opioid consumption among all dosages of gabapentin and pregabalin, with a mean difference of -22.07% (95% CI, -33.22% to -10.92%) for the surface under the cumulative ranking curve compared with placebo. There was no statistically significant difference in adverse events (nausea, vomiting, and dizziness) among all treatments. No substantial inconsistency between direct and indirect evidence was detected for all outcomes.

CONCLUSIONS AND RELEVANCE

These findings suggest that gabapentin 900 mg per day before spine surgery is associated with the lowest VAS pain score among all dosages. In addition, no differences in adverse events were noted among all treatments.

Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery

Importance

Gabapentin has been increasingly used as part of a multimodal analgesia regimen to reduce opioid use in perioperative pain management. However, the safety of perioperative gabapentin use among older patients remains uncertain.

Objective

To examine in-hospital adverse clinical events associated with perioperative gabapentin use among older patients undergoing major surgery.

Design, Setting, and Participants

This retrospective cohort study using data from the Premier Healthcare Database included patients aged 65 years or older who underwent major surgery at US hospitals within 7 days of hospital admission from January 1, 2009, to March 31, 2018, and did not use gabapentin before surgery. Data were analyzed from June 14, 2021, to May 23, 2022.

Exposures

Gabapentin use within 2 days after surgery.

Main Outcomes and Measures

The primary outcome was delirium, identified using diagnosis codes, and secondary outcomes were new antipsychotic use, pneumonia, and in-hospital death between postoperative day 3 and hospital discharge. To reduce confounding, 1:1 propensity score matching was performed. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were estimated.

Results

Among 967 547 patients before propensity score matching (mean [SD] age, 76.2 [7.4] years; 59.6% female), the rate of perioperative gabapentin use was 12.3% (119 087 patients). After propensity score matching, 237 872 (118 936 pairs) gabapentin users and nonusers (mean [SD] age, 74.5 [6.7] years; 62.7% female) were identified. Compared with nonusers, gabapentin users had increased risk of delirium (4040 [3.4%] vs 3148 [2.6%]; RR, 1.28 [95% CI, 1.23-1.34]; RD, 0.75 [95% CI, 0.75 [0.61-0.89] per 100 persons), new antipsychotic use (944 [0.8%] vs 805 [0.7%]; RR, 1.17 [95% CI, 1.07-1.29]; RD, 0.12 [95% CI, 0.05-0.19] per 100 persons), and pneumonia (1521 [1.3%] vs 1368 [1.2%]; RR, 1.11 [95% CI, 1.03-1.20]; RD, 0.13 [95% CI, 0.04-0.22] per 100 persons), but there was no difference in in-hospital death (362 [0.3%] vs 354 [0.2%]; RR, 1.02 [95% CI, 0.88-1.18]; RD, 0.00 [95% CI, -0.04 to 0.05] per 100 persons). Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden (combined comorbidity index <4 vs ≥4: RR, 1.20 [95% CI, 1.13-1.27] vs 1.40 [95% CI, 1.30-1.51]; RD, 0.41 [95% CI, 0.28-0.53] vs 2.66 [95% CI, 2.08-3.24] per 100 persons) and chronic kidney disease (absence vs presence: RR, 1.26 [95% CI, 1.19-1.33] vs 1.38 [95% CI, 1.27-1.49]; RD, 0.56 [95% CI, 0.42-0.69] vs 1.97 [95% CI, 1.49-2.46] per 100 persons).

Conclusion and Relevance

In this cohort study, perioperative gabapentin use was associated with increased risk of delirium, new antipsychotic use, and pneumonia among older patients after major surgery. These results suggest careful risk-benefit assessment before prescribing gabapentin for perioperative pain management.

Opioid Sparing Analgesics in Spine Surgery

Combinations of various nonopioid analgesics have been used to decrease pain and opioid consumption postoperatively allowing for faster recovery, improved patient satisfaction, and decreased morbidity. These opioid alternatives include acetaminophen, NSAIDs, COX-2 specific inhibitors, gabapentinoids, local anesthetics, dexamethasone, and ketamine. Each of these drugs presents its own advantages and disadvantages which can make it difficult to implement universally. In addition, ambiguous administration guidelines for these nonopioid analgesics lead to a difficult implementation of standardization protocols in spine surgery. A focus on the efficacy of different pain modalities specifically within spine surgery was implemented to assist with this standardized protocol endeavor and to educate surgeons on limiting opioid prescribing in the postoperative period. The purpose of this review article is to investigate the various opioid sparing medications that have been used to decrease morbidity in spine surgery and better assist surgeons in managing postoperative pain. Methods. A narrative review of published literature was conducted using the search function in Google scholar and PubMed was used to narrow down search criteria. The keywords “analgesics,” “spine,” and “pain” were used.

What's New in Pain Management for Pediatric Orthopaedic Surgery

BACKGROUND

Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery.

METHODS

An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers.

RESULTS

A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions.

CONCLUSIONS

There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery.

LEVEL OF EVIDENCE

Level IV-literature review.

Gabapentin reduces postoperative pain and opioid consumption in patients who underwent lumbar laminectomy

BACKGROUND

Postoperative pain management solely with opioids elevates the risk of opioid-related adverse events during hospitalization and after discharge from the hospital. Clinical trials have demonstrated gabapentinoids as viable adjunctive treatments for spinal surgeries. However, only a few practice-based studies have examined the efficacy of gabapentin as an opioid-sparing agent for patients undergoing lumbar laminectomy in rural hospital settings.

OBJECTIVE

To determine the effects of gabapentin on opioid consumption and pain perception in patients who underwent lumbar laminectomy at a rural community hospital.

