The spine is one of the most difficult areas to operate with a good post-operative outcome. Compared to other orthopedic surgeries, for example, knee replacement, a greater number of post-operative patients continue to have unpleasant symptoms that often require pain management to allow the patient to live a normal life.
After spine surgery, the use of post-operative pain medicines is fairly common around the world. However, despite the extensive use, there is not a fixed protocol standardizing the type, strength, quantity, and duration of pain medication used. Hence, the type of medications used depends on individual symptoms and needs. The pain medication is usually needed to manage the symptoms the surgery was originally indicated for, although, ideally, the surgery should result in complete resolution of pain excluding the small post-operative period in which management of acute pain is needed.
As spinal procedures are associated with great pain in the post-operative period, adequate management of acute as well as chronic pain is very important. Proper care and pain management after the surgery are associated with better functionality, early discharge, and prevention of development of chronic pain, so, overall, much better outcomes. A number of drugs are available for pain management. Usually, a combination of drugs is used.
The effective treatment of post-operative pain in patients who underwent spinal surgery is complicated by many factors, most important being the fact that many of these patients were already on narcotic analgesics for the management of their chronic pain before the surgery. As a result, most of these patients are tolerant to the effects of most potent pain killers there are i-e opioids. For this reason, these patients are weaned off narcotic analgesics before they are operated.
Some of the pain management approaches commonly used are:
Narcotic Analgesics: These are most commonly used for the treatment of severe pain with excellent results. They can be given by oral, intramuscular or intravenous routes providing a great degree of quick relief. Among narcotics, morphine is a first-line drug provided there is no contraindication.
Non-steroidal Anti-inflammatory Drugs (NSAIDs): These include many of the drugs commonly used such as ibuprofen, diclofenac, and aspirin. These drugs have proved effective for the treatment of post-operative pain, especially after spine surgery. They also resolve symptoms like inflammation, fever and improve post-operative ambulation. However, they are not suitable for exclusive use as they are not as potent analgesics as narcotics. They can be administrated via the oral or intravenous route.
Ketamine: Also used as an anesthetic, ketamine is effective for analgesia as it modifies the pain receptor pathway. Ketamine is also known to reduce or reverse opioid tolerance in chronic opioid users thus reducing the post-operative opioid need for the management of pain.
Corticosteroids: corticosteroids not only reduce inflammation but also decrease the tendency of scar formation in the post-operative period which results in less pain. They also decrease the release of substance P which is a mediator of pain sensation. Studies have also shown that certain corticosteroid help decreases the duration of hospital stay and the need for opioid analgesics.