Managing Pain After Spinal Surgery
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Peter G. Whang, MD, FACS Associate Professor, Spine Service Department of Orthopaedics and Rehabilitation Yale University School of Medicine
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Disclosure Information – – – –
Medtronic Pacira SI BONE Stryker Spine
• Speakers Bureau – Medtronic – Pacira – Stryker Spine
• Stock Options
• Advisory Positions – – – –
Cerapedics DiFusion Histogenics Relievant
• Research/Institutional Support – Vertiflex – SI-BONE – Spinal Kinetics op ae
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– DiFusion
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• Consultant
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Shift toward Ambulatory Setting • A broader number of more complex surgeries moving from inpatient to outpatient setting – Facilitated by improvements in surgical/anesthesia techniques – Increase patient satisfaction – Reduce overall costs c S p in
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Minimally Invasive Techniques
• Potential advantages Avoids morbidity of open procedures Decreased postoperative pain Shorter hospital LOS/reduced utilization of services Improved functional/clinical outcomes al
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Ambulatory Spine Surgery
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Ambulatory Spine Surgery
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– – – –
2
• Retrospective review of large multicenter clinical registry evaluating readmissions after lumbar spine operations • 4.4% incidence of 30-day unplanned admissions (695/15,568 patients)
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• Most frequent reasons for readmission Wound complications – 38.6% Inadequate pain relief – 22.4% Thromboembolic events – 9.4% Systemic infections – 8.0%
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• Retrospective review of consecutive series of ACDF procedures intended to identify factors contributing to increased hospital LOS • Most common complication – uncontrolled postoperative pain (13%)
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– – – –
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Postsurgical Pain 100 90 80
77
82
1995
86
2003 2012
70 60 49 47 45
50 40
25
30 19
20
23 21 23
13
18 8
10
8
0
Slight
Moderate
Severe
Extreme
op ae
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Any
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Treating Postsurgical Pain • Prerequisites for successful management of postoperative pain Provide adequate analgesia Easy to implement Minimal side effects Facilitate mobility Cost-effective op ae
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– – – – –
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Ongoing Challenges • Suboptimal efficacy – Analgesia – Duration
Not staff- or patient-friendly Potential for complications Hinders rehabilitation Expensive
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• • • •
4
Consequences of Postoperative Pain • Prolonged patient suffering – physical and psychological • Longer postsurgical recovery time1 • Delayed ambulation and daily functioning1
• Higher incidence of surgery-related complications2 • Increased length of stay (LOS) in the hospital2 • Hospital readmission3 • Unrelieved acute postsurgical pain is a predictor for chronic pain3 e Or th
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Ashburn MA, Caplan RA. Anesthesiology. 2004;100(6):1573-81. Agency for Healthcare Research & Quality (AHRQ). Acute Pain Management: Operative or Medical Procedures and Trauma. Available at: http://www.ahrq.gov/clinic/medtep/acute.htm. Accessed Sept 30, 2011. Perkins FM, Kehlet, H. Anesthesiology 2000; 93:1123-33.
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Pain and Patient Satisfaction • Pain management is the only clinical marker assessed: The HCAHPS survey contains 27 questions on 8 topics ranging from communication and cleanliness to staff responsiveness and pain management 1 – How often was your pain well controlled? (question 13) – How often did the hospital staff do everything they could to help you with your pain? (question 14) • HCAHPS scores have a direct impact on reimbursement: 30% of a hospital’s value-based incentive payment from CMS is determined by HCAHPS scores 2 • Hospital HCAHPS performance is publically available: Results are reported online quarterly at2: http://www.medicare.gov/hospitalcompare
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1. HCAHPS fact sheet. HCAHPS Website. http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012.pdf. Updated May 17, 2012. Accessed October 9, 2012. op ae 2.Center for Medicare and Medicaid Services. Electronic presentation available at: http://www.hcahpsonline.org/Files/March%202013% 20HCAHPS%20Intro%20Training%20Slides%20Session%20II_3-5-13.pdf Accessed May 6, 2013. e
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Opioid Use is Ubiquitous ~95% of Patients Received Opioid-Based Pain Management
95%
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1. Oderda G, Gan TJ. Poster presented at 46th ASHP Midyear Clinical Meeting & Exhibition; December 4-8, 2011; New Orleans, LA.
