What are the recommendations for post-operative care after spine surgery?

Post-Operative Care After Spine Surgery

The optimal post-operative care after spine surgery should follow a multimodal approach that prioritizes non-opioid analgesics as first-line treatment, with opioids limited to no more than 7 days, to minimize complications while ensuring adequate pain control. 1

Pain Management

First-Line Medications

• NSAIDs and acetaminophen should be administered preemptively and continued throughout the perioperative period as the foundation of pain management 1
• Combination therapy with both NSAIDs and acetaminophen provides superior analgesia and reduces opioid requirements 1
• COX-2 inhibitors (e.g., celecoxib) can be considered as alternatives to traditional NSAIDs, especially in patients with bleeding risk 1
• Short-term use of NSAIDs (less than 2 weeks) appears safe even for patients who have undergone spinal fusion 1

Adjunctive Medications

• Gabapentinoids (pregabalin and gabapentin) significantly reduce postoperative pain scores, opioid consumption, and improve long-term functional outcomes when administered preoperatively and continued postoperatively 1
• Dexamethasone can be included as part of the multimodal approach to reduce inflammation and pain 1

Local Anesthetics

• Local anesthetic wound infiltration with bupivacaine provides immediate postoperative pain relief 2
• Liposomal formulations of bupivacaine may provide extended relief for up to 96 hours with fewer adverse effects 2
• IV lidocaine has analgesic, antihyperalgesic, and anti-inflammatory properties with relatively few side effects 2

Opioid Management

• Opioids should be used judiciously and for the shortest duration possible, no more than 7 days 2, 1
• Patients with preoperative opioid use require closer monitoring as they typically report greater first postoperative pain scores 3
• Patients who were opioid-free for a period before surgery have risks of adverse outcomes similar to opioid-naïve patients 3

Preoperative Risk Assessment

• Preoperative opioid use of any dose is strongly associated with longer duration of postoperative opioid use and worse clinical outcomes 3
• Longer duration of preoperative opioid use correlates with higher complications, longer hospital stays, higher costs, and increased utilization of healthcare resources 3
• Nutritional status should be assessed using serum markers including albumin and prealbumin 3
• Malnutrition is associated with higher rates of surgical site infections, wound complications, nonunions, hospital readmissions, and other medical complications 3

Monitoring and Follow-up

• Regular assessment of pain scores using validated tools is essential to evaluate treatment response and guide adjustments 1
• Follow-up evaluation should assess for persistent symptoms beyond expected duration and functional improvement 1

Common Pitfalls and Considerations

• Overreliance on opioids can lead to respiratory depression, nausea, vomiting, and delayed mobilization 1
• Up to 75% of people entering treatment for heroin addiction report that their first opioids were prescription drugs, highlighting the importance of judicious opioid prescribing 2
• Failure to identify preoperative opioid use is a major predictor of postoperative outcomes and should be thoroughly assessed 3
• Neglecting nutritional status significantly increases complication risk 3
• Side effects of IV lidocaine include neurologic changes such as lightheadedness, dizziness, visual disturbances, and cardiac dysrhythmias 2
• Bupivacaine toxicity can include early neurologic symptoms and severe symptoms such as hypotension, arrhythmias, and cardiac and respiratory arrest 2

Proposed Algorithm for Post-Spine Surgery Pain Management

1. Baseline therapy (for all patients):

   • Scheduled acetaminophen and NSAIDs/COX-2 inhibitors 1
   • Gabapentinoids (pregabalin/gabapentin) 1

2. For moderate pain:

   • Add local anesthetic techniques (wound infiltration with bupivacaine/liposomal bupivacaine) 2
   • Consider dexamethasone for anti-inflammatory effects 1

3. For severe pain:

   • Short-term opioids (≤7 days) 2, 1
   • Consider IV lidocaine or ketamine infusion for refractory pain 2

4. For patients with preoperative opioid use:

   • More intensive monitoring 3
   • Earlier implementation of adjunctive therapies 3
   • Consultation with pain management specialists 3