Perception of pain and influences on opioid use in implant‐based breast reconstruction patients

Although there has been a recent focus on decreasing opioid prescribing through alternative pain medication protocols, the patient's perception of pain related to breast reconstructive surgeries has not been well described. We sought to evaluate patient perception of pain control as it influences opioid use. We hypothesize that modifiable factors may influence patterns in pain perception and postoperative opioid use. Patients undergoing consultation for mastectomy with immediate, implant‐based breast reconstruction were enrolled in a prospective, cohort survey study. A survey was administered at preoperative and postoperative appointments to collect data on pain expectations and pain control. Of 100 patients enrolled, 85% completed the postoperative survey. Over half of patients (52%) reported feeling anxious about pain control after surgery. Patients with preoperative opioid use were more likely to expect complete relief of pain postoperatively (P = .038). Patients with psychiatric comorbidity were more likely to report feeling anxious about postoperative pain (P = .012; 70% vs 42%; OR 3.0 CI 1.2‐7.4). Patients who reported feeling anxious about pain control preoperatively were more likely to report trying opioids (P = .047; 67% vs 44%; OR 2.5 CI 1.0‐6.1) and benzodiazepines (P = .020; 80% vs 56%; OR 3.0 CI 1.2‐8.0) postoperatively. Anxiety related to pain control is common and results in an increased likelihood of trying opioid and benzodiazepine medications postoperatively. This presents an opportunity to educate patients preoperatively by addressing anxiety related to pain control to decrease controlled substance use.     

Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials

Postoperative pain management remains a significant challenge for all healthcare providers. The objective of this systematic review was to quantitatively evaluate the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management. We searched the databases of Medline (1966-2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials (RCTs) using acupuncture for postoperative pain management. We extracted data about postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects. Combined data were analysed using a random effects model. Fifteen RCTs comparing acupuncture with sham control in the management of acute postoperative pain were included. Weighted mean difference for cumulative opioid analgesic consumption was -3.14 mg (95% confidence interval, CI: -5.15, -1.14), -8.33 mg (95% CI: -11.06, -5.61), and -9.14 mg (95% CI: -16.07, -2.22) at 8, 24, and 72 h, respectively. Postoperative pain intensity (visual analogue scale, 0-100 mm) was also significantly decreased in the acupuncture group at 8 and 72 h compared with the control group. The acupuncture treatment group was associated with a lower incidence of opioid-related side-effects such as nausea (relative risk, RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation (RR: 0.78; 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention (RR: 0.29; 95% CI: 0.12, 0.74). Perioperative acupuncture may be a useful adjunct for acute postoperative pain management.     

Predictive nomogram for postoperative delirium in elderly patients with a hip fracture

To evaluate the risk factors for the development of postoperative delirium and design a predictive nomogram for the prevention of delirium in elderly patients with a hip fracture, we retrospectively studied 825 patients who sustained a femoral neck fracture from January 2005 to December 2015. Independent risk factors for developing delirium within 6 months of surgery were identified using multivariable logistic regression analyses. A predictive nomogram model was built based on the results, and the discrimination and calibration were determined by C-index and calibration plot. Of the 825 patients who met inclusion criteria, 118 (14.3%) developed postoperative delirium. According to the results, preoperative cognitive impairment (OR, 4.132, 95% CI, 1.831 to 9.324, P＜0.001), multiple medical comorbidities (OR, 1.452, 95% CI, 0.958–2.202, P?=?0.079), ASA classification (OR, 1.655, 95% CI, 1.073–2.553, P?=?0.023), transfusion exceeding 2 units of red blood cell (OR, 1.599, 95% CI, 1.043–2.451, P?=?0.035), and intensive care (OR, 1.817, 95% CI, 1.127–2.930, P?=?0.014) were identified to be the independent predictors of the development of postoperative delirium. The risk of postoperative delirium increased with the increasing risk score of predictive nomogram, and the C-index was 0.67 (0.62 - 0.72). The calibration showed that the predicted probabilities of delirium in the predictive nomogram were close to the observed frequency of delirium, and the decision curve analysis confirmed the clinical utility of the nomogram when the threshold probabilities were between 8% and 35% due to the net benefit.     