METHODS

Data were collected by retrospective chart reviews of 99 patients who underwent lumbar laminectomy at Yavapai Regional Medical Center from January 1, 2017, to July 1, 2019. The patients were stratified into 2 groups: those who were taking gabapentin as outpatients before surgery and were continued on the same dose postoperatively (n = 50, gabapentin group) and those who were not taking gabapentin preoperatively or postoperatively (n = 49, usual-treatment group). The primary end points were opioid consumption in morphine milligram equivalents (MME) and pain for 24 hours postsurgery.

RESULTS

Outcomes from the mixed-model analysis of variance showed significant main effects of group and time for opioid consumption in MME (F_1,97 = 4.3, P < 0.05 and F_3,291 = 133.9, P < 0.001, respectively) and numerical pain scale scores (F_1,99 = 4.0, P < 0.05 and F_3,241 = 21.4, P < 0.001, respectively) and group-time interaction for opioid consumption in MME (F_3,291 = 2.6, P = 0.05). Post hoc analyses showed that opioid consumption in MME was significantly lower in the gabapentin group than in the usual-treatment group for the first 6 hours postoperatively. The pain scores were significantly lower in the gabapentin group than in the usual-treatment group across all time periods.

CONCLUSION

Patients on gabapentin showed reductions in pain perception and postoperative opioid consumption. The results extend the findings from randomized trials to a real-world clinical setting. These data support using gabapentin in conjunction with opioids for pain management of patients undergoing lumbar laminectomy.

The analgesic evaluation of gabapentin for arthroscopy: A meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of gabapentin for pain management of arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of gabapentin versus placebo on the postoperative pain intensity of arthroscopy.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials assessing the effect of gabapentin versus placebo on pain control of arthroscopy. This meta-analysis is performed using the random-effect model.

RESULTS

Five randomized controlled trials are included in the meta-analysis. Overall, compared with control group for arthroscopy, gabapentin remarkably decreases pain scores at 24 hour (standard mean difference [SMD]=-0.68; 95% confidence interval [CI]=-1.15 to -0.02; P = .21), analgesic consumption (SMD = -18.24; 95% CI=-24.61 to -11.88; P < .00001), nausea and vomiting (OR = 0.42; 95% CI = 0.21 to 0.84; P = .01), but has no obvious influence on pain scores at 6 h (SMD = -1.30; 95% CI = -2.92 to 0.31; P = .11) or dizziness (OR = 1.12; 95% CI = 0.56 to 2.24; P = .75).

CONCLUSIONS

Gabapentin is effective for pain control after arthroscopy.

Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients

Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

Background

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

Methods

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

Results

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

Conclusions

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.

Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01281-1.

Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting

BACKGROUND

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.

METHODS

Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.

RESULTS

Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.

CONCLUSIONS

The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Preemptive Analgesia with a Second Dose of Pregabalin, Acetaminophen, Naproxen, and Dextromethorphan: A Comparative Clinical Trial in Major Surgeries

Background

Postoperative pain management can improve patients’ quality of life and decrease hospitalization rates. Preemptive analgesia may provide an effective approach for both pain control and opioid consumption decrease. A common approach for pain management after surgery is to relieve the pain that has already occurred.

Objectives

The aim of this clinical trial was to compare the preemptive analgesic effect of single-dose versus two-dose administration of pregabalin, acetaminophen, naproxen, and dextromethorphan (PAND) combination.

Methods

This study involved 60 patients who had undergone one surgery (including nephrectomy, cystectomy, prostatectomy, colectomy, Whipple, and RPLND). They were randomly divided into two groups: The first group received a single dose of PAND, while the other group received a second dose within 6 hours after discharge from recovery. Pain intensity was assessed by the Universal Pain Assessment Tool (UPAT) in both groups 2, 4, 6, 8, 12, 24, and 48 hours postoperatively. The postoperative morphine dose in both groups was also recorded. Data were analyzed using SPSS version 25.

Results

Mean pain scores were significantly different between the two groups at 2, 12, 24, and 48 hours after surgery (P < 0.05). There was a statistically significant difference between the two groups in terms of opioid consumption (P < 0.001). The total opioid consumption in the second group (with the second administration of PAND) was lower than the first group.

Conclusions

Preemptive analgesia with a second dose of PAND is an effective method for reducing pain and morphine consumption after surgery.

Neuroanesthesia Guidelines for Optimizing Transcranial Motor Evoked Potential Neuromonitoring During Deformity and Complex Spinal Surgery: A Delphi Consensus Study

STUDY DESIGN

Expert opinion-modified Delphi study.

OBJECTIVE

We used a modified Delphi approach to obtain consensus among leading spinal deformity surgeons and their neuroanesthesiology teams regarding optimal practices for obtaining reliable motor evoked potential (MEP) signals.

SUMMARY OF BACKGROUND DATA

Intraoperative neurophysiological monitoring of transcranial MEPs provides the best method for assessing spinal cord integrity during complex spinal surgeries. MEPs are affected by pharmacological and physiological parameters. It is the responsibility of the spine surgeon and neuroanesthesia team to understand how they can best maintain high-quality MEP signals throughout surgery. Nevertheless, varying approaches to neuroanesthesia are seen in clinical practice.

METHODS

We identified 19 international expert spinal deformity treatment teams. A modified Delphi process with two rounds of surveying was performed. Greater than 50% agreement on the final statements was considered "agreement"; >75% agreement was considered "consensus."

