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The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion

  • Original Article - Neurosurgery general
  • Published:
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Abstract

Purpose

In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects.

Methods

The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose).

Results

In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen’s d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (β =  − 0.83, p < 0.001; β =  − 0.63, p = 0.022) and MED intake for the first two PODs (β =  − 20.8, p = 0.047; β =  − 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10).

Conclusions

In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1–2 opioid requirement while not increasing the risk of any opioid-related side effects.

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Authors and Affiliations

  1. Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202 Boulder, CO 80303, CO, Boulder, USA

    Alan Villavicencio, E. Lee Nelson, Sharad Rajpal, Kara Beasley & Sigita Burneikiene

  2. Justin Parker Neurological Institute, Boulder, CO, USA

    Alan Villavicencio, Sharad Rajpal & Sigita Burneikiene

  3. Department of Integrative Physiology, University of Colorado-Boulder, Boulder, CO, USA

    Hash Brown Taha

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Correspondence to Sigita Burneikiene.

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Comments

Nice well conducted study demonstrating that intrathecal opiod administration, reduces post operative pain on POD1 and need for opiods on POD2. None CSF leaks were noted in the current study, but this risk and the similar effect on pain and opiod consumption on POD3-4, will probably still cause some reluctance towards ITO in the spine community.

Carsten Reides Bjarkam.

Aalborg,Denmark.

The authors of this paper compared their institutional experience with intrathecal administration of different opioids at the end of uncomplicated lumbar fusion procedures—among three groups (morphine vs. morphine + fentanyl vs. none), there were no differences in side effects or complications, but the groups with intrathecal injection had less pain during first day or two after the surgery. The patients were not randomized, and only one- and two-level transforaminal interbody fusions were included in the review.

Although there were no technical or medication-related issues with intrathecal opioid administrations, one may expect them to occur at some point as both the dural penetration and the intrathecal morphine (known from decades of intrathecal morphine trialing for patients with chronic pain) can indeed results in various unpleasant problems, from CSF leaks and seromas, to meningitis and morphine-related itching and hyperalgesia.

Ultimately, recommendation on whether to accept this approach will be determined by prospective randomized studies, perhaps comparing intrathecal opioid administration with application of epidural paste, and then determining if addition of anti-inflammatory medications and/or local anesthetics would make effects more noticeable.

Konstantin Slavin,

Chicago, USA.

This article is part of the Topical Collection on Neurosurgery general.

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Villavicencio, A., Taha, H.B., Nelson, E.L. et al. The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion. Acta Neurochir 164, 3061–3069 (2022). https://doi.org/10.1007/s00701-022-05359-8

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