Jeffrey R Carlson, MD, MBA, CPE, FAAOS
In my last article, I discussed how changes in surgical technique, instrumentation, biologics and anesthesia had helped to pave the way for moving spinal fusion surgery from a strictly inpatient setting to an outpatient setting. In this installment, I will review how further advances in pain management have driven surgeries to ambulatory surgery centers.
Pain Management has always been a big concern post-operatively when trying to get patients home safely after a major procedure such as a spinal fusion. Older generation pain medications often had to be administered intravenously and caused such sedation that respiration was depressed and had to be monitored carefully by hospital nursing staff. We’ve learned a lot about managing pain over the last decade or so and have found that a “cocktail” of different types of medications tends to work better at managing pain vs. a boatload of narcotics given at once.
What types of medications are in this “cocktail”? Yes, that will include some type of analgesic or pain medication. It may or may not be an opioid and if it is, it will be in the lowest dose possible for a week to 10 days to deliver pain relief. We are very mindful of the dangers of addiction and do everything possible to prevent it from happening to our patients. We also supplement with acetaminophen which, when taken together with other pain medications, helps both medications to work against pain better.
Next, I will include a muscle relaxant. Spine surgery usually involves stretching the patient’s neck or back to distend the spinal segments so that I can get a better view and access to them and the spaces between for surgery. This stretching causes the muscles of the area to spasm. If I must cut or move muscle during the surgery, there is further trauma. The muscle relaxant helps these muscles to loosen up and allow blood to flow freely, increasing healing.
We also prescribe gabapentin, which is a nerve medication, to help with calming nerve irritation, especially in those surgeries where we know there is a lot of nerve involvement or where we will be moving nerves out of the way. Many of my patients may have already been taking this medication so we will continue it for a while and then slowly start to wean them off as the nerves start to heal.
Medication patches which contain numbing or pain-relieving medication can also be used.
I can also prescribe a TENS unit for my patients to get the pain-relieving effect of the gentle electric current that it provides.
I also encourage the use of ice and heat, as well as topical creams that can provide relief.
Each patient is different and has a unique tolerance for pain. Some find that their lumbar brace or cervical collar eases their pain, while others will find exactly the opposite will be true. As your physician, I will work with you to ensure that your recovery is as comfortable as possible.
In our next installment, I’ll discuss how changes in the hospital and insurance industries have pushed the surgical exodus to outpatient surgery centers.