Background and Aims Complex spinal procedures are associated with intense pain in the postoperative period. Adequate perioperative pain management has been shown to correlate with improved outcomes including early ambulation and discharge. We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.
Methods A systematic review using the PROSPECT methodology was undertaken. RCTs and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.
Results Out of 111 eligible studies identified, 31 RCTs and 4 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain were paracetamol, COX-2 specific-inhibitors or NSAIDs, intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfacial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.
Conclusions The analgesic regimen should include preoperative or intraoperative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intraoperative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intraoperative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Further qualitative RCTs are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.
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