pain management after spinal fusionpain management after spinal fusion

Similarly, in patients undergoing lumbar posterior fusions, low-dose ketamine continued for 24 h postoperatively had analgesic, but not opioid-sparing effects.22 Two studies investigated ketamine against the backdrop of intra-operative remifentanil-based analgesia. The efficacy of ketamine was investigated in six studies.1823 None of the studies had adequate basic analgesia.6 Bolus doses ranged from high (0.5 mg kg1)18,2021,23 to low (0.1 to 0.2 mg kg1)19,22 and continuous infusion doses ranged from high (up to 10 g kg1 min1)1820 to low (1 to 2 g kg1 min1).19,2123 In patients undergoing major lumbar spinal surgery, Loftus et al.20 demonstrated morphine-sparing effects of intra-operative high-dose ketamine, with decreased pain scores postoperatively and at 6 weeks. Weight Management; Am I Depressed? Thus, vigilant monitoring is necessary. We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. 32. Multimodal analgesia (MMA) is the simultaneous use of multiple analgesic medications that work in a synergistic manner to provide pain control. However, COX-2 dependent production of PGE2 is essential for adequate skeletal regeneration. I'm curious as to what they gave y'all after your spinal fusion. [3,4] Effective pain controls facilitates early mobilization as well as expedites hospital discharge. In a placebo-controlled study, Jirarattanaphochai et al.8 compared placebo with the effect of 40 mg parecoxib 30 min before induction of anaesthesia and then every 12 h for 48 h in patients who underwent PLIF surgery. Recommendations are given when at least two congruent studies support an intervention. Therapeutic effect of intrathecal morphine after posterior lumbar interbody fusion surgery: A prospective, double-blind, randomized study. Reuben SS, Connelly NR, Steinberg R. Ketorolac as an adjunct to patient-controlled morphine in postoperative spine surgery patients. advertisement. Well designed procedure-specific studies are necessary to assess the clinical benefits of the recommendations. [33] COX-2 inhibitors are contraindicated in renal dysfunction are should be used cautiously in patients with history of coronary and cerebrovascular diseases. Tong YC, Kaye AD, Urman RD. Management of Postoperative Pain in Patients Following Spine Surgery: A Similar to them, extended release epidural morphine has been developed which can be administered at the lumbar level. It is helpful in providing analgesia in the immediate postoperative period when gastrointestinal motility is reduced or when rapid analgesia establishment is required. 14. New strategies for pain management are currently under investigati. In recent years, spine surgery has seen the growth of multimodal perioperative protocols for managing pain. Schenk MR, Putzier M, Kgler B, Tohtz S, Voigt K, Schink T, et al. On the basis of available evidence and the PROSPECT approach to providing recommendations, combinations of paracetamol and a NSAID or a COX-2 specific inhibitor are recommended pre-operatively or intra-operatively, and they should be continued postoperatively, unless contraindicated.4246 Fixed-time interval analgesia has been shown to provide superior pain relief in comparison with on-demand analgesia.47,48 For the intra-operative period, we recommend a low-dose i.v. During the procedure, the surgeon places bone graft material between one or more vertebrae to gradually fuse them into a single bone. Subramaniam K, Akhouri V, Glazer PA, Rachlin J, Kunze L, Cronin M, et al. Postoperative pain treatment after spinal fusion surgery: a systematic The epidural catheter should be placed under direct visualisation by the surgeon at the end of surgery. Sinatra RS, Torres J, Bustos AM. After lumbar spinal fusion, you may be given a girdle-type brace that wraps tightly around your lower back and midsection. There are currently no studies in the literature that directly assess the effectiveness of muscle relaxants and nonbenzodiazepines.76 We did not find evidence to promote one surgical technique over another.77. Opioids can also be administered solely or in combination with local anesthetic solutions. Postoperative Pain Management after Spinal Fusion Surgery: An Analysis PW and EA wrote the manuscript, which was reviewed and edited by all the other authors who have also participated in the PROSPECT Working Group meetings using the Delphi method and in defining the methodology of the PROSPECT group. They have proven efficacy in ameliorating postoperative pain,[19] and especially pain following spinal surgeries. 