Brazilian Journal of Pain
https://brjp.org.br/article/doi/10.5935/2595-0118.20230096-en
Brazilian Journal of Pain
Review Article

Multimodal analgesia versus patient-controlled analgesia in the management of acute postoperative spinal pain: systematic review and meta-analysis

Analgesia multimodal versus analgesia controlada pelo paciente no tratamento da dor aguda pós-operatória da coluna: revisão sistemática e meta-análise

Lucas de Melo Castro Deligne; Guilherme Baldez Pinheiro; Marcelo de Oliveira Peres; André Moreira Castilho

Downloads: 0
Views: 74

Abstract

BACKGROUND AND OBJECTIVES: Spine diseases have a high annual prevalence and are the main causes of years lived with disability and chronic pain. Among the postoperative analgesic control options, patient-controlled analgesia (PCA) and multimodal analgesia (MMA) have shown good clinical results. This meta-analysis seeks new evidence to help in the treatment of acute postoperative pain in patients undergoing spinal surgery. 
CONTENTS: The following databases were used: Cochrane Central Register of Controlled Trials, Medline and Embase. Studies that compared two post-surgical analgesic interventions were included; MMA and PCA. The parameters evaluated were: analgesic effect; opioid consumption; length of hospital stay; and adverse effects. Registration of the systematic review protocol: (PROSPERO CRD42023446627). There was no statistical difference when assessing analgesic improvement comparing MMA to PCA (MD -0.12 [-0.41, 0.17] 95%CI with p=0.69). There was a statistical difference, with lower opioid consumption in MMA compared to PCA (MD -3.04 [-3.69, -2.39] 95%CI with p=0.0002). Statistically significant difference regarding length of hospital stay in favor of MMA (MD -13.17 [-16.98, -9.36] 95%CI with p=0.00001), and significantly lower incidence of nausea and vomiting in patients undergoing MMA in compared to PCA (OR 0.26 [0.11, -0.64] 95%CI with p=0.003). 
CONCLUSION: MMA was equivalent to PCA in the treatment of acute postoperative spinal pain, with the significant clinical advantage and safety of lower amounts of infused opioids, shorter hospital stay and lower incidence of adverse effects.

Keywords

Acute pain, Analgesia, Combined modality therapy, Low back pain, Modality therapy, Neck pain

Resumo

JUSTIFICATIVA E OBJETIVOS: As doenças da coluna apresentam alta prevalência anual e são as principais causas de anos vividos com incapacidade e de cronificação da dor. Dentre as opções de controle analgésico pós-operatória, a analgesia controlada pelo paciente (ACP) e a analgesia multimodal (AMM) apresentam bons resultados clínicos. O objetivo deste estudo foi buscar novas evidências que auxiliem no tratamento da dor aguda no pós-operatório do paciente submetido à cirurgia da coluna.
CONTEÚDO: As bases de dados utilizadas: Cochrane Central Register of Controlled Trials,  Medline e Embase. Foram incluídos estudos que compararam duas intervenções analgésicas pós-cirúrgicas; AMM e ACP. Os parâmetros avaliados foram: efeito analgésico; consumo de opioide; tempo de internação hospitalar e efeitos adversos. Registro do protocolo de revisão sistemática: (PROSPERO CRD42023446627). Não houve diferença estatística quando avaliadas a melhora analgésica comparando a AMM à ACP (MD -0,12 [-0,41, 0,17] 95%CI com p=0,69). Houve diferença estatística, com menor consumo de opioide na AMM em comparação à ACP (MD -3,04 [-3,69, -2,39] 95%IC com p=0,0002). Diferença estatística significativa com relação ao tempo de permanência hospitalar a favor da AMM (MD -13,17 [-16,98, -9,36] 95%IC com p=0,00001), e incidência significativamente menor de náuseas e vômitos nos pacientes submetidos a AMM em comparação a ACP (OR 0,26 [0,11, -0,64] 95%IC com p=0,003). 
CONCLUSÃO: A AMM foi equivalente à ACP no tratamento da dor aguda pós-operatória da coluna, com a significativa vantagem clínica e a segurança de menores quantidades de opioides infundidos, menor tempo de internação hospitalar e menor incidência de efeitos adversos.

