Epidural fentanyl for postoperative analgesia after lumbar canal decompression: a randomized controlled trial |
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| Authors: | Mathew R. Guilfoyle Richard J. Mannion Patrick Mitchell Simon Thomson |
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| Affiliation: | 1. Department of Neurosurgery, Addenbrooke''s Hospital, Hills Rd, Cambridge CB2 0QQ, UK;2. Department of Neurosurgery, Newcastle General Hospital, Regional Neurosciences Centre, Royal Victoria Infirmary, Queen Victoria Rd, Newcastle-upon-Tyne, NE1 4LP, UK;3. Department of Neurosurgery, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK;1. Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland;2. Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland;3. Department of Psychiatry, Oulu University Hospital, Oulu, Finland;4. Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland;5. Department of Physical Medicine and Rehabilitation, Jyväskylä Central Hospital, Jyväskylä, Finland;6. Health and Work Ability, and Disability Prevention Centre, Finnish Institute of Occupational Health, Oulu, Finland;1. Orthopaedic Department, University Hospital of Basel, Basel, Switzerland;2. Orthopaedic Department, University Hospital of Canary Islands, Tenerife, Spain;3. Department of Orthopaedics and Clinics, University of Iowa Hospitals and Clinics, Iowa City, USA;1. Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China;2. Orthopedic Institute, Soochow University, Suzhou, China;3. University of Waterloo, Waterloo, Ontario, Canada;1. Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan;2. School of Medicine, Tzu Chi University, Hualien, Taiwan;1. Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA;2. Department of Anesthesiology, University of California at Los Angeles, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA;3. Department of Neuroanesthesia, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA;4. Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA;5. Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA;6. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA |
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| Abstract: | Background contextPostoperative back pain is common after decompression surgery for lumbar stenosis and often delays discharge from hospital. Achieving regional analgesia by intraoperative delivery of epidural opiates after lumbar canal decompression is a promising approach to reduce postoperative pain and enhance early mobilization. However, there have been concerns about opiate-related complications, such as respiratory depression and urinary retention in what is generally an elderly population of patients.PurposeTo assess the analgesic efficacy of bolus epidural fentanyl administered intraoperatively after lumbar decompression for degenerative canal stenosis.Study design/settingPatient-blinded randomized controlled trial conducted at two university neurosurgical centers.Patient sampleAdults (older than 18 years) with neurogenic claudication and/or lower limb radiculopathy and concordant lumbar spinal canal stenosis demonstrated on magnetic resonance imaging. Patients with previous lumbar spinal surgery, a contraindication to fentanyl, or requiring instrumentation were excluded.Outcome measuresThe primary outcome measure was patient-reported Visual Analogue Score (VAS) for pain recorded preoperatively, in recovery, and on the first and second postoperative days if the patient remained in the hospital. Secondary outcomes were duration of surgery, length of stay, and any side effects or complications.MethodsPatients underwent a one to three level lumbar canal decompression as required, via a midline incision, under general anesthesia. Before wound closure either no drug (control) or a 100-μg bolus of fentanyl was administered via an epidural catheter inserted 10 cm rostral to the operated level. Patients were blinded to group allocation, and analysis was by intention to treat. The trial was approved by the National Health Service Research Ethics Service and the Medicines and Healthcare products Regulatory Agency. No commercial or other source of funding was received.ResultsSixty patients were randomized, 29 to fentanyl and 31 to control. Demographics, duration of surgery, and preoperative VAS were not significantly different between the groups. VAS in recovery was significantly lower in patients treated with fentanyl (mean [standard deviation]: 2.6 [2.7] vs. 4.7 [2.4]; p=.003). Later VAS and postoperative length of stay were similar between groups. More patients in the fentanyl group required temporary urinary catheterization, but there was no significant difference in the incidence of side effects.ConclusionsBolus epidural fentanyl provides effective short-term postoperative analgesia after lumbar canal decompression and may be a useful adjunct to pain management in patients undergoing lumbar spine surgery. |
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