55. Jabbour HJ, Naccache NM, Jawish RJ, et al. 64. Tsaousi GG, Pourzitaki C, Aloisio S, Bilotta F. Dexmedetomidine as a sedative and analgesic adjuvant in spine surgery: a systematic review and meta-analysis of randomized controlled trials. Nissen I, Jensen KA, Ohrstrm JK. Hadi BA, Al Ramadani R, Daas R, et al. We included 31 RCTs and four systematic reviews. Spinal fusion. Not all drugs in the RCTs were compared with a multimodal analgesic regimen. 35. A multimodal approach for postoperative pain management after lumbar decompression surgery: A prospective, randomized study. More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Specific to this study, the Embase, MEDLINE and Cochrane Databases were searched for RCTs published between 1 January 2008 and 18 April 2020. Complex spine surgery can be defined as thoracolumbar spine surgery with instrumentation, laminectomy at three or more levels, or scoliosis surgery. For more information, please refer to our Privacy Policy. 52. . Thus, lidocaine infusion is not recommended due to conflicting evidence. The effectiveness of each intervention for each outcome was evaluated qualitatively, by assessing the number of studies showing a significant difference between treatment arms (P < 0.05 as reported in the study publication). Bajwa SJ, Kulshrestha A. Spine Surgeries: Challenging Aspects and Implications for Anaesthesia. Jirarattanaphochai K, Jung S. Nonsteroidal antiinflammatory drugs for postoperative pain management after lumbar spine surgery: a meta-analysis of randomized controlled trials. The opioid administration should be aimed to be stopped by a particular due date, and opioid requirements should be reassessed during discharge. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief. Was there rush too soon to judgment? Turner DM, Warson JS, Wirt TC, Scalley RD, Cochran RS, Miller KJ. Multimodal analgesic therapy with Gabapentin and its association with postoperative respiratory depression. 5. Early postoperative neurological examination was feasible in all patients in both groups. Choi S, Rampersaud YR, Chan VW, et al. Opioid and anaesthetic consumption in the peri-operative period decreased significantly in the TLIP group compared with the control group. Postoperative Pain Management after Spinal Fusion Surgery: An Analysis 74. Sevarino FB, Sinatra RS, Paige D, Ning T, Brull SJ, Silverman DG. Intrathecal morphine and fentanyl can reduce the cumulative opioid demand in patients after spinal surgery. Pain Management at Home after ACDF By: David DeWitt, MD, Orthopedic Surgeon Peer-Reviewed Watch: ACDF Video Some pain is likely after discharge from the hospital. A prospective randomized double-blind trial of the use of intrathecal fentanyl in patients undergoing lumbar spinal surgery. Murphy et al.14 found a positive analgesic effect of methadone 0.2 mg kg1 at the start of surgery compared to hydromorphone 2 mg at surgical closure for spinal fusions. to maintaining your privacy and will not share your personal information without [27,28,29] NSAID's are generally started within 3 days after surgery and continued for 3 or more days. Safety profile of intraoperative methadone for analgesia after major spine surgery: an observational study of 1,478 patients. The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief. They are preferred where hemostasis is a cause of concern. 3. Postoperative pain is the result of activation of various pain mechanisms including nociceptive, neuropathic, and inflammatory. Xu et al.40 compared a continuous local wound infusion of 0.33% ropivacaine with flurbiprofen and pentazocine infusion following thoracolumbar spinal surgery. It is not usually necessary to donate blood before spinal fusion. Overall, opioid use is not reported in the majority of lumbar fusion trials. Development of evidence-based recommendations for procedure-specific pain management: PROcedure-SPECific Pain ManagemenT (PROSPECT) methodology. Henrik Kehlet has received honoraria from Pfizer and Grunenthal. Sept. 24, 2019 The sacroiliac (SI) joint is a common but underrecognized source of continuing back pain in patients who have surgical fusions for the treatment of back pain. Posterior spinal fusion (PSF), which accounts for over 90% of surgical procedures performed for the correction of scoliosis, causes severe postoperative pain because of extensive dissection of the skin, subcutaneous tissues, bones, and ligaments. Spinal cord stimulators consist of thin wires (the electrodes) and a small, . Pain after spine surgery is common and is usually treated with medications such as: Flow diagram for management of acute perioperative pain associated with thoracic surgery. Patients may require oral narcotic medications following discharge therefore laxatives and antiemetics should be concurrently prescribed. