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      Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes.

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          Abstract

          Multimodal approaches to pain management have arisen with the goal of improving postoperative pain and reducing opioid analgesic use. We performed a comprehensive literature review to determine grades of recommendation for commonly used agents in multimodal pain management and provide a best practice guideline. To evaluate common drugs used in multimodal treatment of pain, a search was performed on English language publications on Medline (PubMed; National Library of Medicine, Bethesda, MD, USA). Manuscripts were rated as Level I-V according to the North American Spine Society's (NASS) standardized levels of evidence tables. Grades of recommendation were assigned for each drug based on the NASS Clinical Guidelines for Multidisciplinary Spine Care. There is good (Grade A) evidence gabapentinoids, acetaminophen, neuraxial blockade and extended-release local anesthetics reduce postoperative pain and narcotic requirements. There is fair (Grade B) evidence that preemptive analgesia and nonsteroidal anti-inflammatory drugs (NSAID) result in reduced postoperative pain. There is insufficient and/or conflicting (Grade I) evidence that muscle relaxants and ketamine provide a significant reduction in postoperative pain or narcotic usage. There is fair (Grade B) evidence that short-term use of NSAID result in no long-term reduction in bone healing or fusion rates. Comprehensive assessment of the effectiveness of perioperative pain control can be accomplished through the use of validated measures. Multimodal pain management protocols have consistently been demonstrated to allow for improved pain control with less reliance on opioids. There is good quality evidence that supports many of the common agents utilized in multimodal therapy, however, there is a lack of evidence regarding optimal postoperative protocols or pathways.

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          Author and article information

          Journal
          J Clin Neurosci
          Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
          1532-2653
          0967-5868
          Jun 2015
          : 22
          : 6
          Affiliations
          [1 ] Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Nashville, TN 37232, USA. Electronic address: Clinton.j.devin@vanderbilt.edu.
          [2 ] Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA.
          Article
          S0967-5868(15)00015-6
          10.1016/j.jocn.2015.01.003
          25766366
          8ecc9405-d3ea-47c7-bca3-6ee80c30486d
          Copyright © 2015 Elsevier Ltd. All rights reserved.
          History

          Best practice,Multimodal pain management,North American Spine Society,Peri-operative pain,Post-operative pain

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