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As demonstrated in a national retrospective study utilizing patients from >450 hospitals in a large GPO database
5
Hidden Costs of Opioids • Effective • Low cost • • • • •
Side effects/associated costs Falls Adverse events over 10% Increased length of stay PCAs – Dose errors – Monitoring – Risk of respiratory depression op ae
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• Societal burdens
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Y
Opioid-Related Adverse Events Incidence
Constipation
40%-95%2
Opioid-Related Risk Factors •Can occur with a single dose of morphine 2
Nausea & vomiting
≥50%3,4
•Patients receiving injectable opioids have ~5 times higher risk of requiring medications to treat nausea and vomiting3 •Increases with cumulative opioid dose5
Urinary retention
18%-35%2,6
•Occurs most frequently with intrathecal morphine 2,5 •Risk increases in patients with benign prostatic hyperplasia7
Pruritus
30%->50%5,8
•Highest incidence associated with epidural administration 8
1.1%9
•Different opioid regimens are associated with variations in incidences9
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7. Andriole GL. Benign prostatic hyperplasia (BPH). The Merck Manual Home Health Handbook. http://www.merckmanuals.com/home/mens_health_ issues/prostate_ disorders/benign_ op ae prostatic_hyperplasia_bph.html. Updated October 2008. Accessed December 28, 2011. 8. Medscape Website. Naloxone for the Reversal of Opioid Adverse Effects: Clinical Uses. http://www.medscape.com/viewarticle/441915_4. Accessed Jan 24, 2012. 9. Jarynza D, et al. Pain Manage Nurs. 2011;12(3):118-145.
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1. Oderda GM, et al. J Pain Symptom Manage. 2003;25(3):276-283. 2. Benyamin R, et al. Pain Physician. 2008;11:S105-S120. 3. Suh D, et al. Clin J Pain. 2011;27:508-517. 4. Oderda GM, et al. Ann Pharmacother. 2007;41(3):400-406 5. Barletta J, et al. Ann Pharmacother.. 2011;45(7-8):916-923. 6. Rathmell JP, et al. Anesth Analg. 2005;101:S30-S43
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Respiratory depression
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Common ORAEs
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Opioid-Related Adverse Events
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Why Do We Need to Do Better?
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Preemptive Analgesia • Blockade of noxious stimuli during/immediately after surgery reduces postoperative pain • Prevents sensitization of CNS • Administration of antinociceptive agents
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– Local anesthetics – Opioids/analgesics – Antineuropathic agents
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Novel Strategies for Postsurgical Pain • Medications – Route of administration – po, iv, epidural – Timing – preop, intraop, postop – Mechanism of action – NSAIDs, analgesics, gabapentinoids
• Injectable local anesthetics e Or th
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– Continuous infusion devices – Liposomal bupivicaine
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NSAIDs
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NSAIDs
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Gabapentinoids
• Attenuate the nociceptive response by facilitating central desensitization – Bind to presynaptic calcium channels in nerve fibers – Inhibit release of excitatory neurotransmitters
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Gabapentinoids
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Epidural Local Anesthetics
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Epidural Steroids
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Epidural Steroids
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Epidural Opioids
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Continuous Local Infusion Devices
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• Elastomeric pump with flow restrictor connected to catheter • Allows for consistent delivery of medication into soft tissues • Inserted following wound closure • Patient may be discharged with device in place
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Continuous Local Infusion Devices
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Continuous Local Infusion Devices
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Injectable Liposomal Bupivicaine
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• Indicated for single-dose administration into the surgical site for postoperative analgesia • Requires no catheter, pump, or additional device • Shown to decrease pain and opioid consumption during the perioperative period
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Injectable Liposomal Bupivicaine • Mechanism of action1
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1. Lambert WJ, Los K. DepoFoam multivesicular liposomes for the sustained release of macromolecules. In: Rathbone MJ, Hadgraft J, Roberts MS, Lane ME, eds. Modified release drug delivery technology. 2nd ed. New York: Informa Healthcare; 2008.
