Clinical outcome of surgical treatment of failed back surgery syndrome

BACKGROUND: Failed back surgery syndrome (FBSS) is a condition in which there is failure to improve satisfactorily after back surgery. It is characterized by intractable pain and various degrees of functional disability after lumbar spine surgery. It is estimated that this complication occurs in 5% to 10% of patients after spinal surgeries. The major causes of FBSS are fibrosis and adhesions, spinal instability, recurrent herniated disk, and inadequate decompression. The purpose of this study is to report on the postsurgical outcome after a redo spinal surgery. METHODS: We prospectively studied 50 patients with FBSS. The underlying pathology was identified and all the patients were treated surgically. Redo surgery was targeted at correcting the underlying pathology: removal of recurrent or residual disk, release of adhesions with neural decompression, and fusion with or without instrumentation. The postsurgical outcome was studied using the Oswestry Disability Questionnaire (ODQ). RESULTS: The average preoperative ODQ mean score was 80.8; the average postoperative ODQ mean score was 36.6 at 1 month and 24.2 at 1 year. Best scores were obtained at 3 months of follow-up in most cases. Successful outcome (>50% pain relief) could be achieved in 92% of the patients at 1 year. CONCLUSION: The current study shows that successful management of patients with FBSS could be achieved with proper patient selection, correct preoperative diagnosis, and adequate surgical procedure targeting the underlying pathology.     

后路椎体间融合治疗退变性腰间盘疾病、腰椎滑脱和腰椎手术失败综合征的疗效比较

目的探讨后路椎体间融合(PLIF)治疗退变性腰间盘疾病、腰椎滑脱和腰椎手术失败综合征的疗效比较。方法126例应用PLIF手术治疗患者,其中退变性腰间盘疾病(degenerative lumber disc diseases,DDD)52例、腰椎滑脱(spondylolisthesis,SL)43例、腰椎手术失败综合征(failed back surgery syndrome,FBSS)31例,术前和术后行Oswestry功能障碍评分(the Oswestry disability index,ODI)、腰痛及腿痛视觉疼痛评分(visual analog scales,VAS),评价治疗效果。结果随访12~26个月,平均18个月。ODI评分:DDD组减少22.5分,SL组减少28.2分,FBSS组减少22.2分,各组手术前后有统计学差异(配对t检验,P<0.05),各组间无统计学差异(方差分析,P>0.05)。腰痛VAS评分:DDD组减少4.1分,SL组减少3.8分,FBSS组减少3.2分,各组手术前后有统计学差异(配对t检验,P<0.05)各组间无统计学差异(方差分析,P>0.05)。腿痛VAS评分:DDD组减少3.8分,SL组减少3.5分,FBSS组减少2.2分,各组手术前后有统计学差异(配对t检验,P<0.05),各组间无统计学差异(方差分析,P>0.05)。结论PLIF治疗能够明显减轻DDD、SL和FBSS 3组患者的腰腿痛及改善相关功能障碍,但3组治疗结果间无统计学差异。     

The effect of meperidine-impregnated autogenous free fat grafts on postoperative pain management in lumbar disc surgery

STUDY DESIGN: Prospective, randomized, double-blind clinical study. OBJECTIVE: To examine the effect of meperidine-impregnated autogenous free fat grafts (AFFGs) on postoperative pain management after 1-level, first-time lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Uncontrolled postoperative pain impedes patient recovery. Insufficient control of postoperative pain makes it difficult to convince new patients to undergo the lumbar disc surgery. METHODS: Twenty-seven patients scheduled to undergo lumbar microdiscectomy for the first time were divided into 2 groups by a randomized double-blind method. Group 1 patients received a meperidine-impregnated AFFG in the epidural area. Group 2 received the graft without meperidine impregnation. Both groups were asked to use a Patient Controlled Analgesia device to deliver tramadol, and at 1, 4, 12, and 24 hours postoperatively, the amounts of tramadol used and pain severity on the 10-cm Visual Analog Scale (VAS) were recorded. RESULTS: The VAS scores and total tramadol use were both lower in group 1 compared with the control group (P<0.05). The first hour of VAS scores were significantly lower in group 1 than in the control group (P<0.05). CONCLUSIONS: In this study, we helped patients, who underwent 1-level, first-time lumbar microdiscectomy have a postoperative pain-free and comfortable period by using epidural meperidine-impregnated AFFGs.     