Delirium following vascular surgery: increased incidence with preoperative β-blocker administration

Purpose

To determine if there is an association between perioperative administration of beta-blockers and postoperative delirium in patients undergoing vascular surgery.

Methods

After Institutional Review Board approval, data were retrospectively collected on patients who underwent vascular surgery in an academic hospital during the period January 2006 to January 2007. Patients with preoperative altered level of consciousness, carotid endarterectomy, or discharge within 24 h of surgery were excluded from the study. Identification of delirium was based on evaluation of the level of consciousness with the NEECHAM Confusion Scale and/or a chart-based instrument for delirium. Multivariable logistic regression analysis was used to identify independent perioperative predictors of postoperative delirium. Beta-blockers were tested for a potential effect.

Results

The incidence of postoperative delirium was 128/582 (22%). Independent predictors included age (OR 1.04, 95% CI [1.02–1.07]), history of cerebrovascular accident/transient ischemic attack (OR 2.64, 95% CI [1.57–4.55]), and depression (OR 3.56, 95% CI [1.53–8.28]). Open aortic reconstruction was associated with an OR of 5.34, 95% CI (2.54–11.2) and amputation with an OR of 4.66, 95% CI (1.96–11.09). Preoperative beta-blocker administration increased the odds of postoperative delirium 2.06 times (95% CI [1.18–3.6]). Statin administration reduced the odds of delirium by 44% (95% CI [0.37–0.88]). The model was reliable (Hosmer–Lemeshow test, P = 0.72) and discriminative (area under the receiver operating characteristic [ROC] curve = 0.729).

Conclusions

Preoperative administration of beta-blockers is associated with an increased risk of postoperative delirium after vascular surgery. Conversely, preoperative statin administration is associated with a lower risk of postoperative delirium. A randomized prospective controlled trial is required to validate these findings.     

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty

BackgroundIntra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking.MethodsWe performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use.ResultsPreoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99).ConclusionThe utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.     

Functional Outcome in Patients with Chronic Subdural Hematoma: Postoperative Delirium and Operative Procedure

Chronic subdural hematoma (CSDH) is a common neurosurgical condition and neurological condition improves after treatment in most patients. Recently more patients have poor prognosis because of aging of the population and presence of multiple comorbidities. The risk factors for poor prognosis, including postoperative delirium, were retrospectively evaluated to assess appropriate operative procedures. This study included 108 patients who underwent primary surgery from 2016 to 2017 at a single center. Operative procedures were drainage with or without irrigation. Functional outcome at discharge assessed the effect of various factors including postoperative delirium and operative procedure. Twenty-nine of 108 patients (27%) had worsened modified Rankin Scale (mRS) score at discharge, most with mobility disturbance or deteriorated cognitive function. Multivariate analysis found higher age (odds ratio [OR] = 5.13; 95% confidence interval [CI] = 1.0-1.14), poor pre-hospital mRS score (OR = 1.57; 95% CI = 1.0-2.46), and preoperative consciousness disturbance caused by CSDH (OR = 5.13; 95% CI = 1.27-20) were significant predictors of poor outcome. Operative procedure was not significantly related to functional outcome or recurrence, but irrigation was significantly related to postoperative delirium (OR = 4.83; 95% CI = 1.09-21.7). Patients with postoperative delirium were likely to require longer hospitalization stays (P = 0.028). Higher age, poor pre-hospital mRS, and preoperative consciousness disturbance caused by CSDH are the risk factors for poor recovery after CSDH. Irrigation is significantly likely to cause postoperative delirium and longer hospital stay.     