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– DepoFoam – microvesicular liposomal carrier composed of natural membrane components that are biocompatible and biodegradable – Encapsulates drugs without altering their molecular structure – Allows for controlled release of bupivicaine over time
Y
Injectable Liposomal Bupivicaine • Technique of adminstration
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– 20 mL single-use vial which may be expanded with sterile normal saline – May be stored for up to 4 hours at room temperature prior to injection – Infiltration into soft tissues of surgical site
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Multimodal Regimens
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Multimodal Regimens
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Multimodal Regimens
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Multimodal Regimens
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Multimodal Analgesic Regimens
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Conclusion • Increasing number of spinal surgeries will be performed in ambulatory setting • Success of these procedures contingent upon obtaining adequate postoperative pain control • Multimodal analgesia may be safer, more effective, and give rise to greater cost savings than conventional regimens
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Thank You!
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4/23/2015
Opioid Related Adverse Events & Risk Factors in Spine Surgery Mark F. Kurd, MD Assistant Professor, Orthopaedic Surgery Thomas Jefferson University The Rothman Institute
Opioid use with surgery • Opioid use has become ubiquitous – Retail sales: increased 149% from 1997 to 2007 1
• Post-surgical opioid2 – 98.6% of patient received opioids – 13.6% had an opioid-related adverse event (ORAE)
• Patients with ORAE associated with2 – – – –
55% longer length of stay (LOS) 47% higher costs of care 36% increased risk of 30-day readmission 3.4 times higher risk of inpatient mortality
1 ASIPP 2
Fact Sheet Kessler et al, “Cost and Quality Implications…”, Pharmacotherapy, 2013. 33(4): 383-391.
Opioid use in Spine Surgery • More than 500,000 lumbar procedures annually in the United States • Most common pain management protocol is intravenous narcotics • Approx 22.4% of unplanned readmissions within 30 days postsurgery are related to pain3
3
Pugely et al, “Causes and Risk Factors…”, SPINE, 2014. 39(9): 761-768
1
4/23/2015
Study Objectives
Evaluate ORAE risk using a nationally representative sample of elderly lumbar spine surgery patients. David Polly Jr., M.D., Kevin Ong, Ph.D., Scott Lovald, Ph.D., Edmund Lau, M.S., Kris Radcliff, M.D.
Methods • 5% Medicare Part B claims data (2010-2012) • Identified lumbar laminectomy (LL) and posterior lumbar fusion (LF) patients
Procedure Lumbar laminectomy (LL)
Posterior lumbar fusion (LF)
CPT-4 Code 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048 22612, 22614, 22630, 2263222634, 22800, 22802, 22804, 22840, 22842-22844
Complication Codes Complication
HCPCS and ICD-9 codes
Naloxone exposure
E940.1, J2310
Poisoning by opioids
965.02, 965.09, E850.1, E850.2
Drugs causing adverse effects in therapeutic use Respiratory
E935.1, E935.2
Constipation narcotic induced
786.09, 518.5, 997.3, 799.01, 799.02 E937.9
Acute vertigo
386.2
Acute postoperative ileus
997.4
Paralytic ileus
560.1
Acute nausea/vomiting (PONV)
787.01
Acute delirium
780.09
Acute postoperative confusion
293.9
Rash/itching
698.9
Fall from bed
E884.4
Urinary retention
788.2
Oliguria
997.5
2
4/23/2015
Methods • Excluded patients with less than one year of claim history • 16,765 LF and 24,514 LL patients were • 90-day postop rate of newly-diagnosed ORAEs – Corresponding diagnoses within 90 days prior to surgery were considered as pre-existing conditions and were not included
• Multivariate Cox regression to evaluate risk factors for the complications – Age, socioeconomic status, comorbidity index, race, census region, gender, and year of surgery
Methods • Additional risk factors considered based on diagnoses within 12 months prior to surgery: Complication Risk factors Ileus Diverticulitis/diverticulosis Hernia Respiratory Sleep apnea COPD/emphysema Smoking Transient ischemic attack/stroke Delirium Alzheimer's disease Dementia Obesity
Codes 562.10-562.13 550-553 780.57 490-492, 494, 496 305.1, 989.84, V15.82 435.9, 997.02, 434.91 331.0 290, 291.2, 292.82, 294.1, 294.10, 294.11, 331.1x, 331.19, 331.82 V85.3x, V85.4x, 278.x