RESULTS

Anesthesia regimens and protocols were obtained from the expert centers. There was a large amount of variability among centers. Two rounds of consensus surveying were performed, and all centers participated in both rounds of surveying. Consensus was obtained for 12 of 15 statements, and majority agreement was obtained for two of the remaining statements. Total intravenous anesthesia was identified as the preferred method of maintenance, with few centers allowing for low mean alveolar concentration of inhaled anesthetic. Most centers advocated for <150 μg/kg/min of propofol with titration to the lowest dose that maintains appropriate anesthesia depth based on awareness monitoring. Use of adjuvant intravenous anesthetics, including ketamine, low-dose dexmedetomidine, and lidocaine, may help to reduce propofol requirements without negatively effecting MEP signals.

CONCLUSION

Spine surgeons and neuroanesthesia teams should be familiar with methods for optimizing MEPs during deformity and complex spinal cases. Although variability in practices exists, there is consensus among international spinal deformity treatment centers regarding best practices.

LEVEL OF EVIDENCE

5.

Opioid Alternatives in Spine Surgery: A Narrative Review

Adequate analgesia is known to improve outcomes after spine surgery. Despite recent attention highlighting the negative effects of narcotics and their addiction potential, opioids have been the mainstay of management for providing analgesia following spine surgeries. However, side effects including hyperalgesia, tolerance, and subsequent dependence restrict the generous usage of opioids. Multimodal analgesia regimens acting through different mechanisms offer significant opioid sparing and minimize the side effects of individual drugs. Hence, they are being increasingly incorporated into enhanced recovery protocols. Multimodal analgesia includes drugs such as N-methyl-D-aspartate antagonists, nonsteroidal anti-inflammatory drugs and membrane-stabilizing agents, neuraxial opioids, local anesthetic infiltration, and fascial compartment blocks. Analgesia started before the painful stimulus, termed preemptive analgesia, facilitates subsequent pain management. Both nonsteroidal anti-inflammatory drugs and neuraxial analgesia have been conclusively shown to reduce opioid requirements after spine surgery, and there is a resurgence of interest in the use of low-dose ketamine or methadone. Neuraxial narcotics offer enhanced analgesia for a longer duration with lower dosage and side effect profiles compared with systemic opioid administration. Fascial compartment blocks are increasingly used as they provide effective analgesia with fewer adverse effects. In this narrative review, we will discuss multimodality analgesic regimens incorporating opioid-sparing adjuvants to manage pain after spine surgery.

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction

Importance

An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia.

Objective

To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery.

Design, Setting, and Participants

This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively.

Interventions

Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed.

Main Outcomes and Measures

Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia.

Results

A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001).

Conclusions and Relevance

The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced.

Level of Evidence

3.

A preliminary report on the effect of gabapentin pretreatment on periprocedural pain during in-office posterior nasal nerve cryoablation

BACKGROUND

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique to address allergic and nonallergic rhinitis. Periprocedural pain has been reported after PNN cryoablation and there are no standardized protocols for optimal in-office local anesthesia. This study sought to evaluate the effect of gabapentin on patient discomfort following in-office PNN cryoablation.

METHODS

Multi-institutional prospective analysis of patients undergoing in-office PNN cryoablation for allergic or nonallergic rhinitis between March 2018 and April 2019. Patients received local anesthesia with or without 600 mg oral gabapentin 1 hour preprocedure. Rhinitis diagnosis, demographics, and baseline disease-specific quality of life (mini-Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and Total Nasal Symptom Score [TNSS]) were recorded. Patient discomfort was measured by the pain visual analogue scale (VAS) posttreatment and rated 0 to 10 on an ordinal scale. Fisher's exact and Wilcoxon 2-sample tests were used to evaluate differences between the 2 groups.

RESULTS

A total of 26 patients were enrolled (gabapentin n = 15, control = 11). Baseline TNSS scores in the gabapentin vs control group were median [25th percentile to 75th percentile]) 10 (7.5 to 11.0) and 9 (6.0 to 10.0) (p = 0.35). Baseline Mini-RQLQ scores in gabapentin vs control groups were 3.21 (2.0 to 4.0) and 2.92 (2.78 to 4.35) (p = 0.51). The median VAS pain scores at 5, 20, and 30 minutes in the gabapentin vs control group were 0.0 (0.0 to 2.0) vs 3.0 (1.0 to 4.0), 2.0 (0.0 to 3.0) vs 8.0 (6.0 to 10.0), and 1.0 (0.0 to 1.0) vs 5.0 (4.0 to 6.0) (p = 0.02, p = 0.0043, and p = 0.003, respectively).

CONCLUSION

Preprocedure gabapentin significantly reduces immediate and delayed postprocedural patient discomfort following PNN cryoablation.

Multimodal analgesia in pain management after spine surgery

Multimodal analgesia (MMA) is the simultaneous use of multiple analgesic medications that work in a synergistic manner to provide pain control. In recent years, spine surgery has seen the growth of multimodal perioperative protocols for managing pain. Postoperative pain following spinal procedures is a common complaint, with persistent pain even after the immediate convalescent period leading to negative impacts on health. A multidisciplinary approach is essential in reducing postoperative morbidity and complication rates. This review demonstrates the efficacy in the combined use of opioid-alternative medications such as NSAIDs, gabapentinoids, local anesthetics, acetaminophen, and other neuromodulatory pharmacologic agents. Continued research will be essential in the optimization of the MMA protocol for treating patients who undergo spine procedures.

Anesthesia and postoperative pain control-multimodal anesthesia protocol

Multimodal analgesia (MMA) involves the use of additive or synergistic combinations of analgesics to achieve clinically required analgesia while minimizing significant side effects associated with higher dose of a single equianalgesic medication such as an opioid analgesic. MMA generally involves optimizing non-opioid pharmacologic and non-pharmacologic interventions and reserving opioid use to treat breakthrough pain. Patients receiving medications via MMA protocols are likely to have lower opioid consumption compared to those managed using primarily IV opioid patient-controlled analgesia. MMA pain management strategies have become important components of enhanced recovery after surgery (ERAS) protocols in an effort to optimize care by standardizing analgesic medications in the perioperative setting while minimizing adverse effects and improving quality and patient outcomes. Successful implementation of a MMA requires the input and cooperation of all of the stakeholders including the caregivers as well as the patients. Health system benefits can also be realized from the implementation of an effective MMA, as fewer opioid related side effects can improve patient recovery and lead to faster discharge and improved utilization of resources.