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Bernard JM, Surbled M, Lagarde D, Trennec A. Analgesia after surgery of the spine in adults and adolescents. They compared pre-operative acetaminophen and gabapentin, combined with intra-operative infusions of lidocaine and ketamine, with placebo. The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial. 5. The .gov means its official. The pain scores were not significantly different, but morphine consumption was reduced in both tenoxicam groups. Compared to bupivacaine, ropivacaine offers better systemic safety margin and higher selectivity toward sensory fibers. Chidambaran V, Subramanyam R, Ding L, et al. HHS Vulnerability Disclosure, Help Combining paracetamol (Acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. 57. [63] Early recovery provided with dexmedetomidine also allowed early neurological assessment that is important following spinal surgeries. Criteria employed in the assessment of the quality of eligible studies included allocation concealment, numerical (1 to 5) quality scoring system employed by Jadad to assess randomisation, double blinding and the flow of patients, follow-up of greater or less than 80% of participants, and whether the study met the requirements of the Consolidated Standards of Reporting Trials (CONSORT) 2010 Statement. Epidural administration of drugs is through different techniques such as single and double catheters, intermittent boluses, PCA devices, or continuous infusions. Verret M, Lauzier F, Zarychanski R, et al. 3. Sharma S, Balireddy RK, Vorenkamp KE, Durieux ME. Non-opioid postoperative analgesia. The PCA devices were programmed to deliver a loading dose of 0.05 ml kg1, a continuous infusion of 0.005 ml kg1 h1 and a bolus dose of 0.02 ml kg1 with a 10 min lock-out period. Naik et al.25 reported that dexmedetomidine (1 g kg1 loading dose followed by 0.5 g kg1 h1 infusion) reduced the intra-operative, but not the postoperative, opioid consumption when compared with placebo in patients undergoing thoracic and/or lumbar spine surgery at three levels or more. The Roland Morris disability questionnaire and Oswestry disability index (ODI)/neck disability index (NDI) are validated systems that can be utilized in patients with back pain to ascertain their levels of disability due to pain. Longer lasting analgesia (up to 48 h),[66] lower systemic concentrations of morphine and better patient activity levels[67] are the advantages offered by this modality which makes it a novel and emerging approach to manage post spinal surgery pain. on behalf of the PROSPECT Working Group Collaborators. Inturrisi CE. 22. However, to achieve satisfactory pain control with this method, high doses of opioids must be administered. Pre-emptive pain control: Comparison of ketorolac and diclofenac sodium. Park SY, An HS, Lee SH, et al. The VAS scores in the TLIP group were lower at 12, 24 and 36 h postoperatively. PMID: 31770340 DOI: 10.1097/BRS.0000000000003320 Abstract Study design: Retrospective population-based cohort analysis. [12] NDI is a modification of ODI utilized in patients with cervical ailments. RECOMMENDATIONS The following information should help you understand your options for pain management. A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion. 58. [57] As with intrathecal usage, epidural administration of opioids should be monitored cautiously to prevent inadvertent respiratory depression due to the diffusion of opioids in cerebrospinal fluid. What is a spinal cord stimulator and how does it work? Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India, 1Department of Anaesthesiology, SGPGIMS, Lucknow, Uttar Pradesh, India. 49. Lidocaine significantly reduced the pain scores in the first 48 h postsurgery, the morphine consumption in the first 24 h and the time to the first request for additional analgesia. 