Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion

• Published in: Neurosurgery Vol. 87; no. 1; pp. 130 - 136
• Main Authors: Walker, Corey T, Gullotti, David M, Prendergast, Virginia, Radosevich, John, Grimm, Doneen, Cole, Tyler S, Godzik, Jakub, Patel, Arpan A, Whiting, Alexander C, Little, Andrew, Uribe, Juan S, Kakarla, Udaya K, Turner, Jay D
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01-07-2020; Copyright by the Congress of Neurological Surgeons; Wolters Kluwer Health, Inc
• Subjects: Adult; Aged; Analgesia; Analgesia - methods; Analgesics, Opioid - administration & dosage; Anesthetics, Local - administration & dosage; Anti-Inflammatory Agents, Non-Steroidal - administration & dosage; Back surgery; Care and treatment; Combined Modality Therapy - methods; Cryotherapy - methods; Drug Therapy, Combination; Female; Humans; Length of Stay - trends; Lumbar Vertebrae - surgery; Male; Medical protocols; Methods; Middle Aged; Narcotics; Neurosurgery; Pain; Pain management; Pain Management - methods; Pain Measurement - methods; Pain, Postoperative; Pain, Postoperative - diagnosis; Pain, Postoperative - etiology; Pain, Postoperative - therapy; Patient outcomes; Postoperative period; Retrospective Studies; Spinal fusion; Spinal Fusion - adverse effects; Spinal Fusion - trends; Spine; United States; Analgesia; Pain; Multimodal; Complications; Opioid; Lumbar; Protocol; Fusion; Constipation; Outcomes; Length of stay
• ISSN: 0148-396X; 1524-4040
• DOI: 10.1093/neuros/nyz312

Abstract
BACKGROUND
Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery.
OBJECTIVE
To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol.
METHODS
A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution.
RESULTS
A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P > .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P < .001) and 24 to 72 hr postoperatively (4.7 vs 3.4, P < .001), PRE vs POST, respectively. Maximum pain scores and time to achieving appropriate pain control also significantly improved during these same intervals (all P < .05). A concomitant decrease in opioid consumption during the first 72 hr was seen (110 vs 71 morphine milligram equivalents, P = .02). There was an observed reduction in opioid-related adverse events per patient (1.31 vs 0.83, P < .001) and hospital length of stay (4.6 vs 3.9 days, P = .03) after implementation of the protocol.
CONCLUSION
Implementation of an evidence-based, multimodal analgesia protocol improved postoperative outcomes, including pain scores, opioid consumption, and length of hospital stay, after posterior lumbar spinal fusion.