90-day ORAE Rate LL: 6.3 LF: 9.0
LL/LF: 5.8
LL: 2.8 LF: 3.8LL: 2.1 LF: 3.2 LL: 1.3 LF: 2.2
3
4/23/2015
ORAE Risk Factors Complications
Adjusted Risk Factors
LL
LF
Respiratory
Older patients
X
X
More comorbidities
X
X
History of COPD/Emphysema
X
X
Lower socioeconomic status
X
Older patients
X
Urinary retention
More comorbidities Men
PONV
X X
Older patients
Acute Delirium
Paralytic ileus
X
X
X
More comorbidities
X
X
Women
X
X
Older patients
X
X
More comorbidities
X
X
Obese patients
X
Men
X
X
Discussion • Most common ORAEs – Respiratory complications – Urinary retention
• Risk factors – Older patients – Increased comorbidities
• Higher rates of ORAE for LF vs. LL
Opioid Use • ORAE complications lead to longer stays, higher costs to patients2 • Alternatives to heavy opioid use5: – – – – – –
Short-acting opioids NSAIDs Preoperative “cocktails” Nerve blocks Intravenous acetaminophen Liposomal bupivacaine
• Alternative therapies may regulate pain postsurgery while minimizing adverse side effects 2 5
Kessler et al, “Cost and Quality Implications…”, Pharmacotherapy, 2013. 33(4): 383-391. “Surgeons explore non-opioid options…”, Orthopedics Today, August 2014.
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4/23/2015
Conclusions • Opioids: Effective and Common – acute postoperative pain
• Exposes patients to ORAEs – Older, sicker pts – Respiratory, urinary
• Adversely affect the patient • Increase healthcare costs • Explore the risk benefit ratio of alternative non-opioid pain strategies
Thank you
5
4/20/2015
MIS TLIF in the ASC Setting William Tally MD Associate Professor Orthopedics UGA/Georgia Regents University SOM Athens Orthopedic Clinic Athens Ga
Disclosure: Pacira Pharmaceutical- Research Grant Globus Medical- Consultant, Royalties Stryker Spine- Consultant, Royalties Amenia Medical- Consultant, Royalties, Stock Vivex Biological- Consultant, Research Support Important caveat- Ownership interest in the asc at which this study was performed- No financial support for pharmaceutical cost
TLIF/Laminectomy In transition: Inpatient Outpatient ASC
Becoming possible- due to shorter procedure time and multimodal pain control pathways Think like a total joint surgeon- efficiency!!
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4/20/2015
TLIF/Laminectomy Same way every time! set-up: same way C-arm: use 2 for speed 1) contra wires 2) ipsilateral wires (expose) 3) dilate/dissect 4) decompress/interbody 5)screws- use your assistant
Multimodal pain prevention Pathway Office: Pt/family education Holding: Oral narcotic/pregabalin Preop: Decadron, ketorolac Pre-incision: Local anesthetic Post-op: local anesthetic, rapid mobilization, traditional oral analgesic
Technique: Office Pre-op Pre-op education is key They will tolerate much more pain and discomfort is they know whats normal! PhrasesYou may not like me the first couple of days, but… You’re going to hurt some, would you rather be in your bed or the hospital? Moving around doesn’t make it hurt less, but not moving will make it hurt more On day 3 the numbing will wear off and you may hurt more- nothing is wrong
2
4/20/2015
Technique: HOLDING Oral narcotics Trust me your anesthesiologist will gladly do this- it makes their job easier Pre-gabalin I use anytime I work around the DRG or Plexus Don’t bother with neurontin
Technique: PRE-OP • Decadron – Helps with the airway (anesthesia will like this) – Helps with mobilization – Theoretical risk to fusion
• Toradol (only in non-fusion procedures)
Technique: PRE-INCISION Current ASC multimodal pathway was employed: Time released liposomal marcaine was instilled prior to incision 1)directly at the incision site(s) 2)Circumferentially to the incision(s) to ‘isolate’ the surgical field Approximately 1.5 cm away -22ga spinal needle was used to ensure good depth of administration- confirmed by fluoroscopy
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4/20/2015
Technique: POST-OP • Local Anesthetic- inject any additional sights • Rapid Mobilization – Get them up and into street clothes- not ‘Sick”
• Oral Medications – Hydrocodone 1-2 wean as tolerates – Oxycodone added if that’s not enough – Flexeril for spasm during the day – Valium for night (helps with sleep) – Lyrica for 7 days helps with neuritic pain
Conclusion
Speed and efficiency are key: TLIF under 1.5-2 hrs- so if there are any complications or problems- Time doesn’t become a factor Staff and Equipment are ESSENTIAL!
