Postoperative Care Abstract The control of postoperative pain in the initial 48 hours is especially critical in patients having undergone more extensive surgery requiring instrumentation. Otherwise, the patient may experience a psychological stress that can result in a very deleterious effect on eventual outcome. The multi-modal approach to pain control will decrease narcotic usage. Pre-emptive medication(e.g. gabapentin) within this regimen should be considered. Non-steroidal anti-inflammatory drugs (NSAIDs) are very effective postoperatively as well. But they can effect bone healing and selective Cox 2 inhibitors (e.g. diclofenac, meloxicam] should be avoided. Non-selective Cox inhibitors (e.g. ketorolac, ibuprofen, naproxen] may be used in first 48 hours postoperatively. Acetaminophen (paracetamol) has weak Cox inhibition and has become the drug of choice. An open surgical wound presents as an opportunity for placement of catheter for postoperative epidural analgesia (PEA). This technique can result in dramatic results, but its general advantage over patient-controlled IV analgesia (PCIA) has not been conclusively shown; technical issues are likely factors in this measured equivalency. One main drawback with PEA is the potential for root desensitization when an anesthetic is used, with a confounding postoperative motor weakness. Postoperative infection control is afforded by a meticulous closure technique. As many, if not most, infections begin superficially (subcutaneously) then attention to well-apposed skin edges is mandatory. Drains should be used liberally and should always exit at the cranial end of the incision, away from anal contamination. The duration of postoperative antibiotics should be individualized. The rate of post-operative infection has been consistently shown to be related to the duration of surgery; hence, the duration of postoperative antibiotics dosage should reflect this time-related contamination potential. Keywords: multi-modal pain control, Cox inhibition, postoperative epidural analgesia (PEA), antibiotic powder, lymphocyte count, C-reactive protein In most cases of decompressive degenerative spine surgery, routine intravenous (IV) and oral regimens are adequate for postoperative pain control. More extensive surgeries, especially those requiring instrumentation, require a concerted effort to avoid significant postoperative pain, especially in the first 48 hours. It is critical in this period that the patient avoids a pain traumatization that can later cause psychological consequences with considerable effect on patient outcome. But it also must be emphasized that analgesia is a significant cause of perioperative mortality, especially in young and middle-aged patients. 1 Preemptive Non-narcotics: The reduction of narcotic usage postoperatively can be considered a measure of better pain control and improved quality of life. Non-narcotic regimens with preemptive dosage have been shown to be effective in this regard. These medications include the following: Gabapentin/pregabalin (oral). 6, 7 Nonsteroidal anti-inflammatory drugs (NSAIDs). 8, 9 Nonselective cyclooxygenase (Cox) inhibitors: ibuprofen, ketorolac, indomethacin, piroxicam, naproxen. Selective Cox-2 inhibitors: “Coxibs,” endolac, meloxicam, diclofenac. Weak Cox inhibition: acetaminophen (paracetamol). NSAIDs and Analgesia: Studies have shown that NSAIDs are at least as effective as opiates for pain control after bony fracture or postoperatively after fixation. These drugs, furthermore, avoid the negative side effects of opiates: respiratory depression, sedation, cognitive slowing. The use of IV acetaminophen and ibuprofen peri- and postoperatively has been shown to be effective and relatively safe in nonspinal cases. 10 The reluctance in their use in the setting of bone fracture is related to evidence that they have a negative effect on bone healing. 11 These medications affect the antipyretic, analgesic, and anti-inflammatory properties by inhibition of enzymatic (Cox) production of prostaglandins. 13 After a fracture, there is evidence that the Cox-2 enzymatic prostaglandin release plays a critical role in the induction of osteoblasts in the early stage of bone healing. The effect of prostaglandins on bone cells is unclear, but it may be related to the expression of the bone morphogenic protein (BMP). Selective Cox-1 inhibition does not seem to have a similar effect. Clinical studies on the effect of NSAIDs on bone healing and spinal fusion are conflicting. Some studies suggest no effect on postfusion union rates, 14, 15 while others show a dose-dependent inhibitory effect. 