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Thread: Pain management in major spine surgery

  1. #1
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    Pain management in major spine surgery

    I always wondered why there isn't more epidural anesthesia using in the immediate post op period in the US compared to other countries. That's my impression from the testimonials but I am not sure that is true. This study suggests they should be more.

    Effects of Continuous Epidural Anesthesia and Postoperative Epidural Analgesia on Pain Management and Stress Response in Patients Undergoing Major Spinal Surgery

    Ezhevskaya, Anna A.; Mlyavykh, Sergey G.; Anderson, D. Greg

    Spine. 38(15):1324-1330, July 01, 2013.

    Abstract:

    Study Design. A prospective, randomized study was used to compare 2 anesthesia/analgesia methods for reconstructive spine surgery.

    Objective. To assess the efficacy and influence of 2 anesthetic methods on clinical outcome and stress response during reconstructive spine surgery.

    Summary of Background Data. Pain control is an important goal of the postoperative care after spinal surgery. Some prior studies have suggested that epidural anesthesia with or without postoperative epidural analgesia may blunt the surgical stress response after major surgery. This treatment approach has not been fully investigated for patients undergoing major spinal surgery. We hypothesized that the stress response after major spine surgery would be attenuated by continuous epidural anesthesia/analgesia with ropivacaine, fentanyl, and epinephrine.

    Methods. Eighty-five patients were randomly allocated to 2 groups as follows: group E (n = 45) had epidural anesthesia and endotracheal anesthesia with sevoflurane during surgery and continuous epidural analgesia with ropivacaine, fentanyl, and epinephrine after surgery; group G (n = 40) had general anesthesia with sevoflurane and fentanyl and systemically administered opioids after surgery. Patient pain, nausea, mobility, and satisfaction were measured after surgery along with levels of cortisol, glucose, interleukin (IL)-1β, IL-6, and IL-10 during and after surgery.

    Results. In group E, there were significantly less pain, less nausea, earlier mobility, and higher satisfaction than those in group G. Group E also experienced significantly less introperative and postoperative blood loss. Group E demonstrated lower levels of glucose, cortisol, IL-1β, IL-6, and IL-10 during the postoperative period.

    Conclusion. Combined epidural/general anesthesia and postoperative epidural analgesia produced better pain control, less bleeding, and a lower surgical stress response than general anesthesia with postoperative systemically administered narcotic analgesia. This technique deserves further study in the setting of major spinal surgery.

    Level of Evidence: 1
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  2. #2
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    Sharon...does it have any impact on how soon patients can get
    out of bed and start walking...??
    depending on where they put the epidural...i thought it can
    prevent a patient from being able to walk...???

    Happy 4th...
    jess...and Sparky

  3. #3
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    Jess, That's a good question. I don't know.

    Here's another article on pain management... it is a huge deal and should get more attention in my opinion.


    A Randomized Prospective Evaluation of Three Techniques of Post-Operative Pain Management Following Posterior Spinal Instrumentation and Fusion

    Klatt, Joshua W. B.; Mickelson, Jennie; Hung, Man; Durcan, Simon; Miller, Chris; Smith, John T.

    Spine., POST ACCEPTANCE, 23 May 2013

    Abstract:

    Study Design. Randomized prospective trial

    Objective. To compare the efficacy of intravenous analgesia with single and dual continuous epidural analgesia in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSIF)

    Summary of Background Data. Pain management following PSF for patients with AIS is challenging. While intravenous patient-controlled analgesia (PCA) is used most commonly, continuous epidural analgesia (CEA) has been found to be safe and effective. Recently, the use of two epidural catheters has been thought to be more effective than a single catheter, although the efficacy of using two catheters has not been directly compared to a single catheter.

    Methods. Sixty-six patients with AIS were randomized into 3 groups prior to PSF; PCA, single CEA, and double CEA. Post-operative pain scores as well as side effects, complications, and use of breakthrough medication were collected. Recovery times were also recorded, including hospitalization, times to first bowel movement, and days to walk and climb stairs. Four patients were withdrawn due to the inability to maintain the pain management protocol.

    Results. Pain intensity was most effectively controlled with a double CEA when compared with PCA (p<0.05) and a single CEA (p<0.05). Pain control was equivalent in both the PCA and single CEA groups (p = 0.21). The pain control method with the fewest side effects trended toward the single CEA, with an average of 2.55 side effects per patient. The majority of the side effects included pruritis, constipation, and nausea. Late onset neurological events were absent in all patients.

    Conclusion. These data document that the Double CEA most effectively controls post-op pain following surgery for AIS. The Single CEA trended towards having the fewest side effects when compared to the other techniques. Based on these findings, we now routinely use the double CEA technique for all patients having surgery for AIS.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  4. #4
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    Hi Sharon,

    I tolerate narcotics and anesthesia very poorly (severe nausea and vomitting), so I asked my surgeon about the possibility of having epidural anesthesia along with the general. I asked not for an indwelling epidural but for 24-hour epidural morphine. He told me he never allows it because he feels it can increase the risk of infection, which does make sense.