4
Managing Pain After Spinal Surgery
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op ae
c S p in
al
di
Peter G. Whang, MD, FACS Associate Professor, Spine Service Department of Orthopaedics and Rehabilitation Yale University School of Medicine
e
Y
Disclosure Information – – – –
Medtronic Pacira SI BONE Stryker Spine
• Speakers Bureau – Medtronic – Pacira – Stryker Spine
• Stock Options
• Advisory Positions – – – –
Cerapedics DiFusion Histogenics Relievant
• Research/Institutional Support – Vertiflex – SI-BONE – Spinal Kinetics op ae
c S p in
al
di
– DiFusion
e Or th
• Consultant
e
Y
Shift toward Ambulatory Setting • A broader number of more complex surgeries moving from inpatient to outpatient setting – Facilitated by improvements in surgical/anesthesia techniques – Increase patient satisfaction – Reduce overall costs c S p in
al
di
e Or th
op ae
1
e
Y
Minimally Invasive Techniques
• Potential advantages Avoids morbidity of open procedures Decreased postoperative pain Shorter hospital LOS/reduced utilization of services Improved functional/clinical outcomes al
c S p in
e Or th
op ae
di e
Y
Ambulatory Spine Surgery
c S p in
al
di
e Or th
op ae
e
Y
Ambulatory Spine Surgery
c S p in
al
di
e Or th
op ae
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Y
– – – –
2
• Retrospective review of large multicenter clinical registry evaluating readmissions after lumbar spine operations • 4.4% incidence of 30-day unplanned admissions (695/15,568 patients)
c S p in
al
di
e Or th
op ae
e
Y
• Most frequent reasons for readmission Wound complications – 38.6% Inadequate pain relief – 22.4% Thromboembolic events – 9.4% Systemic infections – 8.0%
op ae
e
Y
• Retrospective review of consecutive series of ACDF procedures intended to identify factors contributing to increased hospital LOS • Most common complication – uncontrolled postoperative pain (13%)
c S p in
al
di
e Or th
– – – –
c S p in
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di
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op ae
3
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Y
Postsurgical Pain 100 90 80
77
82
1995
86
2003 2012
70 60 49 47 45
50 40
25
30 19
20
23 21 23
13
18 8
10
8
0
Slight
Moderate
Severe
Extreme
op ae
c S p in
al
di
e Or th
Any
e
Y
Treating Postsurgical Pain • Prerequisites for successful management of postoperative pain Provide adequate analgesia Easy to implement Minimal side effects Facilitate mobility Cost-effective op ae
c S p in
al
di
e Or th
– – – – –
e
Y
Ongoing Challenges • Suboptimal efficacy – Analgesia – Duration
Not staff- or patient-friendly Potential for complications Hinders rehabilitation Expensive
c S p in
al
di
e Or th
op ae
e
Y
• • • •
4
Consequences of Postoperative Pain • Prolonged patient suffering – physical and psychological • Longer postsurgical recovery time1 • Delayed ambulation and daily functioning1
• Higher incidence of surgery-related complications2 • Increased length of stay (LOS) in the hospital2 • Hospital readmission3 • Unrelieved acute postsurgical pain is a predictor for chronic pain3 e Or th
op ae
al
Ashburn MA, Caplan RA. Anesthesiology. 2004;100(6):1573-81. Agency for Healthcare Research & Quality (AHRQ). Acute Pain Management: Operative or Medical Procedures and Trauma. Available at: http://www.ahrq.gov/clinic/medtep/acute.htm. Accessed Sept 30, 2011. Perkins FM, Kehlet, H. Anesthesiology 2000; 93:1123-33.