Palavras-chave

Analgesia controlada pelo paciente, Cervicalgia, Dor Aguda, Dor lombar, Terapia combinada

References

1 Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783-92.

2 Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769-81.

3 de David CN, Deligne LMC, da Silva RS, Malta DC, Duncan BB, Passos VMA, Cousin E. The burden of low back pain in Brazil: estimates from the Global Burden of Disease 2017 Study. Popul Health Metr. 2020;18(Suppl 1):12.

4 de Melo Castro Deligne L, Rocha MCB, Malta DC, Naghavi M, de Azeredo Passos VM. The burden of neck pain in Brazil: estimates from the global burden of disease study 2019. BMC Musculoskelet Disord. 2021;22(1):811.

5 Carolina CR, Maglioni CB, Machado GB, Araújo JE, Silva JS, Silva ML. Prevalence and characteristics of chronic pain in Brazil: a national internet-based survey study. BrJP. 2018;1(4):331-8.

6 Buruck G, Tomaschek A, Wendsche J, Ochsmann E, Dörfel D. Psychosocial areas of worklife and chronic low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):480.

7 Dieleman JL, Cao J, Chapin A, Chen C, Li Z, Liu A, Horst C, Kaldjian A, Matyasz T, Scott KW, Bui AL, Campbell M, Duber HC, Dunn AC, Flaxman AD, Fitzmaurice C, Naghavi M, Sadat N, Shieh P, Squires E, Yeung K, Murray CJL. Us health care spending by payer and health condition, 1996-2016. JAMA. 2020;323(9):863-84.

8 Davin SA, Savage J, Thompson NR, Schuster A, Darnall BD. Transforming standard of care for spine surgery: integration of an online single-session behavioral pain management class for perioperative optimization. Front Pain Res (Lausanne). 2022;3:856252

9 Carr EC, Thomas VJ. Anticipating and experiencing post-operative pain: the patients’ perspective. J Clin Nurs. 1997;6(3):191-201.

10 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-40.

11 Sommer M, de Rijke JM, van Kleef M, Kessels AG, Peters ML, Geurts JW, Gramke HF, Marcus MA. The prevalence of postoperative pain in a sample of 1490 surgical inpatients. Eur J Anaesthesiol. 2008;25(4):267-74.

12 Fletcher D, Stamer UM, Pogatzki-Zahn E, Zaslansky R, Tanase NV, Perruchoud C, Kranke P, Komann M, Lehman T, Meissner W; euCPSP group for the Clinical Trial Network group of the European Society of Anaesthesiology. Chronic postsurgical pain in Europe: an observational study. Eur J Anaesthesiol. 2015;32(10):725-34.

13 Fuzier R, Rousset J, Bataille B, Salces-y-Nédéo A, Maguès JP. One half of patients reports persistent pain three months after orthopaedic surgery. Anaesth Crit Care Pain Med. 2015;34(3):159-64.

14 Joelsson M, Olsson LE, Jakobsson E. Patients’ experience of pain and pain relief following hip replacement surgery. J Clin Nurs. 2010;19(19-20):2832-8.

15 Barros GAM, Lemonica L. Considerações sobre analgesia controlada pelo paciente em hospital universitário. Rev Bras Anestesiol. 2003;53(1):69-82.

16 Walder B, Schafer M, Henzi I, Tramèr MR. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. A quantitative systematic review. Acta Anaesthesiol Scand. 2001;45(7):795-804.

17 Stiller CO, Lundblad H, Weidenhielm L, Tullberg T, Grantinger B, Lafolie P, Jansson KA. The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty. Acta Anaesthesiol Scand. 2007;51(3):322-30.

18 McKenzie R, Rudy TE, Tantisira T. Comparison of ACP Aline and ACP with continous incisional on pain relief and quality of sleep. Anaesthesiol 1990;73:787-90.

19 Lee GW. A prospective observational cohort study on postoperative intravenous patient-controlled analgesia in surgeries. Anesth Pain Med. 2015;10(1):21-6.

20 White PF. Multimodal analgesia: its role in preventing postoperative pain. Curr Opin Investig Drugs. 2008;9(1):76-82.

21 Chou R, Gordon DB, de Leon-Casasola JM, Rosenberg SB, Bickler S, et al. Guidelines on the management of postoperative pain. J Pain. 2016;17(2):131-57.