NSAID-analgesia, pain control and morbidity in cardiothoracic surgery

OBJECTIVE: While narcotics remain the backbone of perioperative analgesia, the adjunctive role of other analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), is being recognized increasingly. This meta-analysis sought to determine whether adjunctive NSAIDs improve postoperative analgesia and reduce cumulative narcotic requirements. METHODS: A comprehensive search was undertaken to identify all randomized trials, in cardiothoracic patients, of NSAIDs plus narcotics vs narcotics without NSAIDs. Medline, Cochrane Library, EMBASE, and abstract databases were searched up to September 2005. The primary outcome was visual analogue scale (VAS) pain score. Secondary outcomes included 24-hr cumulative morphine-equivalents, rescue medications required, mortality, myocardial infarction, atrial fibrillation, stroke, renal failure, hospital readmissions, and in-hospital costs. RESULTS: Twenty randomized trials involving 1,065 patients were included. A significant reduction in 24-hr VAS pain score was found in patients receiving NSAIDs [weighted mean difference (WMD) -0.91 points, 95% confidence interval (CI) -1.48 to -0.34 points]. In addition, patients required significantly less morphine-equivalents in the first 24 hr (WMD -7.67 mg, 95% CI -8.97 to -6.38 mg). No significant difference was found with respect to mortality [odds ratio (OR) 0.19, 95% CI 0.01 to 4.22], myocardial infarction (OR 0.71, 95% CI 0.09 to 5.71), renal dysfunction (OR 0.95, 95% CI 0.37 to 2.46), or gastrointestinal bleeding (OR 0.96, 95% CI 0.13 to 7.09). CONCLUSION: In patients less than 70 yr of age undergoing cardiothoracic surgery, the adjunctive use of NSAIDs with narcotic analgesia reduces 24-hr VAS pain score and narcotic requirements.     

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

Study objectiveTo determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.DesignRetrospective cohort study.SettingPostoperative recovery.Patients8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.InterventionsWe used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.Measurements.Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.Main Results.After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94–11.14), pulmonary complications (OR 1.83, 95% CI 1.4–2.36), extended hospital stay (OR 1.47, 95% CI 1.26–1.72), readmission (OR 1.27, 95% CI 1.01–1.59) and mortality (OR 1.92, 95% CI 1.54–2.39) were all significantly higher in patients with preoperative delirium compared to those without.ConclusionsAfter controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.     

The analgesic effects of perioperative gabapentin on postoperative pain: a meta-analysis

BACKGROUND AND OBJECTIVES: Gabapentin is an anticonvulsant that has been shown to be effective in the treatment of neuropathic and inflammatory pain in animal and human studies. The analgesic effect of its perioperative use has not been fully elucidated. METHODS: This systematic review (meta-analysis) included 12 randomized controlled trials of 896 patients undergoing a variety of surgical procedures that investigated the impact of perioperative administration of gabapentin on postoperative outcome. RESULTS: The pooled visual analog scores for pain at 4 hours and 24 hours were significantly less in those patients who received gabapentin (weighted mean difference [WMD] = -1.57; 95% confidence interval [CI], -2.14 to -0.99 and WMD = -0.74; CI, -1.03 to -0.45, respectively). A concomitant decrease in opioid usage by those patients who received gabapentin was also noted (odds ratio [OR] = -17.84; CI, -23.50 to -12.18). Gabapentin administration was associated with sedation and anxiolysis (OR = 3.28; CI, 1.21-8.87) but not associated with a difference in lightheadedness, dizziness, nausea, or vomiting. CONCLUSIONS: Based on this systematic review, perioperative oral gabapentin is a useful adjunct for the management of postoperative pain that provides analgesia through a different mechanism than opioids and other analgesic agents and would make a reasonable addition to a multimodal analgesic treatment plan.     

