What is the analgesia protocol for a patient after major spinal surgery?

Postoperative Analgesia Protocol for Major Spinal Surgery

Implement a multimodal analgesia regimen combining scheduled acetaminophen, NSAIDs (if not contraindicated), gabapentinoids, and IV opioids for breakthrough pain, supplemented with regional anesthesia techniques when feasible. 1, 2

Immediate Postoperative Period (PACU/First 24 Hours)

Baseline Multimodal Regimen

• Acetaminophen 1g IV every 6 hours (maximum 4g/day) as the foundation of pain control 1
• NSAIDs: Ketorolac 0.5mg/kg IV (max 30mg) as single intraoperative dose, then 0.15-0.2mg/kg (max 10mg) every 6 hours for maximum 48 hours 1
  • Critical caveat: NSAIDs may increase bleeding risk in spinal surgery and should be used cautiously, weighing analgesic benefit against hemorrhagic risk 1
  • Consider COX-2 selective inhibitors as alternative if available, though cardiovascular risk must be assessed 1

Opioid Management for Breakthrough Pain

• IV hydromorphone 0.2-1mg every 2-3 hours administered slowly over 2-3 minutes for severe pain 3
• Alternative: IV fentanyl 25-100 mcg titrated to effect 1, 4
• Patient-controlled analgesia (PCA) is preferred over fixed-interval dosing for patients with adequate cognitive function 1, 5
  • Continuous low-dose fentanyl or morphine infusion may be considered for complex multilevel procedures 4

Adjunctive Medications

• Gabapentin 300-600mg PO every 8 hours or pregabalin 75-150mg PO every 12 hours initiated preoperatively and continued postoperatively 1, 2, 6
  • Monitor for sedation and dizziness, especially in first 24-48 hours 7
• IV lidocaine infusion: 1-2mg/kg/hr intraoperatively, may continue postoperatively for 24-48 hours with continuous ECG monitoring 1
  • Provides analgesia, anti-inflammatory effects, and opioid-sparing benefits 1
• Ketamine infusion: 0.1-0.5mg/kg/hr for severe pain or opioid-tolerant patients 1, 2
• Dexamethasone 4-8mg IV intraoperatively to reduce inflammation and prolong analgesic effects 1, 7

Regional Anesthesia Techniques

Neuraxial Analgesia (When Appropriate)

• Epidural analgesia with ropivacaine + fentanyl provides superior pain control, reduced stress response, and less bleeding compared to systemic opioids alone 8
  • Place epidural catheter preoperatively at appropriate spinal level
  • Continue for 48-72 hours postoperatively 1, 8
  • Major limitation: Requires expertise in management, risk of hypotension requiring vasopressors (not fluid overload), and urinary retention 1
  • Contraindication: Patients on anticoagulation require careful timing per guidelines 1

Alternative Regional Techniques

• Bilateral erector spinae plane (ESP) blocks with long-acting local anesthetics (ropivacaine or bupivacaine) for multilevel procedures 4
• Interfascial plane blocks as opioid-sparing adjuncts 4
• Intrathecal morphine (0.1-0.3mg) as single-shot technique provides 18-24 hours of analgesia 1
  • Critical monitoring: Respiratory depression risk for 24 hours, especially in elderly 1

Local Infiltration

• Liposomal bupivacaine infiltrated at surgical site provides up to 96 hours of analgesia with lower systemic toxicity 1
  • Evidence is mixed; some studies show benefit while others show no difference 1

Ward Management (24-72 Hours Postoperatively)

Continue Baseline Regimen

• Transition to oral acetaminophen 1g every 6 hours when tolerating PO 1
• Oral NSAIDs: Ibuprofen 400-600mg every 8 hours or diclofenac 50mg every 8 hours 1
• Continue gabapentinoids at established doses 2, 6

Breakthrough Pain Management

• Oral oxycodone immediate-release 5-10mg every 4 hours PRN for moderate pain 5
• Tramadol 50-100mg PO every 6 hours as alternative weak opioid 1
• Taper opioids aggressively as pain improves; most acute postoperative pain should not require opioids beyond 3-7 days 1, 3

Special Populations and Considerations

Elderly Patients

• Reduce opioid doses by 25-50% due to increased sensitivity and side effect risk 1, 3
• Prioritize regional techniques (peripheral nerve blocks, epidural) over systemic opioids when possible 1
• Enhanced monitoring for respiratory depression, delirium, and falls 1

Patients with Renal or Hepatic Impairment

• Reduce hydromorphone dose by 25-50% depending on severity of impairment 3
• Avoid NSAIDs in significant renal dysfunction 1
• Adjust gabapentinoid dosing for renal clearance 2

Opioid-Tolerant Patients

• Higher baseline opioid requirements necessitate multimodal approach with ketamine, lidocaine infusions, and regional techniques 1, 6
• Consider methadone for complex cases due to NMDA antagonism and long half-life 4

Critical Pitfalls to Avoid

• Do not rely on opioids alone: Multimodal analgesia reduces opioid consumption by 30-50% and improves outcomes 2, 5
• Do not use epidural for minimally invasive procedures: Reserve for open multilevel fusions; risk outweighs benefit for less invasive surgery 1
• Do not abruptly discontinue opioids in physically dependent patients; taper gradually 3
• Monitor for opioid-induced hyperalgesia: If pain paradoxically worsens with escalating opioids, consider dose reduction or rotation 3
• Avoid fluid overload for epidural-related hypotension: Use vasopressors after confirming euvolemia 1
• Screen for cardiovascular disease before using COX-2 inhibitors or NSAIDs long-term 1

Discharge Planning

• Prescribe no more than 7 days of oral opioids at discharge 1
• Continue acetaminophen and NSAIDs for 2-4 weeks as baseline analgesia 1
• Taper gabapentinoids gradually over 1-2 weeks when no longer needed 7, 2
• Educate patients on expected pain trajectory, non-pharmacologic measures (ice, positioning), and when to seek help 1