Computed tomography of epidural fibrosis after discectomy: a comparison between symptomatic and asymptomatic patients

The evaluation of patients with symptoms recurrent after disc surgery is a difficult diagnostic problem. The most common causes are recurrent herniation and postoperative scarring; routine x-ray and myelographic differentiation between herniation and scarring is difficult or impossible. High resolution computed tomography (CT) has shown some results in the evaluation of postoperative patients, but the role of epidural fibrosis in failed back surgery syndrome (FBSS) is not clear. Some knowledge of the "normal" CT physiological healing and scarring after disc surgery is necessary. We scanned 20 asymptomatic operated patients and 20 patients with recurrent sciatic nerve pain after disc surgery who did not have bony stenosis, recurrent disc herniation, or other causes of FBSS. Our observations showed no important differences in the fibrosis demonstrated by CT between symptomatic and asymptomatic patients. The degree and type of fibrosis are not related to recurrent symptoms.     

Are drains useful for lumbar disc surgery? A prospective, randomized clinical study

OBJECTIVE: In this prospective, observer-masked clinical study, we evaluated if insertion of a drain had a significant role in decreasing the existence and the size of postoperative epidural hematoma, which is believed to be a factor causing epidural fibrosis in patients undergoing lumbar discectomy. METHOD: Fifty patients undergoing lumbar disc surgery were randomly assigned to two groups: with or without insertion of a drain in the epidural space. A drain was inserted in 22 patients, whereas 28 were left without a drain. All patients were evaluated, by means of magnetic resonance imaging (MRI) on the first postoperative day, specifically looking for the existence and the size of epidural hematoma. The size of epidural hematoma was graded as none, minimal, moderate, or prominent. The patients were clinically examined preoperatively and at the follow-up of 6 months by Oswestry Disability Index and recurrence of pain. A follow-up MRI was repeated at 6 months, and the subsequent development of epidural fibrosis was evaluated. RESULTS: Epidural hematoma was detected in 36% of patients with a drain and in 89% of patients without a drain (P=0.000). There were significant less number of minimum, moderate, and prominent sized hematomas in the group with a drain (P=0.000). On the 6-month follow-up, epidural fibrosis was found in 58.3% of patients without a drain and in 31.6% of patients with a drain (P=0.08). Late clinical outcome (improvement in Oswestry Index and no recurrent pain) was better in the group with drain, but not statistically significant (P=0.4). CONCLUSIONS: Occurrence of hematoma in the epidural space is common after lumbar disc surgery even if meticulous hemostasis has been achieved. Insertion of a drain decreases both the incidence and the size of hematoma on the first postoperative day as detected by MRI. This may have practical implications for the prevention of significant postoperative fibrosis and obtaining better surgical outcome.     

微创和开放TLIF治疗单节段腰椎间盘突出症的比较

目的评价即时三维导航下单节段微创经椎间孔椎体融合术（minimallytransforaminallumbarinterbodyfu．sion,mini—TLIF）与开放后路（openposteriortransforaminallumbarinterbodyfusion,open—TLIF）的短期临床疗效比较。方法2011年10月至2012年2月对40例单节段腰椎间盘突出症患者分别采用即时三维导航下mini—TLIF（20例）和open—TLIF（20例）术式进行对比研究。比较两组手术时间、术中出血量、术后引流量、术后住院时间与总住院时间。视觉模拟评分（visualanaloguescale,VAS）和日本骨科协会（Japaneseorthopaedicassociation,JOA）下腰痛评分评价术后伤口疼痛及功能情况。结果4｜D例均获得随访,mini—TLIF组平均手术时间较open—TLIF组长,差异有统计学意义（P〈0．01）,mini—TLIF组总的住院时间、术后住院的时间较open—TLIF组明显缩短,差异有统计学意义（P〈0．01）;mini—TLIF组术中出血量明显较open—rrIJIF组减少,差异有统计学意义（P〈0．05）;术后引流量明显较open—TLIF组减少,差异有统计学意义（P〈0．01）;术后3dmini—THF组腰痛VAS评分的降低更为明显,差异有统计学意义（P〈0．01）;术后3dmini—TLIF组JOA评分同open—TLIF组比较下降更为明显,差异有统计学意义（P〈O．01）。术前、术后6个月两组腰、腿痛VAS评分、JOA评分比较,差异无统计学意义（P〉0．05）。结论即时三维导航下单节段微创TLIF具有术中出血量少、术后引流少、创伤小、住院时间短、短期疗效确切等优点,是一种有效的治疗方法。     