3. Wherefore Gabapentinoids? Nielsen RV, Formsgaard JS, Siegel H, et al. 69. WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC? Patients undergoing complex spine surgery often present with pre-existing chronic pain and dependence on chronic opioid therapy. Here are some facts about spinal fusions for back pain relief that'll help you and your doctor determine if this is the best course of treatment for your pain. Transcutaneous electrical nerve stimulation (TENS) applied preincisionally and postoperatively reduces the postoperative opioid requirement and provides sufficient analgesia. Spinal procedures are generally associated with intense pain in the postoperative period, especially for the initial few days. There were no major adverse effects reported in the literature.35 Epidural analgesia is recommended, but its use should be individualised. comments sorted by Best Top New Controversial Q&A Add a Comment kjconnor43 Additional comment actions. Wenk M, Liljenqvist U, Kaulingfrecks T, et al. This approach reports true clinical effectiveness by balancing the invasiveness of the analgesic interventions and the degree of pain after surgery, as well as balancing efficacy and adverse effects. Fishman SM, Wilsey B, Mahajan G, Molina P. Methadone reincarnated: novel clinical applications with related concerns. et al. Therefore, combination therapy or multimodal analgesia for proper control of pain appears as the best approach in this regard. A commonly performed orthopedic procedure, with increasing rates worldwide (increase of 118% in the United States between 1998 and 2014), is 1- or 2-level spinal fusion surgery. O'Hara et al. Dosing modifications are needed for patients who have developed tolerance because of their preexisting chronic pain. Efficacy of postoperative analgesia after posterior lumbar instrumented fusion for degenerative disc disease: a prospective randomized comparison of epidural catheter and intravenous administration of analgesics. [54,55] Moreover, the relief from dynamic pain is enhanced following use of combination solutions. 16. Martinez V, Beloeil H, Marret E, et al. [2] Adequate pain relief is, therefore, an important facet of postoperative care of these patients. 56. Statistical analyses and patient follow-up assessment, Additional assessment of overall study quality required to judge LoE, Grade of recommendation (based on overall LoE, considering balance of clinical practice information and evidence), Systematic review with homogeneous results, A (based on two or more studies or a single large, well designed study), Statistics not reported or questionable or <80% follow-up, B (or extrapolation from one procedure-specific LoE 1 study), Nonsystematic review, cohort study, case study; (e.g. Mathiesen O, Dahl B, Thomsen BA, et al. Nonsteroidal anti-inflammatory drugs for postoperative pain control after lumbar spine surgery: a meta-analysis of randomized controlled trials. Please try again soon. An Update on Postoperative Opioid Use and Alternative Pain Control However, the beneficial effects of TENS on cognitive functions could not be demonstrated.[64]. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicenter, double-blind, randomized clinical trial. Intra- and postoperative very low dose intravenous ketamine infusion does not increase pain relief after major spine surgery in patients with preoperative narcotic analgesic intake. Spine (Phila Pa 1976) 2003; 28:739-43. The site is secure. A 10-year period for literature review was chosen because it more likely resembles relevant clinical practice, given that rapid changes occur in peri-operative care including surgical techniques. Myrhe M, Diep LM, Stubhaug A. Pregabalin has analgesic, ventilator and cognitive affects in combination with remifentanil. Reuben SS, Ekman EF. Inclusion in an NLM database does not imply endorsement of, or agreement with, Intra-operative intravenous low-dose ketamine infusion is recommended. 50. Joshi GP, Van de Velde M, Kehlet H, et al. Postoperative pain management after spinal fusion surgery: an analysis Two RCTs, Park et al.30 and Gessler et al.,31 compared the epidural infusion of 0.2% ropivacaine with IV-PCA opioids. Multivesicular liposomes containing bupivacaine produces sustained release of drugs in the vicinity of the surgical site. 10 Facts About Spinal Fusions for Back Pain Relief Patients might feel like they got better for a little while, but then started to get worse again. Therefore, low concentrations of local anaesthetics should be used. Presentations: This systematic review was presented as a poster presentation at the Online SARB (Society for Anesthesia and Resuscitation of Belgium) Graduation Day, 23 of May 2020, Leuven, Belgium. Postoperative Pain Management after Spinal Fusion Surgery: An Analysis In a study by Jabbour et al.,27 patients given magnesium (50 mg kg1) and ketamine (0.2 mg kg1 bolus with an infusion of 0.15 mg kg1 h1) showed a significantly lower average cumulative morphine consumption compared with ketamine alone until 48 h postsurgery. Vernon H, Mior S. The neck disability index: A study of reliability and validity. [11] It allows to identify the location and quality of pain. Wolters Kluwer Health Three studies investigated the effects of local anaesthetic techniques. Schwenk ES, Goldberg SF, Patel RD, et al. Mayo Clinic has developed new techniques for the diagnosis and treatment of patients with SI joint dysfunction. The effect of ketorolac on thoracolumbar posterolateral fusion: a systematic review and meta-analysis. - Pain Management - MedHelp Communities > Pain Management > Pain in legs, groin and back after spinal fusion. The methodological quality assessments of the 31 RCTs included for final qualitative analysis are summarised in Supplementary Table 1, https://links.lww.com/EJA/A489. 