Multimodal Analgesia for Perioperative Management of Patients presenting for Spinal Surgery

Multimodal, non-opioid based analgesia has become the cornerstone of ERAS protocols for effective analgesia after spinal surgery. Opioid side effects, dependence and legislation restricting long term opioid use has led to a resurgence in interest in opioid sparing techniques. The increasing array of multimodal opioid sparing analgesics available for spinal surgery targeting novel receptors, transmitters, and altering epigenetics can help provide an optimal perioperative experience with less opioid side effects and long-term dependence. Epigenetic mechanisms of pain may enhance or suppress gene expression, without altering the genome itself. Such mechanisms are complex, dynamic and responsive to environment. Alterations that occur can affect the pathophysiology of pain management at a DNA level, modifying perceived pain relief. In this review, we provide a brief overview of epigenetics of pain, systemic local anesthetics and neuraxial techniques that continue to remain useful for spinal surgery, neuropathic agents, as well as other common and less common target receptors for a truly multimodal approach to perioperative pain management.

Increased postoperative dexamethasone and gabapentin reduces opioid consumption after total knee arthroplasty

PURPOSE

Dexamethasone and gabapentin are used in multimodal pain management protocols to reduce postoperative pain after total knee arthroplasty. For both analgesic adjuvants, the optimal dose regimen to reduce opioid usage is still unclear.

METHODS

The opioid consumption of patients undergoing primary TKA before and after a change of the analgesic adjuvant medication in our protocol (old protocol: 4 mg of dexamethasone daily for 2 days, 600 mg gabapentin daily for 1 week; new protocol: 10 mg dexamethasone daily for 2 days, 300 mg gabapentin every 8 h for 1 week) were retrospectively compared. All surgeries were performed under spinal anesthesia. Peri- and postoperative pain medication remained unchanged.

RESULTS

A total of 186 patients who received TKA between 11/29/2016 and 06/09/2017 were screened. Six patients who received general anesthesia, 4 patients who underwent simultaneous bilateral TKA, and 16 patients with ongoing opioid consumption at the time of surgery were excluded, leaving 80 patients in each group. Opioid consumption within 24 h [morphine equivalents in mg: mean 50.5, standard deviation (SD) 30.0 (old) vs. 39.8, SD 24.2 (new); P = 0.0470], cumulative consumption over 48 h (97.3, SD 64.4 vs. 70.4, SD 51.2; P = 0.0040) and cumulative consumption over 72 h (108.1, SD 79.5 vs. 82.5, SD 72.6; P = 0.0080), were all significantly lower in the new protocol.

CONCLUSION

Increased postoperative administration of dexamethasone and gabapentin after TKA is associated with lower opioid consumption. Within the first 48 h, up to about 25% of opioids can be spared, comparing high-dose to low-dose protocols.

LEVEL OF EVIDENCE

Therapeutic Level III.

Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS.

SUMMARY OF BACKGROUND DATA

Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings.

METHODS

Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications.

RESULTS

Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure.

CONCLUSIONS

Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively.

LEVEL OF EVIDENCE

This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

The influence of pre- and perioperative administration of gabapentin on pain 3-4 years after total knee arthroplasty

BACKGROUND AND AIMS

Approximately 20% of patients having total knee arthroplasty (TKA) will experience chronic postoperative pain. Recently, preoperative pain facilitation has been associated with chronic pain after TKA, and gabapentin has been shown to decrease pain facilitation. The current study is a secondary follow-up of a primary RCT investigating the effect of gabapentin on acute postoperative pain after TKA and exploring the effect of pre- and perioperative administration of gabapentin on chronic postoperative pain and psychological state 3-4 years after TKA.

METHODS

Patients scheduled for TKA were randomized to either gabapentin 1,300 mg/day, gabapentin 900 mg/day, or placebo daily from 2-h before and 6 days after operation. Pre- and 3-4 years postoperatively pain scores related to pain while walking, at rest, when flexing the hip or the knee were collected. At the same time, the pain catastrophizing scale (PCS) and hospital anxiety and depression scale subscales for anxiety (HADS-A) and depression (HADS-D) were collected.

RESULTS

Lower postoperative pain while walking, flexing the hip, and at rest were found compared with preoperative scores (p<0.03), but these were not associated with gabapentin treatment (p>0.19). Significantly lower postoperative PCS and HADS-A scores were seen compared with preoperative scores (p<0.001), but these were not associated with gabapentin treatment (p>0.55).

CONCLUSIONS

The current study found that pre- and perioperative administrations of gabapentin do not influence the pain or psychological state 3-4 years after TKA.

IMPLICATIONS

The current study does not support that short-term pre- and perioperative use of gabapentin can reduce the development of chronic postoperative pain after TKA.

Effects of a single dose of preoperative pregabalin and gabapentin for acute postoperative pain: a network meta-analysis of randomized controlled trials

Background

Pregabalin (PGB) and gabapentin (GBP) are current and emerging drugs in the field of pre-emptive preoperative analgesia. However, the role of PGB or GBP in acute postoperative pain management still remains elusive.

Materials and methods

We conducted a comprehensive literature search of articles published by December 3, 2017. A total of 79 randomized controlled trials with 6,201 patients receiving single-dose premedication were included. Through a network meta-analysis (NMA), we validated the analgesic effect and incidence of adverse events by using various doses of PGB or GBP administration.

