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Chapter Summary
• Context: Postoperative pain following spine surgery can be intense, complex, and debilitating. Inadequately controlled acute pain impairs early mobilization, increases cardiopulmonary and thromboembolic complications, prolongs hospitalization, and markedly elevates the risk of transition to chronic postsurgical pain (CPSP). Traditional reliance on high-dose postoperative opioid monotherapy is associated with sedation, respiratory depression, nausea, ileus, urinary retention, and potential dependence. In response, Enhanced Recovery After Surgery (ERAS) pathways and multimodal analgesia paradigms have emerged, combining preemptive analgesia, regional/neuraxial blocks, non-opioid systemic agents, and early physical mobilization to provide superior analgesia with reduced opioid-related side effects.
• Chapter Objective: To review evidence-based multimodal strategies for acute postoperative pain control in spine surgery. The reader will learn to structure perioperative protocols including preoperative patient optimization and education, intraoperative regional anesthesia and wound infiltration, systemic non-opioid pharmacotherapy, and safe transition to oral analgesia during recovery.
• Multimodal Analgesia Principles and ERASMultimodal analgesia targets distinct nociceptive pathways simultaneously to achieve additive or synergistic pain relief while minimizing individual drug toxicities. ERAS protocols in spine surgery reduce surgical stress, optimize fluid balance, and expedite functional return.
• Preoperative and Preemptive InterventionsPreoperative patient education and realistic expectation setting reduce anxiety. Preemptive administration of oral acetaminophen, gabapentinoids, and NSAIDs/COX-2 inhibitors dampens central sensitization before surgical incision.
• Intraoperative Regional and Local AnalgesiaUltrasound-guided regional techniques—such as erector spinae plane (ESP) blocks, thoracolumbar interfascial plane (TLIP) blocks, and surgical field infiltration with local anesthetics (e.g., bupivacaine/ropivacaine with liposomal formulations or adjuvants)—provide significant opioid-sparing analgesia for posterior lumbar and thoracic exposures.
• Systemic Pharmacotherapy and Rescue AnalgesiaAround-the-clock intravenous acetaminophen, NSAIDs/COX-2 inhibitors (when bone fusion risks are managed), dexamethasone, and subanesthetic ketamine infusions reduce opioid consumption. Short-acting opioids (patient-controlled analgesia - PCA) are reserved for breakthrough pain, followed by early transition to oral regimens.
• Clinical Application: Implementing an institutional ERAS protocol for spine surgery requires coordination across surgical, anesthetic, and nursing teams. Administer preemptive non-opioids before induction. Incorporate ultrasound-guided ESP blocks or surgical site infiltration with long-acting local anesthetics during closure. Postoperatively, maintain scheduled non-opioid analgesics (acetaminophen, COX-2 inhibitors) and mobilize the patient on postoperative day 0 or 1. Rapidly de-escalate intravenous opioids to prevent bowel dysmotility and delayed discharge.
