Post-operative Pain Management in Spine Surgery

  • Ravi K. Grandhi
  • Alaa Abd-ElsayedEmail author


Following spine surgery, the majority of patients report moderate to severe pain that lasts at least 3–4 days. This pain can be severe and debilitating affecting recovery and discharge from the hospital. This can prolong hospital stays and increase the costs associated with care. Multimodal pain management is the most effective to treat the pain. The multimodal techniques are divided into those given preoperatively, intraoperatively, and postoperatively. The techniques used involve a combination of neuraxial and oral/intravenous medications. Neuraxial analgesia is the most effective for pain management and is often superior to systemic opioids. Use of neuraxial anesthetics has synergistic potential with the systemic opioids. Opioids are often initially delivered via a patient-controlled analgesia (PCA) or neuraxially, but they are transitioned to oral medications as tolerated. Adjuvants that can be used include nonsteroidal agents, acetaminophen, dexmedetomidine, corticosteroids, ketamine, and gabapentin/pregabalin. These adjuvants help limit the side effects of opioids. Treatment is challenging in these patients because many are not narcotic naïve. Use of multimodal analgesia is important to helping these patients.


Spine surgery Pain Multimodal analgesia Neuraxial anesthesia Opioid therapy Analgesic adjuvants 


  1. 1.
    Pyati S, Gan TJ. Perioperative pain management. CNS Drugs. 2007;21(3):185–211.CrossRefGoogle Scholar
  2. 2.
    Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S. Causes and risk factors for 30-day unplanned readmissions after lumbar spine surgery. Spine (Phila Pa 1976). 2014;39(9):761–8.CrossRefGoogle Scholar
  3. 3.
    Ortiz-Cardona J, Bendo AA. Perioperative pain management in the neurosurgical patient. Anesthesiol Clin. 2007;25(3):655–74. xi.CrossRefGoogle Scholar
  4. 4.
    Klimek M, Ubben JF, Ammann J, Borner U, Klein J, Verbrugge SJ. Pain in neurosurgically treated patients: a prospective observational study. J Neurosurg. 2006;104(3):350–9.CrossRefGoogle Scholar
  5. 5.
    Oskouian R, Johnson J. Endoscopic thoracic microdiscectomy. J Neurosurg. 2005;3(6):459–64.Google Scholar
  6. 6.
    Fessler RG, O’Toole JE, Eichholz KM, Perez-Cruet MJ. The development of minimally invasive spine surgery. Neurosurg Clin N Am. 2006;17(4):401–9.CrossRefGoogle Scholar
  7. 7.
    Bajwa SJ, Haldar R. Pain management following spinal surgeries: An appraisal of the available options. J Craniovertebr Junction Spine. 2015;6(3):105–10.CrossRefGoogle Scholar
  8. 8.
    Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth. 2008;101(6):832–40.CrossRefGoogle Scholar
  9. 9.
    Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth Analg. 2000;91(5):1232–42.PubMedGoogle Scholar
  10. 10.
    Hanna MN, Murphy JD, Kumar K, Wu CL. Regional techniques and outcome: what is the evidence? Curr Opin Anaesthesiol. 2009;22(5):672–7.CrossRefGoogle Scholar
  11. 11.
    Amaranath L, Andrish JT, Gurd AR, Weiker GG, Yoon H. Efficacy of intermittent epidural morphine following posterior spinal fusion in children and adolescents. Clin Orthop Related Res. 1989;249:223–6.Google Scholar
  12. 12.
    Ezhevskaya AA, Mlyavykh SG, Anderson DG. Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery. Spine (Phila Pa 1976). 2013;38(15):1324–30.CrossRefGoogle Scholar
  13. 13.
    Volk T, Schenk M, Voigt K, Tohtz S, Putzier M, Kox WJ. Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery. Anesth Analg. 2004;98(4):1086–92.CrossRefGoogle Scholar
  14. 14.
    Jason Lowry K, Tobias J, Kittle D, Burd T, Gaines RW. Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis. Spine. 2001;26(11):1290–3.CrossRefGoogle Scholar
  15. 15.
    Chaterjee S, Ghosh S, Ray S, Rudra A. Pain management after spinal surgery. Indian Journal of Pain. 2015;29(1):9.CrossRefGoogle Scholar
  16. 16.
    Tobias JD. A review of intrathecal and epidural analgesia after spinal surgery in children. Anesth Analg. 2004;98(4):956–65.CrossRefGoogle Scholar
  17. 17.
    Gustafsson LL, Friberg-Nielsen S, Garle M, Mohall A, Rane A, Schildt B, et al. Extradural and parenteral morphine: kinetics and effects in postoperative pain. A controlled clinical study. Br J Anaesth. 1982;54(11):1167–74.CrossRefGoogle Scholar
  18. 18.