Wallis棘突间动态稳定系统在腰椎间盘突出症治疗中的早期疗效观察

[目的]比较髓核摘除术结合Wallis系统与单纯髓核摘除术治疗腰椎间盘突出症的早期疗效.[方法]2008年2月～2010年2月采用髓核摘除术结合Wallis系统治疗腰椎间盘突出症患者18例,以同期行单纯髓核摘除术治疗腰椎间盘突出症的18例患者为对照组.术后12个月为观察点,采用下腰痛及腿痛的视觉模糊评分(visual analogue scale,VAS)、Oswestry功能障碍指数(oswestry disability index,ODI)等指标来评估2组疗效.[结果]36例患者均获12 ～24个月随访,平均16个月,两组患者术后12个月的VAS评分及ODI指数均有明显下降,较术前比较有统计学意义(P=0.0000＜0.05),Wallis组术后12个月的下腰痛VAS评分及Oswestry指数与对照组比较有统计学意义(P =0.000 0 ＜0.05),而腿痛的VAS评分两组比较无统计学意义(P =0.074 ＞0.05).[结论]Wallis系统置入简单,创伤小,结合髓核摘除术治疗腰椎间盘突出症能提高疗效.     

Transpedicular decancellation osteotomy in the treatment of peridural fibrosis

From 1992 to 1997 a series of 12 multiply operated (averaging 2.5 previous operations) patients with recurrent peridural fibrosis and postlaminectomy kyphosis underwent surgery at our clinic. The surgery was designed to restore the physiological lordosis and relax tethered cord and epidural veins by transpedicular decancellation osteotomy at a vertebra other than the vertebra with peridural fibrosis. This paper presents the long-term functional outcome of these 12 patients. Clinical assessments were conducted pre-operatively and at 3-month intervals postoperatively and included X-ray assessment and evaluation of the patients’ functional status by Oswestry Disability Index (ODI) and of pain by visual analogue scale (pain VAS). All symptoms and the pain due to peridural fibrosis disappeared in the early postoperative period. Patients had lower disability and pain scores at their early and long-term follow-ups (follow-up period 24–74 months, mean 36.3 months). For patients with failed medical therapy for peridural fibrosis accompanied by lumbar kyphosis or hypolordosis, transpedicular decancellation osteotomy should be the surgical treatment of choice. Received: 30 July 2000     

A stiff and straight back preoperatively is associated with a good outcome 2 years after lumbar disc surgery: A prospective study of 80 patients

Background and purpose The degree of lumbar lordosis and reduced lumbar mobility are regarded as important clinical features in patients with low back pain, and in lumbar disc herniation A more stiff back preoperatively in a proportion of patients has been shown to be associated with sequestered disc herniation. The main aim of this study was to investigate whether there was any correlation between lumbar lordosis and flexion on the one hand in patients with lumbar disc herniation who were scheduled for surgery, and postoperative pain and disability on the other. Our second aim was to determine the patterns of postoperative improvement in pain, perceived disability, and flexion/lordosis for 2 years after surgery.Methods Pain (VAS), disability (DRI), lumbar flexion and lordosis (Debrunner''s kyfometer) were measured pre- and postoperatively in 80 patients who underwent microscopic lumbar disc surgery.Results Patients with preoperative hyperlordosis had more severe pain and more disability postoperatively than patients with hypolordosis. The level of pain did not change much from 2–6 weeks postoperatively until 2 years, while the perceived disability did not reach a steady state until 6 months after surgery.Interpretation Patients with a stiff and flat back have a good prognosis after lumbar disc surgery, and in most cases the pain will reach the 2-year level during the first 2–6 weeks, while the physical restoration measured by the lumbar flexion and lordosis, and the perceived disability, will continue to improve over the first 6 months after surgery.     

A retrospective study of epidural and intravenous steroids after percutaneous endoscopic lumbar discectomy for large lumbar disc herniation

Objective: To assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD). Methods: 28 consecutive patients who underwent PELD due to large lumbar disc herniation between November 2014 and January 2016 were followed up for 6 months. These patients were divided into two groups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well. Results: There is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p=0.011, p=0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p=0.002, p=0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). The postoperative hospital stay in two groups was not statistically different (p=0.636). But the time return to work in Group A was significantly shorter than that in Group B (p=0.023). Conclusion: Patients who underwent PELD with epidural steroid administration for large lumbar disc herniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.     

