Comparison of the Postoperative Analgesia Effects of Patient-Controlled Analgesia and Epidural Catheter After Posterior Instrumentation Surgery

Abstract

Objective: To prospectively assess the effects of intravenous patient-controlled analgesia (IV PCA) and epidural patient-controlled analgesia (epidural PCA) on postoperative pain management following posterior instrumentation surgery. Materials and Methods: The study involved the ASA 1-2 group, 60 patients who underwent elective thoracic or lumbar posterior instrumentation surgery at our tertiary centre for spinal stenosis. Two groups of patients were created: Group 1 (n = 30), IV PCA group, and Group 2 (n=30), epidural PCA group. IV PCA was applied by fentanyl. Epidural PCA was maintained by lading to epidural space by the neurosurgeon. Bupivacaine was administered to Group 2 patients in the recovery room. Following surgery, patients in both groups were assessed for pain using the visual analogue scale (VAS) and for motor block using the Bromage scale. Additionally, hemodynamic parameters, side effects, and patient satisfaction were noted. Following 48 hours, patients' overall rescue analgesia, opioid, and local anaesthetic requirements were recorded. Results: Postoperative VAS scores of Group 2 at the 1st, 2nd, 4th, 8th and 16th hours were lower than Group 1 and these differences was statistically significant. Postoperative patient satisfaction scores at 1st, 2nd, 4th, 8th, 12th, 16th, 20th, 24th, 30th, 36th, 42nd and 48th hours were significantly different between the groups and the patient satisfaction scores of Group 2 were higher than the Group 1. Side effects were similar in both groups. Group 1 required statistically significantly higher number of rescue analgesia. Conclusion: This study shows that epidural PCA is more comfortable than IV PCA with low VAS and high patient satisfaction scores. As a conclusion, epidural PCA is a safe, highly efficient method for patients with posterior instrumentation surgery.

Keywords

• Analgesia
• Patient-Controlled
• Pain
• Postoperative

References

1. 1. Tosteson AN, Lurie JD, Tosteson TD, et al. Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med. 2008; 149(12):845-53.
2. 2. Ross DA, Drasner K, Weinstein PR, Flaherty JF, Barbaro NM. Use of intrathecally administered morphine in the treatment of postoperative pain after lumbar spinal surgery: a prospective, double-blind, placebo-controlled study. Neurosurgery. 1991; 28(5):700-704.
3. 3. Guilfoyle MR, Mannion RJ, Mitchell P, Thomson S. Epidural fentanyl for postoperative analgesia after lumbar canal decompression: a randomized controlled trial. Spine J. 2012; 12(8):646-51.
4. 4. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013; 22(9):2089-96.
5. 5. Huang AR, Mallet L. Prescribing opioids in older people. Maturitas. 2013; 74(2):123-29.
6. 6. Schenk MR, Putzier M, Kügler B, et al. Postoperative analgesia after major spine surgery: patient-controlled epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg. 2006; 103(5):1311-17.
7. 7. Park SY, An HS, Lee SH, Suh SW, Kim JL, Yoon SJ. A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion. Eur Spine J. 2016; 25(5):1601-607.
8. 8. Pöpping DM, Elia N, Wenk M, Tramèr MR. Combination of a reduced dose of an intrathecal local anesthetic with a small dose of an opioid: a meta-analysis of randomized trials. Pain. 2013; 154(8):1383-90.

9. 9. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: a meta-analysis of randomized trials. Pain. 2012; 153(4):784-93.
10. 10. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009; 467(6):1418-23.
11. 11. Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. Clin Orthop Relat Res. 2005; 441:250-55.
12. 12. O'Hara JF Jr, Cywinski JB, Tetzlaff JE, Xu M, Gurd AR, Andrish JT. The effect of epidural vs intravenous analgesia for posterior spinal fusion surgery. Paediatr Anaesth. 2004; 14(12):1009-15.
13. 13. Cassady JF Jr, Lederhaas G, Cancel DD, Cummings RJ, Loveless EA. A randomized comparison of the effects of continuous thoracic epidural analgesia and intravenous patient-controlled analgesia after posterior spinal fusion in adolescents. Reg Anesth Pain Med. 2000; 25(3):246-53.
14. 14. Klatt JW, Mickelson J, Hung M, Durcan S, Miller C, Smith JT. A randomized prospective evaluation of 3 techniques of postoperative pain management after posterior spinal instrumentation and fusion. Spine. 2013; 38(19):1626-31.
15. 15. Li Y, Lu S, Ma SC, Fan HW, Zhao GQ. Effects of Patient-Controlled Epidural Analgesia and Patient-Controlled Intravenous Analgesia on Analgesia in Patients Undergoing Spinal Fusion Surgery. Am J Ther. 2016; 23(6):1806-12.
16. 16. Kluba T, Hofmann F, Bredanger S, Blumenstock G, Niemeyer T. Efficacy of post-operative analgesia after posterior lumbar instrumented fusion for degenerative disc disease: a prospective randomized comparison of epidural catheter and intravenous administration of analgesics. Orthop Rev. 2010; 2(1):9.
17. 17. Cohen BE, Hartman MB, Wade JT, Miller JS, Gilbert R, Chapman TM. Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. Spine. 1997; 22(16):1892-97.
18. 18. Fisher CG, Belanger L, Gofton EG, et al. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Spine. 2003; 28(8):739-43.
19. 19. Turner A, Lee J, Mitchell R, Berman J, Edge G, Fennelly M. The efficacy of surgically placed epidural catheters for analgesia after posterior spinal surgery. Anaesthesia. 2000; 55(4):370-73. 20. Sucato DJ, Duey-Holtz A, Elerson E, Safavi F. Postoperative analgesia following surgical correction for adolescent idiopathic scoliosis: a comparison of continuous epidural analgesia and patient-controlled analgesia. Spine. 2005; 30(2):211-17.