P-005 - Multimodal Analgesia Following Major Spinal Reconstructive Surgery Improves Postoperative Pain and Function

Abstract Title:

Multimodal Analgesia Following Major Spinal Reconstructive Surgery


Improves Postoperative Pain and Function





Mark Wieland, MD1, Rakeb Lemma2, Brenda Iriele, MD3, Kyle Zielinski, BS4,
Kavya Sanghavi, MPH, BDS5, Kasra Razmjou, MD3, Zan Naseer, MD1





1Department of Orthopaedic Surgery, Medstar Union Memorial Hospital, Baltimore, MD, USA


2Bryn Mawr School, Baltimore, MD, USA


3Department of Anesthesiology, Georgetown University School of Medicine, Washington DC, USA


4Georgetown University School of Medicine, Washington DC, USA


5Medstar Health Research Institute, Hyattsville, Maryland, USA


3Department of Anesthesiology, Georgetown University School of Medicine, Washington DC, USA



Background: Pain during the postoperative period has been a significant challenge for both patients and health care providers alike. Major spine surgery, in particular, is associated with an increased level of pain traditionally requiring opioid medications, which have been associated with long term adverse consequences1-2. As a result, there has been an increased effort to reduce postoperative opioid usage through various methods, one of which is the implementation of multimodal analgesia (MMA)3. Postoperative pain is thought to involve several pathways including neuropathic, inflammatory, and nociceptive pain responses. First described by Kehler in 1993, MMA is the simultaneous use of multiple medications that work in a synergistic manner providing pain control while mitigating the adverse effects of each individual drug due to lower dosage requirements4. MMA typically involves a combination of agents including local anesthetic, acetaminophen, NSAIDs, gabapeninoids, muscle relaxants, alpha-2 antagonists, ketamine, and opioids and has shown success following spine surgery in reducing opioid usage postoperatively and improving time to mobilization.5-8. However, to the best of our knowledge, there have not been any investigations specifically looking at the effectiveness of MMA in regards to objective postoperative functional measurements and patient disposition following their hospitalization.

Purpose/Objectives: The purpose of this study was to investigate whether patients receiving multimodal analgesia demonstrated improved post-operative pain control and function following major spinal reconstructive surgery, which for the purposes of this study was defined as open lumbar fusions +/- decompression between 2 - 5 levels. Specifically, we sought to investigate the impact of MMA, as compared to single agent, patient controlled analgesia (PCA), for each of the following patient outcomes: (1) daily patient-reported pain scores, (2) daily patient function as quantified by ambulation distance with physical therapy, (3) hospital length of stay, and (4) patient disposition to home versus inpatient rehabilitation. We hypothesized that MMA would result in improved postoperative pain scores, increased ambulation distance with physical therapy, shorter hospitalizations, and a greater percentage of discharges to home.

Methods:
MMA was first instituted at our medical center in 2022. We collected data on a consecutive series of patients for a one-year period prior to MMA implementation (PCA group) and another consecutive series of patients for one year following implementation. All patients who underwent 2 – 5 level open, posterior lumbar fusion surgery were included. Minimally-invasive, anterior and lateral procedures were excluded from the study. Furthermore, patients who could not participate in physical therapy postoperatively, such as those sent to the ICU or those requiring post-operative bed rest, were also excluded.





Following approval by our institutional review board, we collected demographic data, body mass index (BMI), American Society of Anesthesiologists Physical Status classification score (ASA score), number of levels fused, revision surgery, placement of transverse lumbar interbody graft (TLIF), daily numeric pain scores (0-10), methadone use, ambulation distance with physical therapy, length of stay, and disposition from the hospital (home versus inpatient rehab). Medication-related complications such as change in mental status or bleeding/hematoma requiring surgical evacuation were also collected.





Chi-squared analysis was used to calculate p-values which were considered significant if p < 0.05. Logistic regression was also utilized to model patient disposition, specifically discharge to home versus inpatient rehab.



Results:
Patient characteristics





There were 192 patients in the MMA group and 235 in the PCA group (overall n=427). Patient demographics were similarly matched between the two groups. There were no significant differences between the MMA and PCA groups when comparing age (MMA=64.9 years, PCA=65.3 years; p= 0.67), sex (MMA: n=113 female and 122 male. PCA: n=101 female and 91 male; p=0.353), BMI (MMA=29.6, PCA=30.9; p=0.019), ASA score (ASA I: MMA n=2, PCA n=1; ASA II: MMA n=121, PCA n=81; ASA III: MMA n=112, PCA n=108; ASA IV: MMA n=0, PCA n=2; p=0.109), methadone use (MMA n=2, PCA n=2; p=0.839), numbers of levels fused (2-3 levels fused: MMA n=185, PCA n=159; 4-5 levels fused MMA n=50, PCA n=33; p=0.288), patients who underwent revision surgery (MMA n=172, PCA n=131; p=0.261) and those who required TLIF (MMA n=136, PCA n=97; p=0.129). All patients were discharged either to home or inpatient rehab by POD #5.