Results

NMA results suggested that the analgesic effect may be dose related. For 24-hour opioid consumption, a consistent decrease was found with the increase in the dose of PGB or GBP. For 24-hour pain score at rest, a high dose (≥150 mg) of PGB was more effective in decreasing pain score than a dose of 75 mg, and a high dose (≥900 mg) of GBP reduced pain intensity than doses of 300 or 600 mg. Moreover, the incidence of adverse reactions varied with varying doses of PGB or GBP.

Conclusion

A dose-response relationship was detected in opioid consumption and postoperative pain for a single-dose preoperative administration of PGB and GBP. Making reasonable choice of drugs and dosage may prevent the occurrence of adverse reactions.

Utility of gabapentin in meeting physical therapy goals following posterior spinal fusion in adolescent patients with idiopathic scoliosis

OF BACKGROUND DATA

Posterior spinal fusion surgery for scoliosis requires extensive postoperative analgesic care. In 2014, we initiated the use of gabapentin as an adjunct for multimodal pain management in spine fusion patients. The effect of gabapentin on postoperative recovery in scoliosis patients was evaluated using the time to meet postoperative physical therapy goals. This measure was chosen because the actions required to achieve the goals are specific and reproducible. Secondary outcomes included morphine equivalents and maximum pain scores.

AIMS

The purpose of this study was to evaluate the effects of gabapentin on time to achieve physical therapy goals following posterior spinal fusion in adolescents with scoliosis.

METHODS

A retrospective chart review was performed and patients treated perioperatively with gabapentin were compared with those who did not receive gabapentin. Outcome measures included the postoperative day that physical therapy goals were met, days to discharge, morphine equivalents, and maximum pain scores. The 4 physical therapy goals included logroll, transition from lying to sitting, ambulate 250 feet, and ascend/descend at least 3 stairs.

RESULTS

There were 50 patients in the gabapentin group and 51 patients in the control group. In the gabapentin group, there was a statistically significant decrease in the time required to meet physical therapy goals. Notably, gabapentin was independently associated with a 5.34 times higher odds of completion of the most challenging physical therapy goal (stairs) within 1 day (P = .04; 95% CI=1.24-37.44). There was not a statistically significant difference in length of hospital stay between the groups (P = .116; 95% CI=0-1).

CONCLUSION

In this retrospective analysis, the use of perioperative gabapentin is associated with a statistically significant decrease in time to completing physical therapy goals after spinal fusion for adolescent idiopathic scoliosis.

Role of Preemptive Gabapentin on Postoperative Analgesia After Infraumbilical Surgeries Under Subarachnoid Block-A Randomized, Placebo-Controlled, Double-Blind Study

BACKGROUND

Preemptive use of gabapentin might accelerate recovery by reducing acute post-inguinal herniorrhaphy pain and opioid requirement being an analgesic.

STUDY QUESTION

Assessing efficacy of three different doses of oral gabapentin premedication for postoperative pain management after inguinal herniorrhaphy under spinal anesthesia.

STUDY DESIGN

This prospective, randomized, placebo controlled study was performed on 120 male patients (ASA I/II) undergoing inguinal herniorrhaphy under subarachnoid block. Patients were divided into 4 groups of 30 patients each to receive placebo (group A) or gabapentin 400 mg (B) or 800 mg (C) or 1200 mg (D), administered orally 2 hours before surgery. Assessment of postoperative pain was made on the basis of the visual analog score (VAS), where 0 cm "no pain" and 10 cm "worst pain imaginable." Patients received IV fentanyl 0.5 μg/kg bolus when VAS >3.

MEASURES AND OUTCOMES

VAS score at regular intervals, the first analgesic requirement and total opioid consumption within 24 hours after surgery along with side/adverse effect (s) of study drug in perioperative period.

RESULTS

The VAS of the study groups B, C, D were significantly lower than placebo group (A) at 0, 1, 2, 4, 8, 12, 16, 20, and 24-hour intervals after surgery (P < 0.05). The first analgesic need and total opioid consumption within 24 hours after surgery of study groups were significantly lower than placebo group (P < 0.005) while within study groups difference was not significant. Dizziness and somnolence were seen maximally in group D patients (P = 0.01). However, pruritus, nausea and vomiting though maximally reported among group (A) patients but statistically non-significant.

CONCLUSION

Preemptive gabapentin is opioid sparing to control postoperative pain with anxiolysis and sedation. We found the optimal dose to be 400 mg for gabapentin. However, increasing dose from 400 to 1200 mg does not increase its efficacy as analgesic but with higher adverse effects.

Dose-related beneficial and harmful effects of gabapentin in postoperative pain management - post hoc analyses from a systematic review with meta-analyses and trial sequential analyses

Background

During the last 15 years, gabapentin has become an established component of postoperative pain treatment. Gabapentin has been employed in a wide range of doses, but little is known about the optimal dose, providing the best balance between benefit and harm. This systematic review with meta-analyses aimed to explore the beneficial and harmful effects of various doses of gabapentin administered to surgical patients.

Materials and methods

Data in this paper were derived from an original review, and the subgroup analyses were predefined in an International Prospective Register of Systematic Reviews published protocol: PROSPERO (ID: CRD42013006538). The methods followed Cochrane guidelines. The Cochrane Library’s CENTRAL, PubMed, EMBASE, Science Citation Index Expanded, Google Scholar, and FDA database were searched for relevant trials. Randomized clinical trials comparing gabapentin versus placebo were included. Four different dose intervals were investigated: 0–350, 351–700, 701–1050, and >1050 mg. Primary co-outcomes were 24-hour morphine consumption and serious adverse events (SAEs), with emphasis put on trials with low risk of bias.