Evaluating the impact of metabolic surgery on patients with prior opioid use

BackgroundMetabolic surgery is the most effective treatment for obesity and may improve obesity-related pain syndromes. However, the effect of surgery on the persistent use of opioids in patients with a history of prior opioid use remains unclear.ObjectiveTo determine the effect of metabolic surgery on opioid use behaviors in patients with prior opioid use.SettingA consortium of public and private hospitals in Michigan.MethodsUsing a statewide metabolic-specific data registry, we identified 16,820 patients who self-reported opioid use before undergoing metabolic surgery between 2006 and 2020 and analyzed the 8506 (50.6%) patients who responded to 1-year follow-up. We compared patient characteristics, risk-adjusted 30-day postoperative outcomes, and weight loss between patients who self-reported discontinuing opioid use 1 year after surgery and those who did not.ResultsAmong patients who self-reported using opioids before metabolic surgery, 3864 (45.4%) discontinued use 1 year after surgery. Predictors of persistent opioid use included an annual income of <$10,000 (odds ratio [OR] = 1.24; 95% confidence interval [CI], 1.06–1.44; P = .006), Medicare insurance (OR = 1.48; 95% CI, 1.32–1.66; P < .0001), and preoperative tobacco use (OR = 1.36; 95% CI, 1.16–1.59; P = .0001). Patients with persistent use were more likely to have a surgical complication (9.6% versus 7.5%, P = .0328) and less percent excess weight loss (61.6% versus 64.4%, P < .0001) than patients who discontinued opioids after surgery. There were no differences in the morphine milligram equivalents prescribed within the first 30 days following surgery between groups (122.3 versus 126.5, P = .3181).ConclusionsNearly half of patients who reported taking opioids before metabolic surgery discontinued use at 1 year. Targeted interventions aimed at high-risk patients may increase the number of patients who discontinue opioid use after metabolic surgery.     

腹壁切口疝修补术后慢性疼痛发生状况及危险因素分析

目的探讨腹壁切口疝修补术后慢性疼痛的发生状况及相关因素,以期降低术后慢性疼痛的发生率,提高患者生活质量。 方法选取2015年1月至2019年12月陕西省人民医院收治的213例腹壁切口疝患者作为研究对象。随访观察患者行腹壁切口疝修补术后1年内发生慢性疼痛的情况,将其分为发生疼痛组和未发生疼痛组,筛选出术后慢性疼痛的危险因素。 结果共有27例患者发生慢性疼痛,发生率为12.68%。单因素分析结果显示,两组性别、体质指数（BMI）、复发疝、术后切口并发症比较,差异均有统计学意义（P<0.05）。进一步行多因素Logistic回归分析显示,女性（β=1.82,OR=6.17,95% CI：1.34~28.46,P=0.020）、BMI≥24 kg/m²（β=1.04,OR=2.82,95% CI：1.09~7.32,P=0.034）、复发疝（β=1.73,OR=5.65,95% CI：1.88~17.02,P=0.002）、术后切口并发症（β=1.43,OR=4.16,95% CI：1.53~11.33,P=0.005）是术后发生慢性疼痛的独立危险因素。 结论女性、BMI≥24 kg/m²、复发疝、术后切口并发症是腹壁切口疝患者术后发生慢性疼痛的独立危险因素,因此在行切口疝修补术时要充分评估,做好预防措施,降低术后慢性疼痛的发生率。     

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m(2) (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.     

Gabapentin: an alternative to the cyclooxygenase-2 inhibitors for perioperative pain management

The cyclooxygenase-2 inhibitor, rofecoxib, was a popular analgesic adjuvant for improving perioperative pain management. We designed this placebo-controlled study to test the hypothesis that gabapentin could produce similar reductions in postoperative pain and opioid analgesic usage, thereby improving the recovery process. One hundred patients undergoing abdominal hysterectomy procedures were randomly assigned to one of four treatment groups: 1) control group received placebo capsules and pills before and for 2 days after surgery, 2) rofecoxib group received 50 mg/d PO and placebo capsules before and after surgery and, 3) gabapentin group received 1.2 g/d PO and placebo pills before and after surgery, and 4) combination group received rofecoxib 50 mg/d and gabapentin 1.2 g/d PO before and after surgery. The anesthetic technique was standardized and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Postoperative pain scores were significantly reduced in all three analgesic treatment groups (versus control group). Compared with the control group, patient-controlled analgesia morphine usage was also significantly reduced in the 3 analgesic treatment groups at 1, 8, 24, and 30 h after surgery. Total PCA morphine usage was decreased by 43%, 24%, and 50% in groups 2, 3, and 4, respectively, compared with group 1. Oral analgesic consumption was also smaller in groups 2 and 4 when compared with the control group. The opioid-sparing effects of rofecoxib and gabapentin lead to a faster recovery of bowel function. Discharge eligibility scores in groups 2 and 4 were improved at 24 h when compared with group 1, and patient satisfaction with postoperative pain management was significantly higher at 24 h in all 3 analgesic treatment groups. At the 72 h follow-up, all of the patients in group 4 were completely satisfied with their pain management compared with only 32%, 64%, and 72% in groups 1, 2, and 3, respectively. Gabapentin (1.2 g/d PO) appears to be an acceptable alternative to rofecoxib (50 mg/d PO) for short-term use as an adjuvant to opioid analgesics in patients undergoing lower abdominal surgery.     