c S p in
3.
di
1. 2.
e
Y
Pain and Patient Satisfaction • Pain management is the only clinical marker assessed: The HCAHPS survey contains 27 questions on 8 topics ranging from communication and cleanliness to staff responsiveness and pain management 1 – How often was your pain well controlled? (question 13) – How often did the hospital staff do everything they could to help you with your pain? (question 14) • HCAHPS scores have a direct impact on reimbursement: 30% of a hospital’s value-based incentive payment from CMS is determined by HCAHPS scores 2 • Hospital HCAHPS performance is publically available: Results are reported online quarterly at2: http://www.medicare.gov/hospitalcompare
c S p in
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di
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1. HCAHPS fact sheet. HCAHPS Website. http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012.pdf. Updated May 17, 2012. Accessed October 9, 2012. op ae 2.Center for Medicare and Medicaid Services. Electronic presentation available at: http://www.hcahpsonline.org/Files/March%202013% 20HCAHPS%20Intro%20Training%20Slides%20Session%20II_3-5-13.pdf Accessed May 6, 2013. e
Y
Opioid Use is Ubiquitous ~95% of Patients Received Opioid-Based Pain Management
95%
e Or th
op ae
al
c S p in
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Y
1. Oderda G, Gan TJ. Poster presented at 46th ASHP Midyear Clinical Meeting & Exhibition; December 4-8, 2011; New Orleans, LA.
di
As demonstrated in a national retrospective study utilizing patients from >450 hospitals in a large GPO database
5
Hidden Costs of Opioids • Effective • Low cost • • • • •
Side effects/associated costs Falls Adverse events over 10% Increased length of stay PCAs – Dose errors – Monitoring – Risk of respiratory depression op ae
c S p in
al
di
e Or th
• Societal burdens
e
Y
Opioid-Related Adverse Events Incidence
Constipation
40%-95%2
Opioid-Related Risk Factors •Can occur with a single dose of morphine 2
Nausea & vomiting
≥50%3,4
•Patients receiving injectable opioids have ~5 times higher risk of requiring medications to treat nausea and vomiting3 •Increases with cumulative opioid dose5
Urinary retention
18%-35%2,6
•Occurs most frequently with intrathecal morphine 2,5 •Risk increases in patients with benign prostatic hyperplasia7
Pruritus
30%->50%5,8
•Highest incidence associated with epidural administration 8
1.1%9
•Different opioid regimens are associated with variations in incidences9
e Or th
7. Andriole GL. Benign prostatic hyperplasia (BPH). The Merck Manual Home Health Handbook. http://www.merckmanuals.com/home/mens_health_ issues/prostate_ disorders/benign_ op ae prostatic_hyperplasia_bph.html. Updated October 2008. Accessed December 28, 2011. 8. Medscape Website. Naloxone for the Reversal of Opioid Adverse Effects: Clinical Uses. http://www.medscape.com/viewarticle/441915_4. Accessed Jan 24, 2012. 9. Jarynza D, et al. Pain Manage Nurs. 2011;12(3):118-145.
di
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1. Oderda GM, et al. J Pain Symptom Manage. 2003;25(3):276-283. 2. Benyamin R, et al. Pain Physician. 2008;11:S105-S120. 3. Suh D, et al. Clin J Pain. 2011;27:508-517. 4. Oderda GM, et al. Ann Pharmacother. 2007;41(3):400-406 5. Barletta J, et al. Ann Pharmacother.. 2011;45(7-8):916-923. 6. Rathmell JP, et al. Anesth Analg. 2005;101:S30-S43
al
Respiratory depression
e
Common ORAEs
Y
Opioid-Related Adverse Events
c S p in
al
di
e Or th
op ae
6
e
Y
Why Do We Need to Do Better?
