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- Postoperative pain management may be a significant issue for patients with chronic pain, specifically back pain, who present with history of long-term high dose opioid therapy prior to surgical intervention.
- Intraoperative methadone has been reported to reduce pain scores and analgesic requirements with acceptable side effects after complex spine surgery. Continuous infusions of short-acting opioids during surgery, such as fentanyl or remifentanil, have been demonstrated to provide adequate intraoperative analgesia and may facilitate an intraoperative “wake-up test.” Postoperative pain is typically managed initially with intravenous opioids, either by patient-controlled analgesia or continuous infusion, if necessary. Injection of long-acting local anesthetic at the site of surgical incision at closure and intravenous acetaminophen may be helpful for immediate postprocedure pain control.
- Adjuncts with demonstrated efficacy to reduce postprocedure analgesic requirements include preoperative acetaminophen, celecoxib, and either gabapentin or pregabalin as well intraoperative administration of dexamethasone and ketamine infusion. Ketamine 0.15 mg/kg bolus before surgical stimulus followed by infusion of 0.015 to 0.02 mg/kg/min has been shown to reduce opioid requirements.