Results

One hundred and twenty-two randomized clinical trials, with 8466 patients, were included. Sixteen were overall low risk of bias. No consistent increase in morphine-sparing effect was observed with increasing doses of gabapentin from the trials with low risk of bias. Analyzing all trials, the smallest and the highest dose subgroups demonstrated numerically the most prominent reduction in morphine consumption. Twenty-seven trials reported 72 SAEs, of which 83% were reported in the >1050 mg subgroup. No systematic increase in SAEs was observed with increasing doses of gabapentin.

Conclusion

Data were sparse, and the small number of trials with low risk of bias is a major limitation for firm conclusions. Taking these limitations into account, we were not able to demonstrate a clear relationship between the dosage of gabapentin and opioid-sparing or harmful effects. These subgroup analyses are exploratory and hypothesis-generating for future trialists.

Perioperative Gabapentin Does Not Reduce Postoperative Delirium in Older Surgical Patients: A Randomized Clinical Trial

BACKGROUND

Postoperative pain and opioid use are associated with postoperative delirium. We designed a single-center, randomized, placebo-controlled, parallel-arm, double-blinded trial to determine whether perioperative administration of gabapentin reduced postoperative delirium after noncardiac surgery.

METHODS

Patients were randomly assigned to receive placebo (N = 347) or gabapentin 900 mg (N = 350) administered preoperatively and for the first 3 postoperative days. The primary outcome was postoperative delirium as measured by the Confusion Assessment Method. Secondary outcomes were postoperative pain, opioid use, and length of hospital stay.

RESULTS

Data for 697 patients were included, with a mean ± SD age of 72 ± 6 yr. The overall incidence of postoperative delirium in any of the first 3 days was 22.4% (24.0% in the gabapentin and 20.8% in the placebo groups; the difference was 3.20%; 95% CI, 3.22% to 9.72%; P = 0.30). The incidence of delirium did not differ between the two groups when stratified by surgery type, anesthesia type, or preoperative risk status. Gabapentin was shown to be opioid sparing, with lower doses for the intervention group versus the control group. For example, the morphine equivalents for the gabapentin-treated group, median 6.7 mg (25th, 75th quartiles: 1.3, 20.0 mg), versus control group, median 6.7 mg (25th, 75th quartiles: 2.7, 24.8 mg), differed on the first postoperative day (P = 0.04).

CONCLUSIONS

Although postoperative opioid use was reduced, perioperative administration of gabapentin did not result in a reduction of postoperative delirium or hospital length of stay.

A meta-analysis of the preoperative use of gabapentinoids for the treatment of acute postoperative pain following spinal surgery

BACKGROUND

Gabapentinoid drugs, which include gabapentin and pregabalin, play an established role in the management of neuropathic pain. However, whether preoperative administration of gabapentinoids has a beneficial role in controlling acute pain after spinal surgery is unknown. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy and safety of the preoperative use of gabapentinoids (gabapentin and pregabalin) for the treatment of acute postoperative pain following spinal surgery.

METHODS

In March 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Library, and Google databases. RCTs comparing gabapentinoids (gabapentin and pregabalin) with placebo in patients undergoing spine surgery were retrieved. The primary endpoint was the visual analogue scale (VAS) score with rest or mobilization at 6, 12, 24, and 48 hours and cumulative morphine consumption at 24 and 48 hours. The secondary outcomes were complications of nausea, vomiting, sedation, dizziness, headache, urine retention, pruritus, and visual disturbances. After tests for publication bias and heterogeneity among studies were performed, data were aggregated for random-effects models when necessary.

RESULTS

Sixteen clinical studies (gabapentin group n = 8 and pregabalin group n = 8) were ultimately included in the meta-analysis. Gabapentinoids were associated with reduced pain scores at 6, 12, 24, and 48 hours. Similarly, gabapentinoids were associated with a reduction in cumulative morphine consumption at 24 and 48 hours. Furthermore, gabapentinoids can significantly reduce the occurrence of nausea, vomiting, and pruritus. There were no significant differences in the occurrence of sedation, dizziness, headache, visual disturbances, somnolence, or urine retention.

CONCLUSIONS

Preoperative use of gabapentinoids was able to reduce postoperative pain, total morphine consumption, and morphine-related complications following spine surgery. Further studies should determine the optimal dose and whether pregabalin is superior to gabapentin in controlling acute pain after spine surgery.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Gabapentin in procedure-specific postoperative pain management - preplanned subgroup analyses from a systematic review with meta-analyses and trial sequential analyses

Background

It has been argued that postoperative pain treatment should be “procedure-specific”, since different analgesics may have specific effects dependent on the surgical procedure. The aim of the present subgroup analysis was to compare the beneficial and harmful effects of perioperative gabapentin treatment in different surgical procedures.

Methods

Relevant databases were searched for randomized clinical trials (RCTs) comparing gabapentin versus placebo. Two authors independently screened titles and abstracts, extracted data and assessed risk of bias. The primary outcomes were differences in 24-h morphine consumption, and serious adverse events (SAE) between surgical procedures. These subgroup analyses were predefined in a PRISMA compliant systematic review registered at PROSPERO (ID: CRD42013006538). It was predefined that conclusions should primarily be based on trials classified as overall low risk of bias.

Results

Seventy-four RCTs with 5645 patients were included, assessing benefit and harm in cholecystectomy, hysterectomy, mastectomy, and arthroplasty surgery, spinal surgery, and thoracic surgery.

Only eight of 74 trials were classified as overall low risk of bias limiting our ability to conclude on the estimates in most meta-analyses. The differences between surgical procedures in these trials were not statistically significant when tested for subgroup differences. Fifteen trials with 1377 patients reported a total of 59 SAEs, most of which were observed in the thoracic surgery group.