椎间孔镜治疗有典型根性症状的腰椎手术失败综合征

目的：评价椎间孔镜治疗有典型根性症状的腰椎手术失败综合征（failedbacksurgerysyndrome,FBSS）的临床效果。方法选择2012年11月～2013年6月12例有典型根性症状的FBSS,其中腰椎间盘突出单纯开窗髓核摘除术后复发5例,腰椎管狭窄髓核摘除并神经根管减压术后复发3例,腰椎间盘突出椎间孔镜髓核摘除术后复发4例。均采用椎间孔镜治疗。结果12例术后患肢直腿抬高试验阴性,神经根刺激所致的患肢疼痛症状均明显缓解,患肢疼痛评分依据视觉模拟评分法（visualanaloguescore,VAS）,术前8．3±1．9,术后1个月2．6±1．1（t＝16．301,P＝0．000）。结论椎间孔镜是治疗有典型根性症状的FBSS安全和有效的微创手术,合理选择手术适应证和成熟的椎间孔镜手术经验是保证手术成功的关键。     

腰椎间盘突出症再手术患者的MRI表现

目的：探讨ＭＲＩ在腰橙是盘突出症手术失败病例诊治过程中的应用价值。方法：分析８３例腰椎间盘同症再手术患者的ＭＲＩ表现。其中男性５６例,女性２７例。年龄２７～７１岁,平均４３．４岁。距初次手术时间８个～６年。结果;椎间盘突出２４例,椎管狭窄４３例,假性脊膜突出３例,硬膜纤维化神经周围瘢痕形成１１例,腰椎不稳２例。结论：ＭＲＩ对于引起腰椎手术失败的多数在均有诊断,尤其适用于未作内固定的病例。     

Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy.

Intraoperative epidural corticosteroids have been used by some surgeons to decrease pain following surgery for a herniated lumbar disc. In this study, 84 consecutively treated, comparable patients with unilateral lumbar disc herniation were prospectively assigned randomly to receive either epidural corticosteroids (40 mg methylprednisolone acetate) or saline at the conclusion of the operative procedure. The postoperative morbidity of these two groups was evaluated by tabulating the following parameters: pain relief as measured by consumption of postoperative pain medications; the length of hospital stay; postoperative functional status; and the time interval from surgery until return to work. The mean postoperative analgesic medications consumed was 12.2 +/- 1.9 mg of morphine equivalents in the corticosteroid group versus 12.2 +/- 1.8 mg of morphine equivalents in the control group. The mean hospital stay was less than 2 days in each group, and the mean interval until return to work was 21.2 +/- 2.7 days in the corticosteroid group versus 25.4 +/- 3.1 days in the control group. Moreover, no statistically significant difference was measured between the steroid-treated and control groups when the data were stratified for sex, age, and site of disc herniation. The mean outcome scores, which are derived from a postoperative assessment of pain relief resulting from surgery, functional status, and interval until return to work, were identical in the corticosteroid and control groups. This study concludes that epidural corticosteroid administration after microsurgical lumbar discectomy for unilateral disc herniation does not lessen postoperative morbidity or improve functional recovery.     

Outcome following lumbar disc surgery: the role of fibrosis

Background  Failed-back surgery syndrome remains a challenge for spinal surgeons. It can be related to several causes, including poor surgical indication, misdiagnosis, surgical technique failure, spondilodiscitis and fibrosis. Fibrosis has been associated with a poorer outcome in lumbar disc surgery, although its role in the generation of symptoms is not yet clear. In this study, the authors have analyzed any possible correlation between the clinical outcome and the degree of fibrosis. Method  Forty consecutive patients were enrolled in a prospective study. All of them had operations in the lower lumbar disc in a single level for the first time. Three months after the operation they were submitted to clinical outcome evaluations and questionnaires, including Numeric Pain Rating scales (NPR) for lumbar and leg pain, the McGill Pain Questionnaire, The Quebec Back Pain Disability scale (QBPD) and Straight Leg Raising test. These data were correlated with the degree of fibrosis as revealed by Magnetic Resonance Imaging (MRI). Findings  After 3 months, the NPR values for lumbar and leg pain ranged from 0 to 8 (mean 2.32 and 1.67 respectively). The values of the post-operative QBPD scale ranged from 1 to 71 (mean 25.9). Every patient showed a varied degree of fibrosis on MRI. However, statistical analysis depicted no significant correlation between fibrosis and a poorer clinical outcome for pain and disability. Conclusions  The authors found no correlation between excessive fibrosis with lumbar and leg pain, disability or straight leg resistance. The role of fibrosis in the generation of symptoms in patients who have had lumbar disc surgery should be reevaluated.     

