Perioperative Lidocaine Offers No Benefits in Patients Undergoing Spinal Fusion

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Postoperative use of opioid analgesics increases the risk of respiratory depression, which can lead to brain damage or death.
Postoperative use of opioid analgesics increases the risk of respiratory depression, which can lead to brain damage or death.

Perioperative lidocaine does not reduce morphine use in the first 24 hours after posterior spinal arthrodesis and offers no measurable benefits, according to a randomized placebo-controlled trial recently published in Pain.1

Postoperative use of opioid analgesics increases the risk of respiratory depression, which can lead to brain damage or death.2 Several studies seeking to evaluate whether administering intravenous (IV) lidocaine before or during a surgical procedure can reduce pain and postoperative opioid use have yielded conflicting results.3,4

For the trial, investigators enrolled 70 patients, age 15 to 56 (median age, 49 years) who were scheduled to undergo spinal arthrodesis at a Belgian hospital. One group of patients received an IV bolus injection of lidocaine (1.5 mg/kg) administered concurrently with anesthesia, and followed by a continuous infusion of lidocaine (1.5 mg/kg/h), continued for 6 hours after surgery. Patients in the control arm received an identical saline regimen. After surgery, all patients were given acetaminophen and a morphine pump for pain. In patients with persistent pain, nurses could supplement on-demand morphine with a morphine injection.

Patients in both arms of the trial used similar amounts of morphine in the first 24 hours after surgery even when the cumulative doses were weight-adjusted (P =.22). Morphine use on the second and third days after surgery was also similar in the lidocaine arm and the control arm.

No differences in pain ratings (assessed using a numeric rating scale; P =.71) or  number of morphine doses demanded from the pumps (P =.59) was found in both groups at any time during the 3 days following surgery. The incidence of postoperative nausea and vomiting, time to return of intestinal function, time to first consumption of solid food, and duration of hospital stay were all similar in both groups. In addition, no differences were observed in the incidence of adverse events in patients administered lidocaine and patients given saline.

The researchers noted that their findings contrasted with several meta-analyses that associated perioperative lidocaine with significant benefits, including better analgesic control, faster gastrointestinal recovery, and a shorter hospital stay. They pointed out that “these meta-analyses included primarily patients undergoing major abdominal surgery.” They added that the evidence supporting the benefits of perioperative lidocaine for other types of surgical procedures were less convincing. “Multimodal analgesia with lidocaine is of limited or no value in orthopedic surgery,” They concluded, recommending additional studies seeking to identify patients more likely to benefit from perioperative lidocaine.

Summary and Clinical Applicability

A randomized placebo-controlled clinical trial found that perioperative systemic lidocaine offered no benefit over saline in patients undergoing spinal fusion surgery: lidocaine treatment did not reduce postoperative pain, morphine use, or the incidence of nausea and vomiting.

Limitations and Disclosures

  • Opioid use significantly affects numeric rating scale scores, complicating efforts to quantify the effect of lidocaine on pain control.
  • Both adults and adolescents were included in the study, which may have influenced outcomes.
  • The study was not adequately powered for any outcome other than the effect of perioperative lidocaine on postsurgical opioid use.

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References

  1. Dewinter G, Moens P, Fieuws S, Vanaudenaerde B, Van de Velde M, Rex S. Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial. Br J Anaesth. 2017;118(4):576-585.
  2. Lee LA, Caplan RA, Stephens LS, et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology. 2015;122(3):659-665.
  3. Dunn LK, Dureux ME. Perioperative use of intravenous lidocaine. Anesthesiology. 2017;126(4):729-737.
  4. Kranke P, Jokinen J, Pace N, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev. 2015;(7):CD009642.

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