c S p in
al
di
e Or th
op ae
e
Y
Preemptive Analgesia • Blockade of noxious stimuli during/immediately after surgery reduces postoperative pain • Prevents sensitization of CNS • Administration of antinociceptive agents
e Or th
op ae
c S p in
al
di
– Local anesthetics – Opioids/analgesics – Antineuropathic agents
e
Y
Novel Strategies for Postsurgical Pain • Medications – Route of administration – po, iv, epidural – Timing – preop, intraop, postop – Mechanism of action – NSAIDs, analgesics, gabapentinoids
• Injectable local anesthetics e Or th
op ae
c S p in
al
di e
Y
– Continuous infusion devices – Liposomal bupivicaine
7
NSAIDs
c S p in
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op ae
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Y
NSAIDs
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di
e Or th
op ae
e
Y
Gabapentinoids
• Attenuate the nociceptive response by facilitating central desensitization – Bind to presynaptic calcium channels in nerve fibers – Inhibit release of excitatory neurotransmitters
c S p in
al
di
e Or th
op ae
8
e
Y
Gabapentinoids
c S p in
al
di
e Or th
op ae
e
Y
Epidural Local Anesthetics
c S p in
al
di
e Or th
op ae
e
Y
Epidural Steroids
c S p in
al
di
e Or th
op ae
9
e
Y
Epidural Steroids
c S p in
al
di
e Or th
op ae
e
Y
Epidural Opioids
c S p in
al
di
e Or th
op ae
e
Y
Continuous Local Infusion Devices
e Or th
op ae
c S p in
al
di e
Y
• Elastomeric pump with flow restrictor connected to catheter • Allows for consistent delivery of medication into soft tissues • Inserted following wound closure • Patient may be discharged with device in place
10
Continuous Local Infusion Devices
c S p in
al
di
e Or th
op ae
e
Y
Continuous Local Infusion Devices
c S p in
al
di
e Or th
op ae
e
Y
Injectable Liposomal Bupivicaine
e Or th
op ae
c S p in
al
di e
Y
• Indicated for single-dose administration into the surgical site for postoperative analgesia • Requires no catheter, pump, or additional device • Shown to decrease pain and opioid consumption during the perioperative period
11
Injectable Liposomal Bupivicaine • Mechanism of action1
e Or th
op ae
al
c S p in
e
1. Lambert WJ, Los K. DepoFoam multivesicular liposomes for the sustained release of macromolecules. In: Rathbone MJ, Hadgraft J, Roberts MS, Lane ME, eds. Modified release drug delivery technology. 2nd ed. New York: Informa Healthcare; 2008.
di
– DepoFoam – microvesicular liposomal carrier composed of natural membrane components that are biocompatible and biodegradable – Encapsulates drugs without altering their molecular structure – Allows for controlled release of bupivicaine over time
Y
Injectable Liposomal Bupivicaine • Technique of adminstration
e Or th
op ae
c S p in
al
di
– 20 mL single-use vial which may be expanded with sterile normal saline – May be stored for up to 4 hours at room temperature prior to injection – Infiltration into soft tissues of surgical site
e
Y
Multimodal Regimens
c S p in
al
di
e Or th
op ae
12
e
Y
Multimodal Regimens
c S p in
al
di
e Or th
op ae
e
Y
Multimodal Regimens
c S p in
al
di
e Or th
op ae
e
Y
Multimodal Regimens
c S p in
al
di
e Or th
op ae
13
e
Y
Multimodal Analgesic Regimens
c S p in
al
di
e Or th
op ae
e
Y
Conclusion • Increasing number of spinal surgeries will be performed in ambulatory setting • Success of these procedures contingent upon obtaining adequate postoperative pain control • Multimodal analgesia may be safer, more effective, and give rise to greater cost savings than conventional regimens
c S p in
al
di
e Or th
op ae
e
Y
Thank You!
c S p in
al
di
e Or th
op ae
14
e
Y
