What is the best analgesia for severe back pain secondary to posterior spinal fusion?

From the Guidelines

For severe back pain following posterior spinal fusion, a multimodal approach is recommended, prioritizing non-opioid medications and minimizing opioid use due to their substantial risks, as suggested by the most recent guideline 1.

Key Components of the Multimodal Approach

• Scheduled acetaminophen (1000 mg every 6 hours, not exceeding 4000 mg daily) is a reasonable first-line option due to its favorable safety profile and low cost, as noted in 1 and 1.
• An NSAID such as celecoxib (200 mg twice daily) can be added if not contraindicated, considering its effectiveness in pain relief but also its potential gastrointestinal and renovascular risks, as discussed in 1 and 1.
• For breakthrough pain, opioids like oxycodone (5-10 mg every 4-6 hours as needed) or hydrocodone/acetaminophen combinations should be used short-term and with caution, given the risks of aberrant drug-related behaviors and the lack of long-term efficacy and safety data, as highlighted in 1 and 1.
• Muscle relaxants such as cyclobenzaprine (5-10 mg three times daily) can help with muscle spasms, and gabapentinoids like gabapentin (starting at 300 mg three times daily, gradually increasing as needed) or pregabalin (75 mg twice daily) are effective for neuropathic pain components, as part of a comprehensive pain management strategy.

Considerations for Optimal Management

• Regular reassessment of pain control and medication side effects is essential for optimal management, allowing for adjustments in the treatment plan as needed to minimize risks and maximize benefits, as emphasized in 1 and 1.
• Physical therapy should be incorporated as soon as medically cleared to improve functional outcomes and reduce long-term pain, addressing the multifaceted nature of recovery from posterior spinal fusion.
• The most recent guideline 1 supports minimizing systemic opioid utilization and developing individualized post-discharge opioid prescribing practices, underscoring the importance of cautious opioid use in postoperative pain management.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

Dosage and Administation: 2. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] .

1. 2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.

The best analgesia for severe back pain secondary to posterior spinal fusion is not explicitly stated in the provided drug label. However, oxycodone is mentioned as an option for managing severe chronic pain. The dosage should be individually titrated to provide adequate analgesia and minimize adverse reactions.

• The initial dosage of oxycodone is 5 to 15 mg every 4 to 6 hours as needed for pain.
• Patients should be closely monitored for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases.
• The dose can be adjusted based on the patient's response to their initial dose of oxycodone 2.

From the Research

Analgesia Options for Severe Back Pain Secondary to Posterior Spinal Fusion

• The use of erector spinae plane (ESP) blocks as part of an opioid-free multimodal anesthetic regimen has been reported to provide adequate analgesia without the need for opioids in a case study 3.
• A systematic review with meta-analyses and trial sequential analyses found that nonsteroidal anti-inflammatory drugs (NSAIDs) and epidural analgesia significantly reduced opioid consumption after spinal fusion surgery 4.
• Implementation of a standardized multimodal postoperative analgesia protocol has been shown to improve pain control, reduce opioid consumption, and shorten length of hospital stay after posterior lumbar spinal fusion 5.
• A pre-emptive opioid-sparing medication protocol started two days prior to surgery has been found to decrease pain and length of hospital stay in children undergoing posterior spinal instrumented fusion for scoliosis 6.
• A narrative review suggests that the use of multimodal analgesia, including intrathecal opioids and nonsteroidal anti-inflammatory drugs, can improve pain management and reduce opioid consumption in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis 7.

Key Findings

• ESP blocks can provide opioid-sparing analgesia for spine surgery 3.
• NSAIDs and epidural analgesia can reduce opioid consumption after spinal fusion surgery 4.
• Standardized multimodal postoperative analgesia protocols can improve pain control and reduce opioid consumption 5.
• Pre-emptive opioid-sparing medication protocols can decrease pain and length of hospital stay in children undergoing posterior spinal instrumented fusion for scoliosis 6.
• Multimodal analgesia can improve pain management and reduce opioid consumption in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis 7.

Considerations

• The quality of evidence for most trials is low to very low, making it difficult to recommend a "gold standard" for analgesic treatment after spinal fusion surgery 4.
• Further studies are needed to investigate the degree of mobilization and opioid consumption after discharge from the hospital 6.
• Appropriate combinations of analgesics have not been established, and more research is needed to determine the best approach for pain management in patients undergoing posterior spinal fusion 7.