Post-operative pain scores





The MMA group reported lower numeric pain scores on postoperative days 1 through 4 (POD#1: MMA 4.7 and PCA 5.8; POD#2: MMA 4.2 and PCA 5.3; POD#3: MMA 4.0 and PCA 5.1; POD#4: MMA 4.0 and PCA 5.4; p< 0.001). There was no statistical difference with pain scores at POD#5 (MMA: 4.4, PCA 5.3; p=0.56). There were no instances of medication related mental status changes or postoperative bleeding/hematoma requiring evacuation in either group.





Post-operative functional assessment





The MMA group demonstrated longer walking distance (feet) at all stages of the postoperative period (POD#1: MMA 38.2’ and PCA 19.2’; POD#2: MMA 106.1’ and PCA 60.2’; POD#3: MMA 131.3’ and PCA 85.2’; POD#4: MMA 127.5’ and PCA 73.3’; POD#5 MMA 151.3’ and PA 64’; p< 0.001), shorter length of stay (MMA 3.2 days, PCA 3.5 days; p< 0.003) and an increased likelihood of being discharged home vs inpatient rehab (MMA 217 of 235 patients discharged home vs PCA 150 of 192 patients; p< 0.001). Logistic regression analysis demonstrated that patients in the MMA group had 2.96 times increased odds of getting discharged home (95% CI 1.61-5.44, p< 0.05).


Conclusions/Implications for future research and/or clinical care:
MMA was superior to PCA in patients undergoing multi-level spinal fusion with regards to post-operative pain and function. In addition to significantly lower pain scores POD #1-4, MMA was also associated with improved ambulation distances throughout all stages of the hospitalization, shorter length of stay and were found to be 2.96 more likely to be discharged home rather than to an inpatient rehabilitation facility.





Not only do these findings have significant patient outcome implications, but they also suggest that MMA may contribute to health care expenditure savings. With rising healthcare costs and increasing emphasis on value-based care in recent years, MMA may play an important role by reducing hospital length of stay and increasing discharges to the home environment. Future research to expand on these findings may find utility in exploring longer-term functional outcomes and healthcare expenditure impact between various postoperative pain management regimen protocols.



References:

1. 
   1. Mendoza-Elias N, Dunbar M, Ghogawala Z, Whitmore RG. Opioid Use, Risk Factors, and Outcome in Lumbar Fusion Surgery. World Neurosurg. 2020;135:e580-e587.
   
   

2. 
   2. Dietz N, Sharma M, Adams S, et al. Enhanced Recovery after Surgery (ERAS) for Spine Surgery: A Systematic Review. World Neurosurg. 2019;130:415-426.
   
   

3. 
   3. Kurd MF, Kreitz T, Schroeder G, et al. The Role of Multimodal Analgesia in Spine Surgery. J Am Acad Orthop Surg 2017;25:260-8.
   
   

4. 
   4. Kehlet H, Dahl JB. The Value of “Multimodal” or “Balanced Analgesia” in Postoperative Pain Treatment. Anesth Analog 1193;77:1048-56.
   
   

5. 
   5. Walker CT, Gullotti DM, Prendergast V, et al. Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion. Neurosurgery. 2020;87(1):130-136.
   
   

6. 
   6. Garcia RM, Cassinelli EH, Messerschmitt PJ, Furey CG, Bohlman HH. A Multimodal Approach for Postoperative Pain Management After Lumbar Decompression Surgery: A Prospective, Randomized Study. J Spinal Disord Tech. 2013:26(6):291-297.
   
   

7. 
   7. Rajpal S, Hobbs SL, Nelson EL, Villavicencio A, Zielenski C, Beasley K, Kantha V, Mesenbrink J, Burneikiene S. The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions. Clin Spine Surg. 2020 Apr;33(3):E135-E140.
   
   

8. 
   8. Mathiesen O, Dahl B, Thomsen BA, Kitter B, Sonne N, Dahl JB, Kehlet H. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013 Sep;22(9):2089-96.
   
   

AI disclosure: AI was not used in the study or in any phase of writing the abstract.


Disclosure: Nothing to be disclosed by any authors.



Funding: No outside funding was received for this study.