中线腰椎融合技术治疗合并骨质疏松的腰椎间盘突出症

目的探讨中线腰椎融合技术治疗合并骨质疏松的腰椎间盘突出症的疗效。方法采用中线腰椎融合技术治疗25例合并骨质疏松的腰椎间盘突出症患者,记录并比较手术前后疼痛VAS评分及JOA评分。结果患者均获得12个月随访。VAS评分:术后1、6、12个月较术前降低,差异均有统计学意义(P<0.01);术后各时间点比较差异均无统计学意义(P>0.05)。JOA评分:术后1、6、12个月较术前升高,差异均有统计学意义(P<0.01);术后各时间点比较差异均无统计学意义(P>0.05)。术后腰痛及下肢症状均得到改善,未发生切口感染或深部椎间隙感染。末次随访时,23例骨性融合,2例未融合,均未发生融合器移位和螺钉松动、退出。结论中线腰椎融合技术治疗合并骨质疏松的腰椎间盘突出症,具有软组织剥离少、出血少、螺钉把持力强、术后并发症少的优点。     

Microsurgical reoperation following lumbar disc surgery. Timing, surgical findings, and outcome in 92 patients

Ninety-two patients who underwent microsurgical reoperation for persistent or new complaints following initial lumbar intervertebral disc surgery were evaluated retrospectively. Sixty percent of all pain relapses occurred within 1 year following the first operation; thereafter, the probability of a relapse declined steadily and was as low as 0.1% per year between 5 and 20 years. The results of microsurgical reoperation in terms of pain relief and working capability were considered "excellent" in 22% of patients, "good" in 30%, and "satisfactory" in 29%. Thus, 81% of the patients could be considered as treated successfully and in 19% the result was not successful. The most common intraoperative findings were: a true recurrence at the same level in 43% of cases, a new herniation at another level in 15%, and a small recurrent fragment embedded in epidural fibrosis in 23%. Five percent of patients had severe epidural fibrosis as the only pathology. In 15%, reoperation was performed within 1 month to treat persisting pain, and either a missed disc fragment, an inadequately decompressed lateral recess, or an unrecognized second-level disc protrusion was found. The clinical outcome is affected predominantly by the intraoperative pathology and the time interval between the first and second operation. An excellent or good outcome was usually achieved in patients with a recurrence of pain after 1 year resulting from a true recurrent disc or a new herniation at another level. In contrast, very unfavorable results were noted with most reoperations performed during the 1st year when extensive epidural fibrosis (or fibrosis with a small recurrence) was present.     

显微镜与椎间盘镜辅助腰椎间盘切除术治疗腰椎间盘突出症疗效的对比分析

目的 报道显微镜辅助直视下腰间盘切除术与椎间盘镜辅助腰间盘切除术两种不同手术方法治疗单节段腰椎间盘突出症的临床疗效.方法 比较分析显微镜与椎间盘镜辅助下的两种不同手术方法治疗单节段腰椎间盘突出症病例,治疗病例分别为33例和36例.比较手术时间、术中出血量、并发症、住院天数、术前及术后腰腿疼痛的JOAS(Japanese Orthopaedic Association Score)及VAS(Visual Analog Scales)评分、围手术期并发症等指标.结果 所有病例平均随访2年2个月(11个月至4年),2组术前及术后腰腿疼痛的JOAS及VAS评分、围手术期并发症、住院天数差异无统计学意义(P＞0.05),而在手术时间、术中出血量上差异具有统计学意义(P＜0.05).结论 显微镜辅助直视下腰间盘切除术与椎间盘镜辅助腰间盘切除术治疗单节段腰椎间盘突出症均疗效满意,均为理想的微创手术方法.     