22 Eziliano MS, Silva AD, Lourenço AM, Zanetti BV, Santos Júnior HAG, Velloso LUF, Reis PAT, Silva VCB, Sales TM. Estratégias de analgesia multimodal no manejo da dor aguda em adultos na emergência. Rev Eletrônica Acervo Científico. 2021;31.

23 Lorentzen V, Hermansen IL, Botti M. A prospective analysis of pain experience, beliefs and attitudes, and pain management of a cohort of Danish surgical patients. Eur J Pain. 2012;16(2):278-88.

24 https://training.cochrane.org/handbook

25 https://www.crd.york.ac.uk/prospero/

26 http://www.prisma-statement.org/documents/PRISMA-P-checklist.pdf

27 Choi SW, Cho HK, Park S, Yoo JH, Lee JC, Baek MJ, Jang HD, Cha JS, Shin BJ. Multimodal Analgesia (MMA) versus Patient-Controlled Analgesia (ACP) for one or two-level posterior lumbar fusion surgery. J Clin Med. 2020;9(4):1087.

28 Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost D, Trost GR, Zdeblick TA, Resnick DK. Comparison of perioperative oral multimodal analgesia versus IV ACP for spine surgery. J Spinal Disord Tech. 2010;23(2):139-45.

29 Singh K, Bohl DD, Ahn J, Massel DH, Mayo BC, Narain AS, Hijji FY, Louie PK, Long WW, Modi KD, Kim TD, Kudaravalli KT, Phillips FM, Buvanendran A. Multimodal analgesia versus intravenous patient-controlled analgesia for minimally invasive transforaminal lumbar interbody fusion procedures. Spine (Phila Pa 1976). 2017;42(15):1145-50.

30 Bohl DD, Louie PK, Shah N, Mayo BC, Ahn J, Kim TD, Massel DH, Modi KD, Long WW, Buvanendran A, Singh K. Multimodal versus patient-controlled analgesia after an anterior cervical decompression and fusion. Spine (Phila Pa 1976). 2016;41(12):994-8.

31 https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009.

32 Garcia RM, Cassinelli EH, Messerschmitt PJ, Furey CG, Bohlman HH. A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study. J Spinal Disord Tech. 2013;26(6):291-7.

33 Bullock WM, Kumar AH, Manning E, Jones J. Perioperative analgesia in spine surgery: a review of current data supporting future direction. Orthop Clin North Am. 2023;54(4):495-506

34 Berger RA, Sanders SA, Thill ES, Sporer SM, Della Valle C. Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res. 2009;467(6):1424-30.

35 Young A, Buvanendran A. Recent advances in multimodal analgesia. Anesthesiol Clin. 2012;30:91-100.

36 Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med. 2010;83(1):11-25.

37 Jules-Elysee KM, Goon AK, Westrich GH, Padgett DE, Mayman DJ, Ranawat AS, Ranawat CS, Lin Y, Kahn RL, Bhagat DD, Goytizolo EA, Ma Y, Reid SC, Curren J, YaDeau JT. Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 2015;97(10):789-98.

38 Koyuncu S, Friis CP, Laigaard J, Anhøj J, Mathiesen O, Karlsen APH. A systematic review of pain outcomes reported by randomised trials of hip and knee arthroplasty. Anaesthesia. 2021;76(2):261-269.

39 Branton MW, Hopkins TJ, Nemec EC. Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis. Int J Clin Pharm. 2021;43(2):394-403.

40 Imrey PB. Limitations of Meta-analyses of Studies With High Heterogeneity. JAMA Netw Open. 2020;3(1):e1919325.

41 Waelkens P, Alsabbagh E, Sauter A, Joshi GP, Beloeil H; PROSPECT Working group** of the European Society of Regional Anaesthesia and Pain therapy (ESRA). Pain management after complex spine surgery: a systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol. 2021;38(9):985-94.

42 Zealley I. Retrospective studies - utility and caveats. J R Coll Physicians Edinb. 2021 Mar;51(1):106-110. Zealley I. Retrospective studies - utility and caveats. J R Coll Physicians Edinb. 2021;51(1):106-10.
 


Submitted date:
09/08/2023

Accepted date:
10/24/2023

6660854fa9539504f362a3c3 brjp Articles

BrJP

Share this page
Page Sections