Conclusion

Both beneficial and harmful effects in these subgroup analyses were influenced by bias and insufficient data, limiting conclusions. With these limitations, we could not adequately test for differences in beneficial or harmful outcomes between six surgical subgroups undergoing perioperative gabapentin treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0373-8) contains supplementary material, which is available to authorized users.

Pregabalin can decrease acute pain and morphine consumption in laparoscopic cholecystectomy patients: A meta-analysis of randomized controlled trials

BACKGROUND

Pregabalin has been used as an adjunct for the management of acute pain in laparoscopic cholecystectomy. This meta-analysis aimed to illustrate the efficacy and safety of pregabalin for pain management following laparoscopic cholecystectomy.

METHODS

In March 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google databases. Data on patients prepared for laparoscopic cholecystectomy in studies that compared pregabalin versus placebo were retrieved. The primary endpoints were the visual analog scale (VAS) score with rest or mobilization at 6, 12, and 24 hours and total morphine consumption. The secondary outcomes were the morphine-related complications (i.e., nausea, vomiting, dizziness, somnolence, headache, pruritus, urine retention, respiratory depression, and blurred vision). Continuous outcomes were expressed as the weighted mean difference (WMD) with a corresponding 95% confidence interval (CI), and discontinuous outcomes were expressed as a risk ratio (RR) with a corresponding 95% CI.

RESULTS

Twelve clinical studies with 938 patients (gabapentin group = 536, control group = 402) were ultimately included in the meta-analysis. Pregabalin was associated with reduced pain scores with rest at 6, 12, and 24 hours, which corresponded to a reduction of 11.27 points at 6 hours, 9.46 points at 12 hours, and 3.99 points at 24 hours on a 100-point VAS. Moreover, pregabalin was associated with reduced pain scores with mobilization at 6, 12, and 24 hours, which corresponded to a reduction of 8.74 points, 5.80 points and 6.37 points at 6, 12, and 24 hours, respectively, on a 110-point VAS. Furthermore, pregabalin reduced the occurrence of nausea and vomiting. There were no significant differences in the occurrence of respiratory depression, pruritus, dizziness, blurred vision, and headache.

CONCLUSIONS

Pregabalin was efficacious in the reduction of postoperative pain, total morphine consumption, and morphine-related complications following laparoscopic cholecystectomy. In addition, a high dose of pregabalin was more effective than a low dose. The dose of pregabalin differed across the studies, and the heterogeneity was large. More studies are needed to verify the optimal dose of pregabalin in laparoscopic cholecystectomy patients.

Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: A meta-analysis of randomized controlled trials

BACKGROUND

Approximately 80% of patients who underwent spinal surgeries experience moderate to extreme postoperative pain. Gabapentin was used as an adjunct for the management of acute pain in approximately half of enhanced recovery programs. This meta-analysis aimed to illustrate the efficacy and safety of gabapentin for pain management following spinal surgery.

METHODS

In January 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on patients prepared for spine surgery in studies that compared gabapentin versus placebo were retrieved. The primary endpoint was the visual analog scale (VAS) at 12 hours and 24 hours and total morphine consumption. The secondary outcomes were complications that included nausea, dizziness, somnolence, headache, pruritus, urine retention, and vomiting. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

RESULTS

Seven clinical studies with 581 patients (gabapentin group=383, control group=198) were ultimately included in the meta-analysis. Gabapentin was associated with reduced pain scores at 12 hours and 24 hours, corresponding to a reduction of 11.18 points (95% CI, -13.85 to -8.52 points) at 12 hours and 9.94 points (95% CI, -13.99 to -5.89 points) at 24 hours on a 100-point VAS. Similarly, gabapentin was associated with a reduction in total morphine consumption (-2.04, 95% CI -2.71, -1.37). Furthermore, gabapentin can reduce the occurrence of vomiting (risk ratio [RR] 0.46, 95% CI 0.27, 0.78, P = 0.004), urine retention (RR = 0.57, 95% CI 0.34, 0.98, P = 0.041, NNT = 11.9) and pruritus (RR = 0.38, 95% CI 0.22, 0.66, P = 0.001, NNT = 5.6) and the number needed to treat (NNT = 20.1). There were no significant differences in the occurrence of nausea, dizziness, somnolence, or headache.

CONCLUSIONS

Gabapentin was efficacious in the reduction of postoperative pain, total morphine consumption, and morphine-related complications following spine surgery. In addition, a high dose (≥900 mg/d) of gabapentin is more effective than a low dose (<900 mg/d). The number of included studies is limited, and more studies are needed to verify the effects of gabapentin in spinal surgery patients.

Preventive Gabapentin versus Pregabalin to Decrease Postoperative Pain after Lumbar Microdiscectomy: A Randomized Controlled Trial

Study Design

Randomized controlled trial.

Purpose

The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital.

Overview of Literature

Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery.

Methods

This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively.

Results

Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R²=0.018).

Conclusions

Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed.

Combination of gabapentin and celecoxib for analgesia after major orthopedic surgery: a randomized, controlled trial

Background: The use of analgesics with different mechanism of action enhances post-operative pain relief by opioids. Both celecoxib and gabapentin have opioid-sparing effect, but it is unclear whether combination of the two drugs accentuates postoperative analgesia and further reduced opioid requirement.

Objective: Determine whether the perioperative use of celecoxib in combination with gabapentin reduces the amount of post-operative opioid consumption in comparison to celecoxib alone or gabapentin alone in patients that have major orthopedic surgery.