    I have heard of others here who have had epidurals, and they all reported significantly less pain, which I would have loved. My pain was very poorly controlled after my first surgery. I was never under an 8-9 while in the hospital. Part of it was my own fault because I am so severely nauseated with narcotics that I skimped myself. Definitely not advisable!

    Linda, do the UCSF surgeons allow epidurals?
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  5. #5
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    Quote Originally Posted by leahdragonfly View Post
    Hi Sharon,

    I tolerate narcotics and anesthesia very poorly (severe nausea and vomitting), so I asked my surgeon about the possibility of having epidural anesthesia along with the general. I asked not for an indwelling epidural but for 24-hour epidural morphine. He told me he never allows it because he feels it can increase the risk of infection, which does make sense.

    I have heard of others here who have had epidurals, and they all reported significantly less pain, which I would have loved. My pain was very poorly controlled after my first surgery. I was never under an 8-9 while in the hospital. Part of it was my own fault because I am so severely nauseated with narcotics that I skimped myself. Definitely not advisable!

    Linda, do the UCSF surgeons allow epidurals?
    Hey Gayle. This is such an important point you make. I think they need to do some studies on the infection rates because the epidurals sound so much better than what is the usual now.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  6. #6
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    Hi Gayle... I've never seen any dictation where an adult patient got a periop epidural. I know that it increases the complication rate significantly, but don't know all the details. I'll ask around and get back to you.

    Jess, I assume that it's different medication, but the epidural that this study addresses is not meant to numb. Giving a patient something that would keep them in bed for even another day, would almost certainly increase the complication rate by a lot.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    If you've signed up and are having trouble posting, please check your spam folder. An email was sent to the email address which you subscribed. You have to follow the instructions in that email. Done that and still having trouble posting? Contact Joe O'Brien at jpobrien@scoliosis.org.

  7. #7
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    yes, i looked it up and it is not supposed to cause any problems with walking...
    but i do remember i had some numbness/tingling in upper part of
    one leg after my first epidural injection, done at Columbia Pres
    in Manhattan...
    it didn't last long...
    unfortunately, i never got much pain relief from epidural injections...
    tried them several times...
    maybe it works better after surgery.

    jess
    Last edited by jrnyc; 07-04-2013 at 02:02 PM.

  8. #8
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    I had so many hoses that they just had me stand by the bed hooked up to all these fancy machines....This is what everyone told me since I have no idea what happed for a few days.....It’s a complete blank, so I have no recall of “pain” or any “feelings”(except for the NG tube throat irritation) for the first 4-5 days. My surgeon told me that they were not going to wake me during this period in ICU. I was a zombie.

    I wish I had those details.....they are not in my hospital reports. Funny also, since around 15 different doctors submitted various reports....I had no idea that this many people were part of Dr Menmuir’s “team”. Sounds expensive, doesn’t it? It would be an exhausting workout simply signing those checks.....I wouldn’t blame the insurance people for wanting to be knocked out....(smiley face)

    I did NOT hallucinate at all. After the 4-5 days, I was in or out with injections every 4 hours till the 10th day. Injectable Morphine, Dialuid and Lortab were rotated during this period. Upon a shot, (I became a begger) it was 4-10 seconds till I was out, slept for 60-70 minutes, then stared at the clock till the 4th hour. Its amazing that I could remember when my next shot was scheduled.....I stared at the clock. I was by the nurses station.

    With all of this, the get well cards piled up in the room, but don’t remember visitors coming down.....So, if you go to visit someone at the hospital, bring a card with you because its proof you showed up. “I came down”, “No you didn’t”......???

    I can understand where Melissa is at with her memory loss.....this is an extremely difficult thing to deal with. Its why I quit meds cold turkey at 6 weeks. I couldn’t take it anymore, I wanted my brain back regardless of pain.

    I learned to ask the anesthesiologist for extra antimetics on my gall bladder removal surgery....after my shoulder surgery I was vomiting often. If you have an NG tube you don’t have to worry about this.

    Anesthesia is such a complicated subject......Dr Nuzzo’s layman attempts are in this link....
    http://www.pediatric-orthopedics.com...sthesia_1.html


    Ed
    49 yr old male, now 58, the new 53...
    Pre surgery curves C12,T70,L70
    ALIF/PLIF T2-Pelvis 01/29/08, 01/31/08 7" pelvic anchors BMP
    Dr Brett Menmuir St Marys Hospital Reno,Nevada

    Bending and twisting pics after full fusion
    http://www.scoliosis.org/forum/showt...on.&highlight=

    My x-rays
    http://www.scoliosis.org/forum/attac...2&d=1228779214

    http://www.scoliosis.org/forum/attac...3&d=1228779258

  9. #9
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    Gayle, how is having adverse reactions to narcotics your fault? When you are in that much pain, you don't want to be hurling your guts out, too. That was not your fault. They should have come up with something better to control your pain.