21. Pain Control After Surgery: Symptoms, Treatment The surgery is done to help stabilize your spine, reduce pain, or address spine issues, such as scoliosis. Does ketamine improve postoperative analgesia. Dexmedetomidine infusion (0.01 to 0.02 g kg1 min1) was compared with remifentanil infusion (0.01 to 0.2 g kg1 min1) in patients undergoing PLIF surgery by Hwang et al.24 The pain scores in the dexmedetomidine group were significantly lower than those in the remifentanil group at the immediate and late postoperative periods (48 h after surgery). Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. The standard of care for pain management for spine surgery in children consists of continuous infusion of intravenous (IV) morphine supplemented with patient-controlled analgesia (PCA). Bhaskar SB, Bajwa SS. The intra-operative infusion of dexmedetomidine is not recommended due to limited procedure-specific evidence, although intra-operative dexmedetomidine infusion has been reported to reduce peri-operative opioid use and lower postoperative pain scores.24,26 When compared with remifentanil, dexmedetomidine showed fewer side effects such as hypotension, shivering, postoperative nausea and vomiting, and bradycardia.65, Gabapentinoids are not recommended due to limited evidence, although they have an established role in the management of neuropathic pain, which may be a concern in complex spine surgery.6668 Current evidence does not support the routine use of gabapentinoids as part of a multimodal analgesic regimen in complex spine surgery, and there are concerns regarding side effects such as sedation and respiratory depression.6972. Yefet E, Taha H, Salim R, et al. Foulkes GD, Robinson JS., Jr Intraoperative dexamethasone irrigation in lumbar microdiskectomy. [15] Being a noncompetitive N-Methyl-D-aspartate (NMDA) receptor antagonist,[16,17] it mitigates pain and also reduces (or prevents) opioid tolerance. Narcotic pain medication is usually prescribed to help reduce the pain in the first 1 to 4 weeks after surgery. Devin C, McGirt M. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. 68. 70. Pain management after major orthopaedic surgery: Current strategies and new concepts. Ketamine and magnesium association reduces morphine consumption after scoliosis surgery: prospective randomised double-blind study. Recovery After Spinal Fusion: What to Expect - Healthgrades | Find a Doctor The influence of anaesthetic drug selection for scoliosis surgery on the management of intraoperative haemodynamic stability and postoperative pain pharmaceutical care programme. Please try after some time. Experts strongly suggest the inclusion of multimodal analgesia for the management of such patients as the quality of analgesia is improved vastly and the side effects of individual drugs diminish. There were no differences in pain scores and rescue analgesia. Get new journal Tables of Contents sent right to your email inbox, http://creativecommons.org/licenses/by-nc-nd/4.0, EJA_2020_12_29_BELOEIL_EJA-D-20-00614_SDC1.docx; [Word] (24 KB), EJA_2020_12_29_BELOEIL_EJA-D-20-00614_SDC2.docx; [Word] (25 KB), EJA_2020_12_29_BELOEIL_EJA-D-20-00614_SDC3.docx; [Word] (24 KB), Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations, Articles in Google Scholar by Piet Waelkens, Other articles in this journal by Piet Waelkens, Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations, Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines, Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022, Current issues in postoperative pain management, Blood pressure targets during general anaesthesia for noncardiac surgery: A systematic review of clinical trials. I am in constant pain now that ranges from a 6 to a 9. Moore UJ, Marsh VR, Ashton CH, Seymour RA. Ong CK, Seymour RA, Lirk P, Merry AF. Pain 2017; 158:463 . However, they were not specific for complex spine surgery. My lower back is my only area without the fusion. This was demonstrated in the PODCAST trial.60 There is insufficient evidence that supports the continuation of ketamine infusion in the postoperative period. Objective: Given the lack of large-scale data on the use and efficacy of multimodal analgesia in spine fusion surgery, we conducted a population-based analysis utilizing the nationwide claims-based Premier Healthcare database. