title: Perioperative nonopioid agents for pain control in spinal surgery.
abstract: OBJECTIVE
  Commonly used nonopioid analgesic agents that are incorporated into multimodal perioperative pain management protocols in spinal surgery are reviewed.
  
  
  CONCLUSIONS
  Spinal procedures constitute perhaps some of most painful surgical interventions, as they often encompass extensive muscle dissection, tissue retraction, and surgical implants, as well as prolonged operative duration. Perioperative nonopioid analgesics frequently used in multimodal protocols include gabapentin, pregabalin, acetaminophen, dexamethasone, ketamine, and nonsteroidal antiinflammatory drugs (NSAIDs). There is evidence to suggest that gabapentin is safe and effective in reducing opioid consumption and pain scores at optimal doses of 600-900 mg orally administered preoperatively. Pregabalin 150-300 mg orally perioperatively has been shown to reduce both pain and narcotic consumption. Most reports concur that a single 1-g i.v. perioperative dose is safe in adults and that this dose has been shown to reduce pain and attenuate narcotic requirements. Dexamethasone's influence on postoperative pain has primarily been investigated for minor spinal procedures, with limited evidence for spinal fusions. Ketamine added to a patient-controlled analgesia regimen appears to be efficacious for 24 hours postoperatively when implemented for microdiskectomy and laminectomy procedures at doses of 1 mg/mL in a 1:1 mixture with morphine. For patients undergoing laminectomy or diskectomy, NSAIDs appear to be safe and effective in reducing pain scores and decreasing opioid consumption.
  
  
  CONCLUSIONS
  Preemptive analgesic therapy combining nonopioid agents with opioids may reduce narcotic consumption and improve patient satisfaction after spinal surgery. Such therapy should be considered for patients undergoing various spinal procedures in which postoperative pain control has been historically difficult to achieve.
authors.affiliation: Anna Rivkin, Pharm.D., BCPS, is Assistant Professor of Pharmacy Practice, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, and Clinical Pharmacist, Critical Care, Mercy Fitzgerald Hospital, Darby, PA. Mark A. Rivkin, D.O., M.Sc., is Chief Resident, Neurosurgery, Philadelphia College of Osteopathic Medicine, Bala Cynwyd, PA. arivkin@mercyhealth.org.
authors.forename: Anna
authors.initials: A
authors.lastname: Rivkin
authors.affiliation: Anna Rivkin, Pharm.D., BCPS, is Assistant Professor of Pharmacy Practice, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, and Clinical Pharmacist, Critical Care, Mercy Fitzgerald Hospital, Darby, PA. Mark A. Rivkin, D.O., M.Sc., is Chief Resident, Neurosurgery, Philadelphia College of Osteopathic Medicine, Bala Cynwyd, PA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Rivkin
mesh_terms: D000328:Adult; D018712:Analgesics, Non-Narcotic / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000894:Anti-Inflammatory Agents, Non-Steroidal; D006801:Humans; D010146:Pain / Q000188:drug therapy*; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control*; D019990:Perioperative Care; D013131:Spine / Q000601:surgery*
chemical_list: D018712:Analgesics, Non-Narcotic; D000894:Anti-Inflammatory Agents, Non-Steroidal