    Linda,
    The studies that Sharon posted said that the epidurals decreased complications, including blood loss. Why do your doctors say that it increases complications? I can understand the increase of infection, but people are getting all sorts of epidurals and spinal taps all of the time. Anesthesiologists seem to have no trouble getting near the spine with low infection rates.

    Jess,
    They have the intrathecal device that delivers continual pain medication directly to the spinal cord. This device is secured within the abdominal cavity and the catheter is secured into the spinal canal. I'm guessing this is more what they are talking about except without the pump being implanted.

    Sharon,
    Thanks for the post. I've wondered about that myself when I see on here some people having them and some people not. It sounds like a very viable solution for those especially that have a difficult time with narcotics. Very little gets into the actual blood stream per a doc that wanted to implant the intrathecal device in me.
    Be happy!
    We don't know what tomorrow brings,
    but we are alive today!

  10. #10
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    Hi Jess...

    This is an epidural catheter that we're talking about (as opposed to an epidural injection).

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    If you've signed up and are having trouble posting, please check your spam folder. An email was sent to the email address which you subscribed. You have to follow the instructions in that email. Done that and still having trouble posting? Contact Joe O'Brien at jpobrien@scoliosis.org.

  11. #11
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    thanks, Linda
    my mistake...
    sounds safer for keeping medicine where it should be....

    am just wondering, after reading the articles, and reading
    the meds used...if the doctors can use ANY medication
    they choose in this way...
    it reminds me of the articles i've read about doctors
    trying to put chemo drugs close to where the cancer
    is (or was) being treated, rather than administering the
    chemo by usual IV route...

    jess

  12. #12
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    I had two epidurals, one thoracic, one lumbar. Dr. Askin sets the needles in place before he closes. I felt no pain for the three (maybe four) days they were there. I did feel vaguely uncomfortable. I could wriggle and move limbs, fingers and toes. I could stand and walk. I went straight to oral pain meds when they were removed. I slept most of that first three days so feel I was well rested to deal with any pain after the epidurals were removed and was on solid food by then.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

  13. #13
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    Hi Jennifer,

    That sounds SO wonderful compared to what I endured.

    I guess every surgeon has different preferences and protocols.
    Gayle, age 50
    Oct 2010 fusion T8-sacrum w/ pelvic fixation
    Feb 2012 lumbar revision for broken rods @ L2-3-4
    Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


    mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
    2010 VBS Dr Luhmann Shriners St Louis
    2017 curves stable/skeletely mature

    also mom of Torrey, 12 y/o son, 16* T, stable

  14. #14
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    Yes, I feel very fortunate that I had epidurals. I realise epidurals do present another opportunity for infection but I was lucky. I now know 5 other patients of Dr. Askin's and they all had epidurals and none got infections.
    Surgery March 3, 2009 at almost 58, now 63.
    Dr. Askin, Brisbane, Australia
    T4-Pelvis, Posterior only
    Osteotomies and Laminectomies
    Was 68 degrees, now 22 and pain free

  15. #15
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    Quote Originally Posted by leahdragonfly View Post
    Hi Jennifer,

    That sounds SO wonderful compared to what I endured.

    I guess every surgeon has different preferences and protocols.
    Gayle, If you ever need surgery again, you need to meet with a pain management doctor or PhD pharmacist before surgery and then multiple times after surgery to get your pain under control.

    I asked Dr. Hu about an in dwelling catheter and she responded about infection concerns and said that there would be a pain management MD that visited with me in the hospital. I remember so little about my postop stay, but I do remember a doctor or pharmacist named Deke who was there frequently checking on me. I am allergic to codeine and oxycodone, so I was really concerned about pain control. Deke was awesome!

    So sorry that you suffered. That is unnecessary with the choices in analgesia that we have now.
    Susan
    Adult Onset Degenerative Scoliosis @65, 25* T & 36* L w/ 11.2 cm coronal balance; T kyphosis 90*; Severe disc degen T & L stenosis

    2013: T3- S1 Fusion w/ ALIF L4-S1/XLIF L2-4, PSF T4-S1 in 2 surgeries
    2014: Hernia @ ALIF repaired; Emergency screw removal surgery for Spinal Cord Injury at T4,5 sec to PJK
    2015: Revision Broken Bil T & L rods and no fusion: 2 revision surgeries; hardware P. Acnes infection
    2016: Ant/Lat Lumbar diskectomy w/ 4 cages + BMP + harvested bone + prayer

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