Updated Spine (Multimodal) Analgesia Protocol

A multi-disciplinary team from Rush University Medical Center in Chicago, Illinois, unveiled a revised version of its standardized multimodal analgesia (MMA) protocol for patients undergoing spinal fusion. The original version, “Multimodal Analgesia Versus Intravenous Patient-Controlled Analgesia for Minimally Invasive Transforaminal Lumbar Interbody Fusion Procedures,” appeared in the August 1, 2017 edition of Spine.

Kern Singh, M.D., co-director of the Minimally Invasive Spine Institute at Rush, told OTW, “Revisions were made to the original protocol due to mental status changes observed with elderly patients and the long acting narcotic. The most recent iteration of the protocol is being evaluated and will be submitted for publication in Spine in 2019.A significant advancement in the MMA protocol was due to the collaboration with the director of Orthopedic Anesthesiology, Asokumar Buvanendran, MBBS.”

“As surgeons we have naturally focused more on the technical side of things. It appears, however, that while we have plateaued in improving efficiency, we can still do better in the realm of postoperative pain management. In looking at cervical and lumbar fusions we tweaked the protocol and looked at the best pathway by which to treat pain. It is increasingly obvious that pain is multifaceted; if you burn the tip of your finger the pain is mediated by a local response, so you give a local anesthetic. In other instances, the pain response goes to the head so central acting medications are required.”

“Our new protocol begins with preoperative counseling regarding anesthesia and analgesia. On the day of surgery, we initiate pain management in the preoperative holding area prior to the beginning of the procedure. We continue pain control intraoperatively and use a variety of modalities, including cryotherapy, muscle relaxants, neuropathic pain relievers, acetaminophen, and opioids. We discharge patients with muscle relaxants, acetaminophen, and opioids.”

“The critical thing,” adds Dr. Singh, “is staff education. With our patients, from the minute they register they are given preop meds (anti-inflammatories, muscle relaxants, etc.) so that it all takes effect before the incision. Staff must be trained at every step that pain is not just treated with narcotics. Also, in order to achieve a good postoperative outcome, it is necessary to begin with preop patient education. They need to understand what they should expect and that they should anticipate some pain, that there are different types of pain, and that muscle spasms or irritation is within the normal range.”