Postoperative Single-Shot Epidural Fentanyl and Bupivacaine for Postoperative Analgesia After Lumbar Decompression

A Prospective, Double-Blind Randomized Study

Mannuel Feliciano B. Alican, MD; Mario R. Ver, MD, FPOA, FPCS; Miguel Rafael D. Ramos, MD; Lulu Joan C. Mamaril, MD, FPBA

Disclosures

Spine. 2020;45(15):1017-1023. 

In This Article

Abstract and Introduction

Abstract

Study Design: Randomized clinical trial.

Objective: To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery.

Summary of Background Data: Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery.

Methods: We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated.

Results: Pain scores were noted to be significantly lower at all time points in the epidural group (P < 0.001). In turn, they also received less on-demand oral pain medications than those in the control group (P = 0.000). The mean time to ambulation was 0.09 days in the epidural group and 0.91 days in the decompression-alone group (P = 0.000). Criteria for hospital discharge were usually met on Day 0 in the epidural and Day 1 in the control group (P = 0.000). Within the study period, only one infection was noted in the epidural group which necessitated additional lumbar spine surgery (4.3%). No adverse events or complications related to Fentanyl use were observed.

Conclusions: A postoperative bolus of Fentanyl and Bupivacaine is effective in reducing early postoperative pain without the related complications of opiod administration.

Level of Evidence: 2

Introduction

Lumbar decompression has been proven to be an efficacious treatment option in select patients suffering from sciatica, radiculopathy, and neurogenic claudication.[1–4] However, a common complaint in the postoperative period is back and buttock pain which has been shown to decrease patient-reported outcomes and satisfaction rates, as well as impair quality of recovery and increase hospital costs.[5–8] This pain has been reported to be worst in the first 3 postoperative days[9] and may predict the development of chronic debilitating pain necessitating additional lumbar surgery in the future.[10] Immediately following surgery, unwanted pain often translates into late mobilization and prolonged hospital stay, resulting in recumbent-related morbidities such as deep vein thrombosis and hospital acquired pneumonia.[11] The goal of effective pain control should facilitate early mobilization, as well as expedite hospital discharge.

Currently, the standard of postsurgical anesthetic care ranges from continuous parenteral and oral medications to neuraxial infusions via intrathecal or epidural routes. Satisfactory outcomes have been achieved with these regimens, but adverse effects secondary to their usage cannot be discounted. Common drug-related complaints of frequently prescribed postoperative analgesics include gastric upset with nonsteroidal anti-inflammatory drugs (NSAIDs) and central nervous system depression with opioid use.[12] Current research has explored the use of more potent medications as well as other routes of delivery to avoid potential systemic toxicity.

Opioids have been shown to provide excellent postoperative pain control albeit its adverse effects such as respiratory depression, constipation, and nausea. Epidural administration of morphine directly acts on the spinal level of infusion and has been shown to provide adequate preemptive analgesia when given preoperatively or postoperatively.[13] However, a common adverse effect in epidural administration is pruritis. This is due to its hydrophilic nature which has allowed the capacity to act on supraspinal and extraspinal sites. Fentanyl, on the other hand, is a lipophilic opioid, preferentially targeting receptors of the spinal level at which it is administered and with better safety profile. Riley et al[14] concluded that a bolus of epidural Fentanyl maintained segmental anesthesia versus a more systemic, supraspinal analgesic effect of a continuous epidural infusion without compromising postoperative pain control. In addition, combination with local anesthetic agents has been shown to synergistically increase the local effect of epidural Fentanyl while avoiding systemic events and adverse reactions of both medications.[15] In our study, a postoperative bolus of epidural Fentanyl and Bupivacaine (FB) was assessed in its ability to provide adequate, immediate postoperative pain control, lessen the need for oral analgesics, allow early ambulation, and decrease the duration of hospital stay.

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