The public health crisis attributed to opioids has placed increasing emphasis on other approaches to pain management, both pharmacologic and nonpharmacologic. Although some people find the term “multimodal pain management” to be ambiguous when used in clinical research or patient care, it emphasizes the need for a broader (and multidisciplinary) approach to pain management.
On the pharmacologic side, pregabalin has been found to be a variably effective adjunctive analgesic in research involving joint arthroplasty. However, its use in adolescents and children has not been adequately explored. In the February 5, 2020 issue of The Journal, Helenius et al. investigate the impact of pregabalin on total opioid consumption and pain scores in a randomized, placebo-controlled trial of 63 adolescents undergoing posterior instrumented spinal-fusion procedures. These operations are quite invasive and often result in ICU admission because of the amount of narcotics required. In this study, induction and maintenance of anesthesia and mobilization protocols were standardized for patients in both the pregabalin and placebo groups, and the authors precisely measured opioid consumption during the first 48 hours after surgery with data from patient-controlled anesthesia systems.
According to the findings from this adequately powered trial, adjunctive pregabalin did not have a positive impact on opioid consumption or postoperative pain scores. Despite these negative findings, it is my hope that this drug and others being investigated as adjunctive “modes” in multimodal pain management will be subjected to similarly designed trials, so we can accurately determine which agents work best in limiting opioid utilization.
Marc Swiontkowski, MD
Analgesia after total knee arthroplasty (TKA) is a multimodal affair these days. Main goals include maintaining adequate patient comfort while limiting opiate use and permitting early mobilization.
In the August 2, 2017 issue of JBJS, Sogbein et al. report on a blinded randomized study comparing the performance of two types of analgesia often used in multimodal TKA pain-management protocols: preoperative motor-sparing knee blocks and intraoperative periarticular infiltrations.
Prior to surgery, the 35 patients in the motor-sparing block group received a midthigh adductor canal block under ultrasound guidance, combined with posterior pericapsular and lateral femoral cutaneous injections. The 35 patients in the periarticular infiltration group received study-labeled local anesthetics intraoperatively, just prior to component implantation.
Defining the “end of analgesia” as the point at which patient-reported pain at rest or activity rated ≥6 on the numerical rating scale and rescue analgesia was administered, the authors found that the duration of analgesia was significantly longer for the motor-sparing-block group compared with the periarticular-infiltration group. The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no between-group differences in time to mobilization, length of hospital stay, opiate consumption, or functional recovery.