Materials and methods: Randomized double-blinded placebo controlled trial was done in 99 patients underwent major orthopedic surgery. They were randomly allocated into four groups. One to two hours before anesthesia, they received midazolam 7.5 mg plus study drugs. Group P received placebo plus placebo at 12 and 24 hours later. Group C received celecoxib 400 mg plus celecoxib 200 mg at 12 and 24 hour later. Group G received gabapentin 400 mg plus gabapentin 300 mg at 12 and 24 hour later. Finally, group CG received celecoxib 400 mg + gabapentin 400 mg plus celecoxib 200 mg + gabapentin 300 mg at 12 and 24 hour later. The patients underwent surgery under general anesthesia. Post-operative pain was treated by intravenous morphine patient-controlled analgesia.

Results: Median morphine consumption (minimum-maximum) in twenty-four hours was 18.0, 15.0, 15.5, and 8.0 mg, in group P, C, G, and CG, respectively. The group CG significantly consumed less morphine (41%) in 24 hour than group G, but not significantly less (38%) than group C. Pain score, sedation score, and nausea/vomiting at postoperative hour 1, 4, 8, 12, 16, 20, and 24 was not significantly different.

Conclusion: Combination of celecoxib and gabapentin further accentuated post-operative analgesia by morphine comparing to celecoxib or gabapentin alone without change in pain score and other side effects of the medications.

A Prospective, Observational Study to Evaluate the Role of Gabapentin as Preventive Analgesic in Thyroidectomy under General Anesthesia

Background:

Effective management of postoperative pain is a part of well-organized perioperative care, which helps in reduced morbidity and improved patient satisfaction. Preventive analgesia can reduce acute and chronic pain by blocking the noxious inputs to pain pathways, preventing sensitization. Studies have reported efficacy of gabapentin as a preventive analgesic in perioperative pain. In this study, we aimed to determine whether preoperative gabapentin reduced postoperative pain and tramadol consumption after thyroidectomy under general anesthesia.

Materials and Methods:

Sixty patients scheduled for thyroidectomy were allocated to two groups of thirty each for this prospective, observational study. Patients in Group A and Group B received oral gabapentin 600 mg (6 × 10⁻⁴ kg) and diazepam 10 mg (1 × 10⁻⁵ kg), respectively, 2 h prior to surgery. Tramadol was given as rescue analgesic for postoperative pain with a verbal rating score of two. The analgesic efficacy of preoperative gabapentin was assessed in terms of postoperative pain scores at rest or swallowing, time to first rescue analgesic, and total tramadol consumption for 24 h. Ramsay sedation score and side effects of drug were also looked into.

Results:

Postoperative pain scores and total tramadol consumption were significantly lower in Group A during 24 h (P = 0.00). Time to first rescue analgesic was significantly prolonged in Group A (P = 0.001). Side effects were comparable.

Conclusion:

Oral gabapentin is effective as a preventive analgesic in reducing postoperative pain and tramadol consumption after thyroidectomy under general anesthesia.

Gabapentinoids as a Part of Multi-modal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study

Background:

Gabapentinoids have been used as preemptive analgesics for pain management following laparoscopic cholecystectomy. Recently, multimodal analgesic techniques have been found superior to preemptive analgesia alone.

Aim:

The aim of this study is to evaluate and compare a single preoperative dose of pregabalin 150 mg and gabapentin 300 mg for pain relief following laparoscopic cholecystectomy as a part of multimodal drug regime.

Settings and Design:

This randomized, single-blind study was conducted after Ethical Committee approval and written informed consent from the patients.

Materials and Methods:

Fifty patients undergoing laparoscopic cholecystectomy under general anesthesia were randomly allocated to receive either 150 mg pregabalin (Group PG), or 300 mg gabapentin (Group GB) orally, 2 h before surgery. Standard anesthesia induction and maintenance were done. For intraoperative pain management, injection fentanyl 2 μg.kg^-1 intravenous (IV) along with injection voveran 75 mg IV and port site infiltration was used. Postoperatively, injection diclofenac 75 mg intramuscular TDS was continued. Severity of postoperative pain (visual analog scale [VAS]), postoperative fentanyl requirement and incidence, and severity of side effects were assessed. When VAS >40 mm or on patient's request, a Fentanyl bolus at an increment of 25–50 μg IV was given as rescue analgesia.

Results:

Intraoperative fentanyl requirement was 135 ± 14 μg in Group PG and 140 ± 14 μg in Group GB (P = 0.21). Postoperative, fentanyl requirement was 123 ± 18 μg in Group PG and 131 ± 23 μg in Group GB (P = 0.17) There was no statistically significant difference in the VAS score for static and dynamic pain. Time to the first requirement of analgesic was 5.4 ± 1.1 h in Group PG and 4.6 ± 1.6 h in Group GB (P = 0.015). No side effects were observed.

Conclusion:

We conclude that a single preoperative dose of pregabalin (150 mg) or gabapentin (300 mg) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects.

India contribution to Spine Surgery: 15 most influential articles

OBJECTIVE

To determine the number of articles published by Indian authors related to spine surgery and to enumerate the 15 most influential articles from India published in the field of spine surgery in national & international journals based on the citations they have received both in pubmed and google scholar.

MATERIAL AND METHODS

A retrospective study using Pubmed database was performed for the years between 1960 and 2015, for the articles published from India in the field of spine surgery in various national and international journals. A total of 3181 citations were received for top 15 most influential articles in the field of spine surgery from India.

RESULTS

A total of 885 papers from India were identified which were published by Indian authors related to spine surgery between year 1960 to 2015. The largest numbers of papers were published in International journals such as Spine (82) and in European Spine Journal (47).

CONCLUSION

There are an increasing number of papers from India in the field of spine surgery literature. Most of the highly cited papers were related to tuberculosis. We expect further contributions from our country to the medical literature in the future.