Perioperative Multimodal Analgesia for Adults Undergoing Surgery of the Spine-A Systematic Review and Meta-Analysis of Three or More Modalities

BACKGROUND: Multimodal analgesia is a strategy that can be used to improve pain management in the perioperative period for patients undergoing surgery of the spine. However, no review evidence is available on the quanti-tative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the effects of maximal (?_3 analgesic agents) multimodal analgesic medication for patients undergoing surgery of the spine.METHODS: We included randomized controlled trials that had evaluated the use of ?_3 multimodal analgesia components (maximal multimodal analgesia) in patients undergoing spinal surgery. We excluded patients who had received neuraxial or regional analgesia. The control group consisted of placebo, stan-dard care (any therapeutic modality including 2 pound analgesic components). The primary outcomes were the postoperative pain scores at rest evaluated at 24 and 48 hours. We searched MEDLINE via OvidSP, EMBASE via OvidSP, and the Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used the Cochrane standard methods.RESULTS: We identified consistently improved analgesic endpoints across all predetermined primary and secondary outcomes. A total of 11 eligible studies had evaluated the primary outcome of pain at rest at 24 hours. The patients who had received maximal multimodal analgesia were identified to have had lower pain scores with an average mean difference of-1.03 (P < 0.00001). The length of hospital stay was shorter for the patients who had received multimodal analgesia (mean difference,-0.55; P < 0.00001).CONCLUSIONS: Perioperative maximal multimodal analgesia consistently improved the visual analog scale scores for an adult population in the immediate postoperative period, with a moderate quality of evidence. We found a signifi-cant decrease in the hospital length of stay for patients who had received maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.