    Cohen M, Zuk J, McKay N, Erickson M, Pan Z, Galinkin J. Intrathecal morphine versus extended-release epidural morphine for postoperative pain control in pediatric patients undergoing posterior spinal fusion. Anesth Analg. 2017;124(6):2030–7.CrossRefGoogle Scholar
  19. 19.
    Vineyard JC, Toohey JS, Neidre A, Fogel G, Joyner R. Evaluation of a single-dose, extended-release epidural morphine formulation for pain control after lumbar spine surgery. J Surg Orthop Adv. 2014;23(01):9–12.CrossRefGoogle Scholar
  20. 20.
    Reynolds RA, Legakis JE, Tweedie J, Chung Y, Ren EJ, Bevier PA, et al. Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of continuous infusion of local anesthetics. Global Spine J. 2013;3(1):7–14.CrossRefGoogle Scholar
  21. 21.
    Mathiesen O, Dahl B, Thomsen BA, Kitter B, Sonne N, Dahl JB, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):2089–96.CrossRefGoogle Scholar
  22. 22.
    Grandhi RK, Lee S, Abd-Elsayed A. Does opioid use cause angiogenesis and metastasis? Pain Med. 2016;18(1):140–51.CrossRefGoogle Scholar
  23. 23.
    McDonald AJ, Cooper MG. Patient-controlled analgesia: an appropriate method of pain control in children. Paediatr Drugs. 2001;3(4):273–84.CrossRefGoogle Scholar
  24. 24.
    Gottschalk A, Durieux ME, Nemergut EC. Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112(1):218–23.CrossRefGoogle Scholar
  25. 25.
    Lee B, Park J, Suk K, Kim T, Lee H, Park M, et al. Pre-emptive and multi-modal perioperative pain management may improve quality of life in patients undergoing spinal surgery. Pain Physician. 2013;16(3):E217–26.PubMedGoogle Scholar
  26. 26.
    Ash SA, Buggy DJ. Does regional anaesthesia and analgesia or opioid analgesia influence recurrence after primary cancer surgery? An update of available evidence. Best Pract Res Clin Anaesthesiol. 2013;27(4):441–56.CrossRefGoogle Scholar
  27. 27.
    O’Keefe RJ, Tiyapatanaputi P, Xie C, Li TF, Clark C, Zuscik MJ, et al. COX-2 has a critical role during incorporation of structural bone allografts. Ann N Y Acad Sci. 2006;1068:532–42.CrossRefGoogle Scholar
  28. 28.
    Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth. 2005;52(5):506–12.CrossRefGoogle Scholar
  29. 29.
    Li Q, Zhang Z, Cai Z. High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion. Spine (Phila Pa 1976). 2011;36(7):E461–8.CrossRefGoogle Scholar
  30. 30.
    Hans P, Brichant JF, Bonhomme V, Triffaux M. Analgesic efficiency of propacetamol hydrochlorid after lumbar disc surgery. Acta Anaesthesiol Belg. 1993;44(4):129–33.PubMedGoogle Scholar
  31. 31.
    Dahl V, Raeder JC. Non-opioid postoperative analgesia. Acta Anaesthesiol Scand. 2000;44(10):1191–203.CrossRefGoogle Scholar
  32. 32.
    Flowers R, Vane J. Inhibition of prostaglandin synthetase in brain explains the anti-pyretic activity of paracetamol (4-acetamidophenol). Nature. 1972;240(5381):410–1.CrossRefGoogle Scholar
  33. 33.
    Tjolsen A, Lund A, Hole K. Antinociceptive effect of paracetamol in rats is partly dependent on spinal serotonergic systems. Eur J Pharmacol. 1991;193(2):193–201.CrossRefGoogle Scholar
  34. 34.
    Blanco JS, Perlman SL, Cha HS, Delpizzo K. Multimodal pain management after spinal surgery for adolescent idiopathic scoliosis. Orthopedics. 2013;36(2 Suppl):33–5.CrossRefGoogle Scholar
  35. 35.
    Rockemann MG, Seeling W. Epidural and intrathecal administration of alpha 2-adreno-ceptor agonists for postoperative pain relief. Schmerz. 1996;10(2):57–64.CrossRefGoogle Scholar
  36. 36.
    Jellish WS, Abodeely A, Fluder EM, Shea aJ. The effect of spinal bupivacaine in combination with either epidural clonidine and/or 0.5% bupivacaine administered at the incision site on postoperative outcome in patients undergoing lumbar laminectomy. Anesth Analg. 2003;96(3):874–80.CrossRefGoogle Scholar
  37. 37.
    Gupta N, Rath GP, Prabhakar H, Dash HH. Effect of intraoperative dexmedetomidine on postoperative recovery profile of children undergoing surgery for spinal dysraphism. J Neurosurg Anesthesiol. 2013;25(3):271–8.CrossRefGoogle Scholar
  38. 38.
    Ngwenyama NE, Anderson J, Hoernschemeyer DG, Tobias JD. Effects of dexmedetomidine on propofol and remifentanil infusion rates during total intravenous anesthesia for spine surgery in adolescents. Paediatr Anaesth. 2008;18(12):1190–5.PubMedGoogle Scholar
  39. 39.
    Marks R. Use of dexmedetomidine (Precedex) for spine surgery. J Spine. 2015;04(01):e115. Scholar
  40. 40.
    Hwang W, Lee J, Park J, Joo J. Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol. 2015;15:21.CrossRefGoogle Scholar
