Changing the Way We Look at Pain & Functional Outcomes in Spine Surgery


Clint DevinSpine surgery has made great strides over the past decade from a big open procedure to a small, less invasive surgery in many cases. Patients are able to ambulate quicker, leading to shorter length of stay at the hospital, faster recovery and ultimately higher patient satisfaction. In the future, many spine cases will be moved into the outpatient setting.

But to make the transition safely and effectively, many spine surgeons are looking for a better way to handle postoperative pain management, especially for patients who have been dependent on narcotics for non-operative pain management.


"Prior to the 1990s, pain was managed without narcotics, or narcotics were limited. Around 1995, the American Pain Society in conjunction with the American Society of Anesthesiologists began a national campaign to address the perceived under-treatment of pain. Pain as the '5th vital sign initiative' emerged in 1998 from the Veterans Affairs system, followed in 2001 by implementation of new pain management standards by the Joint Commission. Around this time there was a push in pain management to begin using narcotics in non-malignant conditions, such as back and joint procedures, and then there was an exponential growth in the use of narcotics. Interestingly, current domestic sales account for 99 percent of the global hydrocodone consumption. More alarming is the fact that opioid overdose is the second leading cause of accidental death," says Clinton Devin, MD, assistant professor of Orthopaedic Surgery and Neurosurgery at Vanderbilt Spine in Nashville, Tenn.


"In response to these complications, the pendulum is swinging the other direction and policy makers and physicians are beginning to recognize the significant dangers of the inappropriate use of narcotics," says Dr. Devin. "Fortunately laws are being enacted to prevent the overprescribing of narcotics." The issue however, is that many of these patients initially present to a spine physician's office having been prescribed opioids for months if not years as the primary method of managing pain. In patients with a structural issue, for which surgery is appropriate, physicians must address any prior narcotics use and abuse before they are able to perform a successful surgery.


"I will have opioid dependent patients go through a detox program before they undergo surgery," says Dr. Devin. "Careful preoperative counseling is important, validating the patient's pain, but noting that postoperative pain management in opioid dependent patients can be challenging." In both opioid dependent and opioid naïve patients, poor pain control leaves patients dissatisfied with their experience and often lengthens hospital stays and recovery time.


At the 2011 annual meeting for the American Society of Health Systems Pharmacists, data was presented showing opioid-related adverse events increased hospital length of stay by more than one day and added at least $1,100 in hospital costs. Another study found the median hospitalization costs increased 7.4 percent with ORAEs and length of stay increased 10.3 percent.


A 2003 study in Anesthesia Analogue reported 80 percent of postsurgical patients experience pain, and the worst pain occurs within the first 24 hours to 48 hours after surgery. A Frost & Sullivan survey of medical and surgical nurse managers and directors shows 60 percent reported inadequate pain control being problematic in 20 percent of postsurgical cases. Additionally, 56 respondents reported problems with complications related to postsurgical pain management in at least 20 percent of cases.


It's also important to note that increased length of stay increased medication costs and nursing time. While readmissions were fully reimbursed in the past, new payment methods for government payers, which are quickly being adopted by shared savings programs among commercial payers, will not reimburse — or not fully reimburse — for complications and readmissions. This puts providers at substantial financial risk for each patient who returns to the hospital or needs additional care due to adverse events.


Pain is the single most common reason for readmission after same-day surgery, according to a report published in the Journal of Clinical Anesthesia, and the average cost of follow-up care per readmitted patient was $13,900. Additional expense could arise from litigation and medical malpractice suits associated with pain management deficiencies.


Perioperative pain management should employ a multimodal approach to optimize pain control, minimize complications and achieve more rapid discharge criteria. "There is a much better multimodal approach to pain management that we are just beginning to see utilized," says Dr. Devin. "The overarching idea is to address the patient's pain with narcotics in combination with local anesthetics and other medications. We are looking at different pathways and mechanisms to address pain."


Traditional anesthesia coupled with postoperative opioids to alleviate the pain leave patients too groggy for ambulation and can have several side-effects, including nausea and vomiting, constipation, urinary retention, respiratory depression, delirium and pruritus. Opioids remain a critical component of a multimodal approach, but decreased amounts are required when used in combination with other non-opioid therapies. Non-steroidal anti-inflammatory drugs are gaining interest, but also bare risks such as renal toxicity, bleeding and inhibition of bone healing.


Another powerful class of medications includes gabapentin and pregabalin however; these can have significant sedative effects, especially in the elderly. Acetaminophen has recently gained attention as a pain control adjunct and can be administered intravenous versus oral. Finally, local anesthetics can be delivered via an epidural catheter versus in the subcutaneous surgical site. Epidural catheters are effective, but can be costly due to anesthesia management and carry the risk of urinary retention and hypotension. Subcutaneous anesthetics in their standard form can augment pain control on the day of surgery, but unfortunately have a very short half life.


One of the newest options for postsurgical pain control is EXPAREL, which combines bupivacaine with the DepoFoam proprietary drug delivery technology that uses multivesicular liposomes to encapsulate the bupivacaine and release it over time. Pacira Pharmaceuticals developed EXPAREL, which has been proven effective for postoperative pain management in several applications, including orthopedics and spine, in more than 21 clinical studies.


EXPAREL is designed for administration to the surgical site to extend analgesia for up to 72 hours as part of the multimodal approach to a patient's pain management. In the appropriate patient, surgeons can administer EXPAREL to help the patients ambulate more quickly after surgery and return home within 23 hours, potentially moving some of the more complex spine cases into the outpatient setting.


"How do we better manage pain with non-narcotic methods? That's where we are focusing a lot of our research today. We know spine surgeries work and have a significant impact on the quality of life, but we need to figure out how to better optimize the 90-day morbidity and mortality," says Dr. Devin.


In the Frost & Sullivan's survey, 90 percent of nurses believed a long acting, non-opioid, local analgesic would have moderate, substantial or high value, and 80 percent of respondents thought it would somewhat or significantly decrease the opioid burden on patients. Avoiding pain pumps and IVs for postoperative pain management could also have an economic benefit on spine care.


"One nice thing about EXPAREL is they have kept their product very affordable. It is important that added treatments provide additional value to care while keeping cost in mind. Utilizing an extended release anesthetic as part of a multimodal pain regimen will help decrease length of stay, improve outcomes and minimize complications," says Dr. Devin.


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