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. [30] However, increasing evidence has been gathered over the past few years that impaired bone healing is dependent upon higher doses (120-240 mg/day)[31] and longer duration[32] of treatment with ketorolac. Le Roux PD, Samudrala S. Postoperative pain after lumbar disc surgery: A comparison between parenteral ketorolac and narcotics. Bethesda, MD 20894, Web Policies sharing sensitive information, make sure youre on a federal 40. HOW DOES THIS GUIDELINE DIFFER FROM OTHER GUIDELINES? Various nociceptors and mechanoreceptors that are capable of eliciting pain transmit these sensations. Messerschmitt PJ, Furey CG, Bohlman HH. Recommendations for optimal pain relief are graded A to D according to the overall level of evidence (as determined by the quality of studies included), consistency of evidence and source of evidence (Table 1). A recent review of 179 surgical procedures has rated spinal surgeries among the top six procedures causing highest degree of postsurgical pain. 24. FOIA Post Spinal Fusion Pain : r/scoliosis Opioids may be used as postoperative rescue analgesic. Minimizing blood loss in spine surgery. Please enable scripts and reload this page. When compared with the other orthopedic subspecialties, such as joint replacement surgery, a higher percentage of postoperative patients continue to have symptoms that require pain medication utilization and some require further surgeries. Ekatodramis G, Min K, Cathrein P, Borgeat A. Dahl V, Raeder JC. [5] Pain from the back originates from different tissues such as vertebrae, intervertebral discs, ligaments, dura, nerve root sleeves, facet joint capsules, fascia, and muscles. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Methadone given intra-operatively was superior to hydromorphone and sufentanil for lowering postoperative pain scores and opioid requirement.14,15 However, the benefits of methadone may be related to the duration of action because it was compared with shorter-acting opioids. Any discrepancies between results were discussed within the working group and a decision was made on inclusion or exclusion by consensus. Analysis of intervertebral disc CCR6 and IL-6 gene levels with short official website and that any information you provide is encrypted [10], Accurate measurement of postoperative pain is imperative to provide optimum pain relief. The preexisting pain along with long-term consumption of analgesics and/or opioids alters pain perception in these patients thereby complicating pain management. Suffering from Lumbar Spinal Stenosis? A meta-analysis was not performed due to the limited number of studies with homogeneous design and differences in how results were reported, restricting pooled analysis. government site. Possible complications include: Poor wound healing. Davis MP, Walsh D. Methadone for relief of cancer pain: A review of pharmacokinetics, pharmacodynamics, drug interactions and protocols of administration. ibuprofen 30 min prior to incision versus placebo in patients undergoing multilevel posterior lumbar interbody fusion (PLIF) surgery. There was a significantly lower cumulative piritramide requirement in the intrathecal morphine group without any serious increase of opioid-associated side effects. Health Information (Sponsored) Take the Chronic Pain Quiz. Evaluation of clinical factors associated with adverse drug events in patients receiving sub-anesthetic ketamine infusions. Similarly, Pacreu et al.21 demonstrated methadone-sparing effects when ketamine infusion was superimposed on a remifentanil maintenance regimen. Exclusive use of NSAID's for providing postoperative analgesia is, however, questionable. The primary outcomes sought were postoperative pain scores and analgesic requirements. Pain Management After Outpatient Spine Surgery . Eipe N, Penning J, Yazdi F, et al. Financial support and sponsorship: The PROSPECT Working group provided a grant to cover the open access publication costs for this article. The higher affinity and selectivity of dexmedetomidine aid in decreasing the dosages as well as adverse effects of local anesthetics and opioids when used simultaneously with dexmedetomidine.