Use of a Multifunctional Cocktail for Postoperative Bleeding and Pain Control in Spinal Fusion

A Randomized, Double-blind, Controlled Trial

Wei Jiang, PhD; Mengyu Fu, MA; Wei Dong, MA; Nian Zhou, PhD; Jieliang Shen, PhD; Xiaojun Zhang, PhD; Jie Hao, PhD

Disclosures

Spine. 2022;47(18):1328-1335. 

In This Article

Abstract and Introduction

Abstract

Study Design: A prospective, randomized, double-blind controlled trial.

Objective: To explore the effect of multifunctional cocktail for bleeding and pain control after spinal fusion.

Summary of Background Data: Managing postoperative bleeding and pain after spinal fusion remains a challenge. Topical application of tranexamic acid or anesthetic agents for bleeding or pain management just started recently, and the multifunctional cocktail for bleeding and pain control simultaneously after spinal fusion have never been published.

Methods: Ninety patients who underwent posterior spinal fusion were enrolled in this study. The multifunctional cocktail was injected into the incision before wound closure in the cocktail group. In the control group, an equal volume of normal saline was injected and a patient-controlled analgesic pump was used. Visual analogue scale score; opioid consumption; intraoperative, postoperative, hidden and total blood loss; volume of drainage, hematocrit levels of drainage; hemoglobin levels; and complications were compared between the two groups.

Results: There were no differences in the visual analogue scale within 48 hours after surgery between the two groups. However, the opioid dosages in the control group were higher than those in the cocktail group. The postoperative blood loss, total blood loss, and hidden blood loss were lower in the cocktail group than in the control group. The drainage volume showed no differences between the two groups; however, the hematocrit level of drainage at 24 hours after surgery was lower in the cocktail group than in the control group. The hemoglobin level was higher in the cocktail group than in the control group at postoperative day 3. Thirteen patients with unbearable nausea and vomiting in the control group, whereas no complications in the cocktail group.

Conclusion: Topical application of a multifunctional cocktail that we designed provides an effective and safe method for reducing pain and bleeding after spinal fusion.

Introduction

Managing postoperative bleeding and pain after spinal fusion remains a challenge because the procedure requires extensive exposure and dissection of the paraspinal muscles.[1,2] On the one hand, excessive postoperative bleeding could cause the need for a blood transfusion, which is accompanied by risks of hypersensitivity, cross-infection, and rejection.[3] Bleeding at the surgical site after spinal fusion could also form an epidural hematoma, which can compress the cauda equina.[4] On the other hand, higher levels of postoperative pain are associated with delayed postoperative mobilization and hospital discharge and increased risks of complications, such as hospital-acquired infections and thromboembolic events.[5] Therefore, a safe and efficient treatment strategy to reduce perioperative blood loss and pain simultaneously is very necessary for spinal fusion.

Tranexamic acid (TXA), an antifibrinolytic agent that can help to improve coagulation function by inhibiting the degradation of fibrin,[6,7] has been confirmed to reduce blood loss and transfusion requirements in many types of orthopedic surgery.[8–10] Although considerable, serious systemic side effects after intravenous TXA exposure are quite rare, they have occurred.[11] Recently, TXA was applied via intra-articular injection or irrigated into the wound before skin closure in hip and knee arthroplasty and was confirmed to reduce postoperative blood loss and blood transfusion requirements in these surgical disciplines, providing a possibility for exploring its hemostatic function in the field of spinal surgery.[12]

Opioids are widely used in acute pain management after spinal surgery. However, there are numerous side effects and limitations associated with their use.[13,14] Compared to opioids, local infiltration analgesia (LIA) is a more attractive method with the advantages of safety, simplicity, and low-cost.[2] The current trend is to combine different adjuvants, including epinephrine, dexamethasone, etc., with different local anesthetic agents to augment postoperative analge-sia.[15] Ropivacaine is considered the better choice of local anesthetic agent, with a longer duration of action with much safer cardiotoxicity profile.[16] A recent study reported that ropivacaine combined with epinephrine and methylprednisolone diminished postoperative pain from total knee arthroplasty effectively and safely.[17]

Topical application of TXA or anesthetic agents for bleeding or pain management just started recently, and the effects of a multifunctional cocktail combined with TXA and ropivacaine for bleeding and pain control after spinal fusion have never been published. Therefore, we designed this prospective, randomized, double-blind trial to evaluate the effects of the topical application of a multifunctional cocktail combined with TXA and ropivacaine for bleeding and pain management after spinal fusion.

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