  41. 41.
    Lundin A, Magnuson A, Axelsson K, Kogler H, Samuelsson L. The effect of perioperative corticosteroids on the outcome of microscopic lumbar disc surgery. Eur Spine J. 2003;12(6):625–30.CrossRefGoogle Scholar
  42. 42.
    King JS. Dexamethasone--a helpful adjunct in management after lumbar discectomy. Neurosurgery. 1984;14(6):697–700.CrossRefGoogle Scholar
  43. 43.
    Urrutia J, Carmona M, Briceno J. Do corticosteroids affect lumbar spinal fusion? a rabbit model using high-dose methylprednisolone. J Orthop Sci. 2011;16(4):439–42.CrossRefGoogle Scholar
  44. 44.
    Jeyamohan SB, Kenning TJ, Petronis KA, Feustel PJ, Drazin D, DiRisio DJ. Effect of steroid use in anterior cervical discectomy and fusion: a randomized controlled trial. J Neurosurg Spine. 2015;23(2):137–43.CrossRefGoogle Scholar
  45. 45.
    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review J Neurosurg Spine. 2010;13(6):745–57.CrossRefGoogle Scholar
  46. 46.
    Ma QP, Woolf CJ. Noxious stimuli induce an N-methyl-D-aspartate receptor-dependent hypersensitivity of the flexion withdrawal reflex to touch: implications for the treatment of mechanical allodynia. Pain. 1995;61(3):383–90.CrossRefGoogle Scholar
  47. 47.
    Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology. 2005;102(1):211–20.CrossRefGoogle Scholar
  48. 48.
    Sharma S, Balireddy RK, Vorenkamp KE, Durieux ME. Beyond opioid patient-controlled analgesia: a systematic review of analgesia after major spine surgery. Reg Anesth Pain Med. 2012;37(1):79–98.CrossRefGoogle Scholar
  49. 49.
    Rusy LM, Hainsworth KR, Nelson TJ, Czarnecki ML, Tassone JC, Thometz JG, et al. Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial. Anesth Analg. 2010;110(5):1393–8.CrossRefGoogle Scholar
  50. 50.
    Turan A, Karamanlioglu B, Memis D, Hamamcioglu MK, Tukenmez B, Pamukcu Z, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology. 2004;100(4):935–8.CrossRefGoogle Scholar
  51. 51.
    Pandey CK, Sahay S, Gupta D, Ambesh SP, Singh RB, Raza M, et al. Preemptive gabapentin decreases postoperative pain after lumbar discoidectomy. Can J Anaesth. 2004;51(10):986–9.CrossRefGoogle Scholar
  52. 52.
    Pandey CK, Navkar DV, Giri PJ, Raza M, Behari S, Singh RB, et al. Evaluation of the optimal preemptive dose of gabapentin for postoperative pain relief after lumbar diskectomy. J Neurosurg Anesthesiol. 2005;17(2):65–8.CrossRefGoogle Scholar
  53. 53.
    Kim JC, Choi YS, Kim KN, Shim JK, Lee JY, Kwak YL. Effective dose of peri-operative oral pregabalin as an adjunct to multimodal analgesic regimen in lumbar spinal fusion surgery. Spine (Phila Pa 1976). 2011;36(6):428–33.CrossRefGoogle Scholar
  54. 54.
    Gianesello L, Pavoni V, Barboni E, Galeotti I, Nella A. Perioperative pregabalin for postoperative pain control and quality of life after major spinal surgery. J Neurosurg Anesthesiol. 2012;24(2):121–6.CrossRefGoogle Scholar
  55. 55.
    Reuben SS, Buvanendran A, Kroin JS, Raghunathan K. The analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesth Analg. 2006;103(5):1271–7.CrossRefGoogle Scholar
  56. 56.
    Burke SM, Shorten GD. Perioperative pregabalin improves pain and functional outcomes 3 months after lumbar discectomy. Anesth Analg. 2010;110(4):1180–5.PubMedGoogle Scholar
  57. 57.
    Ozgencil E, Yalcin S, Tuna H, Yorukoglu D, Kecik Y. Perioperative administration of gabapentin 1,200 mg day −1 and pregabalin 300 mg day −1 for pain following lumbar laminectomy and discectomy: A randomised, double-blinded, placebo-controlled study. Singap Med J. 2011;52(12):883–9.Google Scholar
  58. 58.
    Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost D, Trost GR, et al. Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech. 2010;23(2):139–45.CrossRefGoogle Scholar
  59. 59.
    Cho YH, Kim CK, Heo KH, Lee MS, Ha IH, Son DW, et al. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2015;15(3):279–91.CrossRefGoogle Scholar
  60. 60.
    Archer KR, Coronado RA, Haug CM, Vanston SW, Devin CJ, Fonnesbeck CJ, et al. A comparative effectiveness trial of postoperative management for lumbar spine surgery: changing behavior through physical therapy (CBPT) study protocol. BMC Musculoskelet Disord. 2014;15:325.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyMaimonides Medical CenterBrooklynUSA
  2. 2.Department of Anesthesiology, UW Health Pain ServicesUniversity of Wisconsin-MadisonMadisonUSA

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