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      A comparison of the postoperative analgesic efficacy between epidural and intravenous analgesia in major spine surgery: a meta-analysis

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          Abstract

          Postoperative analgesia remains a challenge for orthopedic surgeons. The aim of this meta-analysis is to compare the efficacy of epidural analgesia (EA) and intravenous patient-controlled analgesia (IV-PCA) following major spine surgery. We searched electronic databases, including the PubMed, EMBASE, Ovid and Cochrane databases, for randomized controlled trials (RCTs) published before June 2016. The quality of the included trials was assessed using the Cochrane risk-of-bias tool. Random effects models were used to estimate the standardized mean differences (SMDs) and relative risks (RRs), with the corresponding 95% confidence intervals (CI). Subgroup analyses stratified by the type of epidural-infused medication and epidural delivery were also performed. A total of 17 trials matched the inclusion criteria and were chosen for the following meta-analysis. Overall, EA provided significantly superior analgesia, higher patient satisfaction and decreased overall opioid consumption compared with IV-PCA following major spine surgery. Additionally, no differences were found in the side effects associated with these two methods of analgesia. Egger’s and Begg’s tests showed no significant publication bias. We suggest that EA is superior to IV-PCA for pain management after major spine surgery. More large-scale, high-quality trials are needed to verify these findings.

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          Efficacy of postoperative epidural analgesia: a meta-analysis.

          Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial. To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative technique. Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to April 25, 2002) and other sources for studies related to postoperative epidural analgesia. Inclusion criteria were a comparison of epidural therapy vs parenteral opioids for postoperative analgesia, measurement of pain using a visual analog scale (VAS) or numeric rating scale, randomization of patients to either therapy, and adult patients (> or =18 years). A total of 1404 abstracts were identified, 100 of which met all inclusion criteria. Each article was reviewed and data extracted from tables, text, or extrapolated from figures as needed. Weighted mean pain scores, weighted mean differences in pain score, and weighted incidences of complications were determined by using a fixed-effect model. Epidural analgesia provided better postoperative analgesia compared with parenteral opioids (mean [SE], 19.40 mm [0.17] vs 29.40 mm [0.20] on the VAS; P<.001). When analyzed by postoperative day, epidural analgesia was better than parenteral opioids on each postoperative day (P<.001 for each day after surgery). For all types of surgery and pain assessments, all forms of epidural analgesia provided significantly better postoperative analgesia compared with parenteral opioid analgesia (P<.001 for all), with the exception of thoracic epidural analgesia vs opioids for rest pain after thoracic surgery (weighted mean difference, 0.6 mm; 95% confidence interval, -0.3 to 1.5 mm; P =.12). The complication rates were lower than expected for nausea or vomiting and pruritus but comparable with existing data for lower extremity motor block. Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids.
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            Effectiveness of acute postoperative pain management: I. Evidence from published data.

            This review examines the evidence from published data concerning the incidence of moderate-severe and of severe pain after major surgery, with three analgesic techniques; intramuscular (i.m.) analgesia, patient controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which represent the experience of a total of nearly 20,000 patients, form the basis of this review. Different pain measurement tools provided comparable data. When considering a mixture of three analgesic techniques, the overall mean (95% CI) incidence of moderate-severe pain and of severe pain was 29.7 (26.4-33.0)% and 10.9 (8.4-13.4)%, respectively. The overall mean (95% CI) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.4-4.6)% and 19.4 (16.4-22.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain was 67.2 (58.1-76.2)% and that of severe pain was 29.1 (18.8-39.4)%. For PCA, the incidence of moderate-severe pain was 35.8 (31.4-40.2)% and that of severe pain was 10.4 (8.0-12.8)%. For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.8-24.0)% and that of severe pain was 7.8 (6.1-9.5)%. The incidence of premature catheter dislodgement was 5.7 (4.0-7.4)%. Over the period 1973-1999 there has been a highly significant (P < 0.0001) reduction in the incidence of moderate-severe pain of 1.9 (1.1-2.7)% per year. These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful in setting standards of care for Acute Pain Services.
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              Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis.

              The authors performed a meta-analysis and found that epidural analgesia overall provided superior postoperative analgesia compared with intravenous patient-controlled analgesia. For all types of surgery and pain assessments, all forms of epidural analgesia (both continuous epidural infusion and patient-controlled epidural analgesia) provided significantly superior postoperative analgesia compared with intravenous patient-controlled analgesia, with the exception of hydrophilic opioid-only epidural regimens. Continuous epidural infusion provided statistically significantly superior analgesia versus patient-controlled epidural analgesia for overall pain, pain at rest, and pain with activity; however, patients receiving continuous epidural infusion had a significantly higher incidence of nausea-vomiting and motor block but lower incidence of pruritus. In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared to intravenous patient-controlled analgesia.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2017
                14 February 2017
                : 10
                : 405-415
                Affiliations
                Department of Orthopedics, Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University, Shanghai, People’s Republic of China
                Author notes
                Correspondence: Xuhui Zhou; Rui Gao, Department of Orthopedics, Changzheng Hospital, Second Affiliated Hospital of Second Military Medical University, No 415 Fengyang Road, Shanghai 200003, People’s Republic of China, Tel +86 21 8188 6999, Fax: +86 21 6352 0020, Email xhzhouspine@ 123456163.com ; rgaospine@ 123456163.com
                [*]

                These authors contributed equally to this work

                Article
                jpr-10-405
                10.2147/JPR.S128523
                5319425
                © 2017 Meng et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

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