Epidural fentanyl for postoperative analgesia after lumbar canal decompression: a randomized controlled trial
ABSTRACT Postoperative back pain is common after decompression surgery for lumbar stenosis and often delays discharge from hospital. Achieving regional analgesia by intraoperative delivery of epidural opiates after lumbar canal decompression is a promising approach to reduce postoperative pain and enhance early mobilization. However, there have been concerns about opiate-related complications, such as respiratory depression and urinary retention in what is generally an elderly population of patients.
To assess the analgesic efficacy of bolus epidural fentanyl administered intraoperatively after lumbar decompression for degenerative canal stenosis.
Patient-blinded randomized controlled trial conducted at two university neurosurgical centers.
Adults (older than 18 years) with neurogenic claudication and/or lower limb radiculopathy and concordant lumbar spinal canal stenosis demonstrated on magnetic resonance imaging. Patients with previous lumbar spinal surgery, a contraindication to fentanyl, or requiring instrumentation were excluded.
The primary outcome measure was patient-reported Visual Analogue Score (VAS) for pain recorded preoperatively, in recovery, and on the first and second postoperative days if the patient remained in the hospital. Secondary outcomes were duration of surgery, length of stay, and any side effects or complications.
Patients underwent a one to three level lumbar canal decompression as required, via a midline incision, under general anesthesia. Before wound closure either no drug (control) or a 100-μg bolus of fentanyl was administered via an epidural catheter inserted 10 cm rostral to the operated level. Patients were blinded to group allocation, and analysis was by intention to treat. The trial was approved by the National Health Service Research Ethics Service and the Medicines and Healthcare products Regulatory Agency. No commercial or other source of funding was received.
Sixty patients were randomized, 29 to fentanyl and 31 to control. Demographics, duration of surgery, and preoperative VAS were not significantly different between the groups. VAS in recovery was significantly lower in patients treated with fentanyl (mean [standard deviation]: 2.6 [2.7] vs. 4.7 [2.4]; p=.003). Later VAS and postoperative length of stay were similar between groups. More patients in the fentanyl group required temporary urinary catheterization, but there was no significant difference in the incidence of side effects.
Bolus epidural fentanyl provides effective short-term postoperative analgesia after lumbar canal decompression and may be a useful adjunct to pain management in patients undergoing lumbar spine surgery.
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ABSTRACT: Opioids are commonly used for the management of pain in patients with musculoskeletal disorders; however, national attention has highlighted the potential adverse effects of the use of opioid analgesia in this and other nonmalignant pain settings. Chronic opioid users undergoing orthopaedic surgery represent a particularly challenging patient population in regard to their perioperative pain control and outcomes. Preoperative evaluation provides an opportunity to estimate a patient's preoperative opioid intake, discuss pain-related fears, and identify potential psychiatric comorbidities. Patients using high levels of opioids may also require referral to an addiction specialist. Various regional blockade and pharmaceutical options are available to help control perioperative pain, and a multimodal pain management approach may be of particular benefit in chronic opioid users undergoing orthopaedic surgery.The Journal of the American Academy of Orthopaedic Surgeons 10/2014; 22(10):614-622. DOI:10.5435/JAAOS-22-10-614 · 2.40 Impact Factor
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ABSTRACT: COMMENTARY ON: Guilfoyle MR, Mannion RJ, Mitchell P, Thomson S. Epidural fentanyl for postoperative analgesia after lumbar canal decompression: a randomized controlled trial. Spine J 2012;12:646-51 (in this issue).The spine journal: official journal of the North American Spine Society 08/2012; 12(8):652-5. DOI:10.1016/j.spinee.2012.08.023 · 2.80 Impact Factor
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ABSTRACT: Persistent posthoracotomy pain (PPP) reaches 50-80%. Nerve damage and central sensitization involving NDMDAr activation may play an important role. This study evaluates the efficacy of adding intravenous or epidural ketamine to thoracic epidural analgesia (TEA) after thoracotomy. Double-blind randomized study on patients undergoing thoracotomy allocated to one of the following: Group Kiv (intravenous racemic ketamine 0.5 mg/kg preincisional +0.25 mg/kg/h for 48 h), Group Kep (epidural racemic ketamine 0.5 mg/kg preincisional +0.25 mg/kg/h for 48 h), or Group S (saline). Postoperative analgesia was ensured by TEA with ropivacaine and fentanyl. Visual analog scale (VAS), Neuropathic Pain Symptom Inventory (NPSI), Catastrophizing Scale and Quantitative Sensory Testing (QST), measuring both the peri-incisional and distant hyperalgesia area, were conducted preoperatively and postoperatively until 6 months. Plasma ketamine levels and stability of the analgesic solutions were analyzed. A total of 104 patients were included. PPP incidence was 20% at 6 months. VAS scores on coughing were significantly lower in Kiv and Kep than in S at 24 hours and 72 hours, but there were no differences afterwards. There were no significant differences in VAS at rest, NPSI and Catastrophizing Scale, or in the area of mechanical allodynia at any time. Adverse effects were mild. Plasma ketamine levels did not differ significantly between groups. Analgesic solutions were stable. Adding epidural or intravenous racemic ketamine to TEA after thoracotomy did not lead to any reduction in PPP or allodynia. Epidural administration produced similar plasma ketamine levels to the intravenous route.The Clinical journal of pain 11/2013; 30(6). DOI:10.1097/AJP.0000000000000005 · 2.70 Impact Factor