漏斗胸患者Nuss手术后慢性疼痛的危险因素

目的 探讨漏斗胸微创矫正术(Nuss手术)后慢性疼痛的危险因素.方法 回顾性分析2013年1月至2019年9月择期行胸腔镜Nuss手术患者168例,男130例,女38例.收集患者联系方式、人口学资料、术前合并症、漏斗胸严重程度分级、神经阻滞情况、手术时间和术后24 h VAS疼痛评分.电话随访患者或家属完成术后慢性疼痛...     

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients

Background. Postoperative delirium and cognitive decline arecommon in elderly surgical patients after non-cardiac surgery.Despite this prevalence and clinical importance, no specificaetiological factor has been identified for postoperative deliriumand cognitive decline. In experimental setting in a rat model,nitrous oxide (N₂O) produces neurotoxic effect at high concentrationsand in an age-dependent manner. Whether this neurotoxic responsemay be observed clinically has not been previously determined.We hypothesized that in the elderly patients undergoing non-cardiacsurgery, exposure to N₂O resulted in an increased incidenceof postoperative delirium than would be expected for patientsnot receiving N₂O. Methods. Patients who were 65 yr of age, undergoing non-cardiacsurgery and requiring general anaesthesia were randomized toreceive an inhalational agent and either N₂O with oxygen oroxygen alone. A structured interview was conducted before operationand for the first two postoperative days to determine the presenceof delirium using the Confusion Assessment Method. Results. A total of 228 patients were studied with a mean (range)age of 73.9 (65–95) yr. After operation, 43.8% of patientsdeveloped delirium. By multivariate logistic regression, age[odds ratio (OR) 1.07; 95% confidence interval (CI) 1.02–1.26],dependence on performing one or more independent activitiesof daily living (OR 1.54; 95% CI 1.01–2.35), use of patient-controlledanalgesia for postoperative pain control (OR 3.75; 95% CI 1.27–11.01)and postoperative use of benzodiazepine (OR 2.29; 95% CI 1.21–4.36)were independently associated with an increased risk for postoperativedelirium. In contrast, the use of N₂O had no association withpostoperative delirium. Conclusions. Exposure to N₂O resulted in an equal incidenceof postoperative delirium when compared with no exposure toN₂O. ⁴Present address: Staff Statistician, University of Pittsburgh,PA 15213, USA     

Nonsteroidal antiinflammatory drugs for postoperative pain management after lumbar spine surgery: a meta-analysis of randomized controlled trials

OBJECT: The authors undertook this meta-analysis to assess the efficacy and safety of nonsteroidal antiinflammatory drugs (NSAIDs) in addition to opioid analgesics on perioperative pain management in lumbar spine surgery. METHODS: The authors searched MEDLINE, Excerpta Medica (EMBASE), The Cochrane Library, CINAHL, PsycINFO, Allied and Complementary Medicine (AMED), and Science Citation Index Expanded databases. In addition, they manually searched key journals and their references. They included randomized trials comparing the use of NSAIDs in addition to opioid analgesics versus opioid analgesics alone after posterior lumbar discectomy, laminectomy, or spinal fusion. Two independent reviewers performed an assessment of the quality of the methods. RESULTS: Seventeen studies comprising 400 patients who received NSAIDs in addition to opioid analgesics and 389 patients receiving opioid analgesics alone were included. Patients receiving NSAIDs in addition to opioid analgesics had lower pain scores and consumed fewer opioids than the group receiving opioid analgesics alone. There was no difference in the incidence of adverse effects. CONCLUSIONS: This meta-analysis provides evidence that the addition of NSAIDs to opioid analgesics in lumbar spine surgery provided better pain control than opioid analgesics alone.