Perioperative Multimodal Analgesia for Adults undergoing surgery of the Spine- Systematic Review and Meta-analysis of Three or More Modalities.

Abstract

Multimodal analgesia is a strategy which may be employed to improve pain management in the perioperative period in patients undergoing surgery of the spine. However, there is no review evidence available on quantitative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the impact of maximal (three or more analgesic agents) multimodal analgesic medication in patients undergoing surgery of the spine. We included randomized controlled trials (RCT's) evaluating the use of three or more multimodal analgesia components (maximal multi modal analgesia) in patients undergoing spinal surgery. We excluded patients receiving neuraxial or regional analgesia. The control group consisted of placebo, standard care (any therapeutic modality including two or less analgesic components). Primary outcomes were post-operative pain scores at rest, at twenty-four, and forty eight hours. We searched the MEDLINE via Ovid SP; EMBASE via Ovid SP; and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used Cochrane's standard methods. We identified consistently improved analgesic endpoints across all pre-determined primary and secondary outcomes. A total of eleven eligible studies evaluated the primary outcome of pain at rest at twenty four hours. Patients receiving maximal multimodal analgesia were identified to have lower pain scores with an average of MD [-1.03], p<0.00001. Length of hospital stay was decreased in patients receiving multimodal analgesia MD [-0.55], p<0.00001. Perioperative maximal multimodal analgesia consistently improves visual analogue scale outcomes in adult population in the immediate post-operative period, with a moderate quality of evidence. There is significant decrease in hospital length of stay in patients receiving maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.