经Wiltse入路与后正中入路治疗腰椎椎间盘突出症的疗效比较

目的比较Wiltse入路与后正中入路治疗腰椎椎间盘突出症(LDH)的疗效。方法收集2012年1月—2015年12月在本院行手术治疗的LDH患者85例,其中经Wiltse入路43例(A组),传统后正中入路42例(B组)。记录2组患者的手术时间、术中出血量、术后引流量及住院天数等资料;采用视觉模拟量表(VAS)评分评价患者腰痛和下肢痛,采用Oswestry功能障碍指数(ODI)评价患者功能状况,采用日本骨科学会(JOA)评分评价患者腰椎功能。结果 A组患者在术中出血量、术后引流量、住院天数、术后腰痛VAS评分方面优于B组,差异有统计学意义(P0.05);2组手术时间、术后下肢痛VAS评分、ODI及JOA评分差异无统计学意义(P0.05)。术后随访6个月、2年,A组腰痛VAS评分优于B组,差异有统计学意义(P0.05)。结论采用Wiltse入路治疗LDH在降低手术创伤、减少住院天数、减少术后腰痛、减少残留神经功能后遗症等方面均优于传统后正中入路,临床值得推广。     

Early postoperative MRI findings following surgery for herniated lumbar disc

Summary MRI is routinely used in the evaluation and management of patients with failed back surgery syndrome (FBSS). However, its value is unclear in the early detection of signs that can negatively affect the later course of surgical cases. The purpose of the present study is to describe the MR images of early postoperative MRI at 3 days in 30 unselected patients who underwent lumbar microdiscectomy, and to correlate the findings with follow up MRI at 8 weeks and with final outcome. The findings are correlated with literature data. Early postoperative MRI findings were consisting of pseudohernia in 24 patients (80%), annular rent in 23 patients (80%), and other non-specific postoperative findings. On the late MRI the pseudohernia persisted in 12 patients (50%), the annular rent in 4 patients (15%) and asymptomatic pseudo-spondylodiscitis was apparent in 3 patients (10%) as was a case of true spondylodiscitis. Therefore, early postoperative findings have limited value in the management of patients after surgery for lumbar disc herniation, since the images were not correlated with the immediate clinical course after surgery nor with the late radiological and clinical outcome. The evident imaging changes in the early postoperative period after lumbar disc surgery limit the accuracy of the interpretation of MRI examinations.     

Comparison of low-dose intrathecal and epidural morphine and bupivacaine infiltration for postoperative pain control after surgery for lumbar disc disease

This prospective, blinded, placebo-controlled study was performed to compare the postoperative analgesic efficacy of low-dose intrathecal and epidural morphine with paraspinal muscle infiltration of bupivacaine in lumbar discectomy cases. Eighty ASA I-III adult patients undergoing elective surgery for lumbar disc disease were enrolled in the study. Patients were randomized to four groups by envelopes. Study groups were as follows: group 1 (n = 20), intrathecal morphine 0.1 mg; group 2 (n = 20), epidural morphine 2 mg; group 3 (n = 20), 30 mL of bupivacaine 0.25% paraspinal muscle infiltration; group 4 (n = 20), 30 mL of saline paraspinal muscle infiltration before wound closure. Recorded parameters were time to response to painful and verbal stimuli and postoperative pain assessed at 30 minutes and 2, 4, 6, 8, 12, and 24 hours by Visual Analog Scale (VAS) and Numeric Pain Scale (NPS). Hemodynamic data, sedation scores, and side effects were also recorded. Meperidine and naproxen sodium were used for postoperative analgesia. Follow-up was performed by a blinded investigator. Mean VAS scores were lower in groups 1 and 2 at 30 minutes (P < 0.05). Mean VAS score of group 2 was lower than that of group 4 at 4 hours postoperatively (P < 0.05). Mean NPS scores were lower in groups 1 and 2 at 2, 4, and 6 hours (P < 0.05) and in group 2 at 8 hours compared with the other groups. The number of patients requiring meperidine at early postoperative phase (0-6 hours) was less in groups 1 and 2 compared with groups 3 and 4 (P < 0.05).There were no statistically significant differences in the late postoperative analgesic requirements, after correction for multiple testing. In conclusion, low-dose intrathecal and epidural morphine provide lower postoperative pain scores and a reduction in early postoperative analgesic requirement with insignificant side effects compared with paraspinal bupivacaine or saline infiltration.