Multimodal Pain Management and Postoperative Outcomes in Lumbar Spine Fusion Surgery: A Population-based Cohort Study

Spine (Phila Pa 1976). 2020 May 1;45(9):580-589. doi: 10.1097/BRS.0000000000003320.


Study design: Retrospective population-based cohort analysis.

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.

Summary of background data: Multimodal analgesia, combining different pain signaling pathways to achieve additive and synergistic effects, is increasingly emerging as the standard of care.

Methods: Cases of posterior lumbar fusion surgery were extracted (2006-2016). Opioid-only analgesia was compared to multimodal analgesia, that is, systemic opioid analgesia + either acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, or neuraxial anesthesia (categorized into 1, 2, or >2 additional analgesic modes). Mixed-effects models measured associations between multimodal analgesia categories and outcomes, including opioid prescription dose, cost/length of hospitalization, and opioid-related complications. Odds ratios (ORs, or % change) and 95% confidence intervals (CIs) are reported.

Results: Among 265,538 patients the incidence of multimodal analgesia was 61.1% (162,156); multimodal pain management-specifically when adding NSAIDs/COX-2 inhibitors to opioids-was associated with reduced opioid prescription (-13.3% CI -16.7 to -9.7%), cost (-2.9% CI -3.9 to -1.8%) and length of hospitalization (-7.3% CI -8.5 to -6.1%). Multimodal analgesia in general was associated with stepwise decreased odds for gastrointestinal complications (OR 0.95, 95% CI 0.88-1.04; OR 0.84, CI 0.75-0.95; OR 0.78, 95% CI 0.64-0.96), whereas odds were increased for postoperative delirium (OR 1.14, 95% CI 1.00-1.32; OR 1.33, 95% CI 1.11-1.59; OR 1.31, 95% CI 0.99-1.74), and counterintuitively- naloxone administration (OR 1.25, 95% CI 1.13-1.38; OR 1.56, 95% CI 1.37-1.77; OR 1.84, 95% CI 1.52-2.23) with increasing analgesic modes used: one, two, or more additional analgesic modes, respectively. Post-hoc analysis revealed that specifically gabapentinoid use increased odds of naloxone requirement by about 50%, regardless of concurrent opioid dose (P < 0.001).

Conclusion: Although multimodal analgesia was not consistently implemented in spine fusion surgery, particularly NSAIDs and COX-2 inhibitors demonstrated opioid sparing effects. Moreover, results suggest a synergistic interaction between gabapentinoids and opioids, the former potentiating opioid effects resulting in greater naloxone requirement.

Level of evidence: 3.

MeSH terms

  • Adult
  • Aged
  • Analgesics / therapeutic use*
  • Analgesics, Opioid / therapeutic use
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Cohort Studies
  • Cyclooxygenase 2 Inhibitors / therapeutic use
  • Female
  • Humans
  • Lumbar Vertebrae / surgery*
  • Male
  • Middle Aged
  • Pain Management / methods*
  • Pain, Postoperative / diagnosis
  • Pain, Postoperative / drug therapy*
  • Pain, Postoperative / etiology
  • Population Surveillance* / methods
  • Retrospective Studies
  • Spinal Fusion / adverse effects*
  • Treatment Outcome


  • Analgesics
  • Analgesics, Opioid
  • Anti-Inflammatory Agents, Non-Steroidal
  • Cyclooxygenase 2 Inhibitors