16, 17, 18 These studies analyze various NSAIDs, dose regimens, duration of usage, and subject age variances; thus, no definitive general conclusions can be drawn from these uncontrolled studies. However, with the established biochemistry, and with and the results of in vitro and animal model studies, caution is warranted in the use of Cox inhibitory NSAIDs after spinal fusion. Acetaminophen: As acetaminophen is a weak Cox inhibitor, it has minimal effect on prostaglandin synthesis. There are no studies demonstrating a significantly negative effect on bone healing and/or fusion. In one animal study, the acute treatment of acetaminophen had no effect on fracture healing, contrasting with a significantly higher nonunion rate in celecoxib-treated animals. 19 Acetaminophen is thus the logical choice for NSAID use in perioperative setting. 20 The availability of an IV form removes problematic issues of oral intake in this period. Perioperative nonnarcotic medications reduce opiate use for postoperative pain control, thus diminishing the negative side effects of narcotics, and with greater patient satisfaction. Gabapentin (1,200 mg/d) or pregabalin (300 mg/d) has opiate sparing effect if administered from 12 hours preoperatively to 12 to 24 hours postoperatively. NSAIDs similarly can be effectively added to a multimodal regimen. Because Cox inhibition (with subsequent diminished prostaglandin production) has been shown to be associated with decreased bone healing and fusion, selective Cox-2 inhibitory NSAIDs should be avoided for perioperative pain control in cases involving bony arthrodesis. In the acute postoperative period (24–48 hours), nonselective Cox inhibitors may be an effective alternative to acetaminophen. Acetaminophen is the NSAID of choice for adjutant acute pain control when bony fusion is desired (1 g IV intraoperatively and 1 g IV every 6–8 hours for 24–48 hours postoperatively). The use of epidural analgesia after nonspinal abdominal and thoracic surgeries has been proven to be of significant benefit. 21, 22 Similar benefits after spinal surgery would seem a logical extrapolation, especially as the open surgical field allows for direct placement of the epidural catheter. The value of postoperative epidural analgesia (PEA) may be proportional to the anticipated stress response of the surgery. 23 Single bolus epidural fentanyl has been shown to be effective. 24, 25 The use of PEA via indwelling catheter remains controversial. Controlled studies report conflicting conclusions as to the efficacy of pain control in patients with patient-controlled epidural analgesia (PCEA) versus patient-controlled IV analgesia (PCIA). 26, 27, 28 Furthermore, the potential for epidural medication to confound the postoperative neurological exam (with the possibility of masking neurologic compromise from an epidural hematoma) has prevented a wider acceptance of this technique. 29 The published efficacy of PEA is difficult to interpret due to the variability in the regimens/dosages, techniques, and outcome measurement. Intraoperative bolus optional. Infusion control: continuous infusion, patient controlled, both. Duration of infusion: 1 to 4 days. Onset of infusion: immediately in postanesthesia care unit (PACU) or after patient awakes following a neurologic examination. Infusion regimen: narcotic, anesthetic, both; variable rates of infusion. Narcotic infusion: fentanyl, sufentanil, morphine. Anesthetic infusion: bupivacaine, ropivacaine Placement of catheter: at site of surgery, varying distance cephalad of site. Catheter: diameter, rigidity, aperture configuration. With or without radiographic confirmation of catheter position. Patient assessment: VAS (visual analog scale), subjective. Functional capabilities: turning in bed, time to ambulation, length of hospital stay. Supplementary narcotic usage.
9.1 Systemic Pain Control
9.1.1 Introduction
9.1.2 Multimodal Approach 2, 3, 4, 5
9.1.3 Effect of NSAIDs on Bone Healing/Fusion 8, 9, 12
9.1.4 Conclusion
9.2 Postoperative Epidural Analgesia
9.2.1 Regimens/Dosages
9.2.2 Techniques
9.2.3 Outcomes Assessment
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