|Year : 2016 | Volume
| Issue : 2 | Page : 260-266
Efficacy of sacral epidural blockade with bupivacaine versus morphine as pre-emptive analgesia for lumbar laminectomy surgeries
Eid Mansy Mohammed Hussien, Gihan Seif El Nasr Mohammed, Ahmed Nagah Elhassanin El Shaer, Abdelaziz Abdallah Abdelaziz, Assem Adel Moharram
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
|Date of Submission||01-Mar-2015|
|Date of Acceptance||02-Oct-2015|
|Date of Web Publication||11-May-2016|
Abdelaziz Abdallah Abdelaziz
Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain-Shams University, 11371 Cairo
Source of Support: None, Conflict of Interest: None
Patients undergoing lumbar laminectomy experience severe pain in the postoperative period, which may increase the incidence of postoperative morbidity and complications. Adequate pain relief hastens rehabilitation and decreases the incidence of chronic pain. This study was designed to compare the efficacy of pre-emptive image-guided caudal epidural blockade with bupivacaine at low concentrations versus morphine administration on the attenuation of the stress response during and after lumbar laminectomy surgeries.
Patients and methods
Ninety adult American Society of Anaesthesiologists' physical status I and II patients were scheduled to undergo a single-level lumbar laminectomy and were administered a pre-emptive caudal injection of either 30 ml of bupivacaine 0.125% (group A) or 50 mg/kg preservative-free morphine added to a total dose of 30 ml saline (group B) or 30 ml saline (group C). Intraoperative vital data (heart rate, systolic, and diastolic blood pressure) were collected. The postoperative verbal rating scale score, the time of the first rescue analgesia, the total dose of rescue analgesia, and adverse effects were recorded for all patients in the first 24 h after surgery.
The total verbal rating scale score and the need for rescue analgesia were significantly less in group A and group B than in group C, indicating better analgesia. There was no significant difference between the three groups in itching or the sedation score. Group C had a higher incidence of vomiting than groups A and B, whereas there was delayed ambulation in group A in comparison with the other groups.
A single caudal epidural injection of morphine is a safe, simple, and effective technique that provides prolonged postoperative duration of analgesia with fewer analgesic requirements postoperatively with earlier patients' ambulation without occurrence of any hemodynamic changes or increased incidence of adverse effects in lumber laminectomy surgeries.
Keywords: lumbar laminectomy, perioperative analgesia, sacral epidural blockade
|How to cite this article:|
Hussien EM, Mohammed GS, El Shaer AN, Abdelaziz AA, Moharram AA. Efficacy of sacral epidural blockade with bupivacaine versus morphine as pre-emptive analgesia for lumbar laminectomy surgeries. Ain-Shams J Anaesthesiol 2016;9:260-6
|How to cite this URL:|
Hussien EM, Mohammed GS, El Shaer AN, Abdelaziz AA, Moharram AA. Efficacy of sacral epidural blockade with bupivacaine versus morphine as pre-emptive analgesia for lumbar laminectomy surgeries. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 May 9];9:260-6. Available from: http://www.asja.eg.net/text.asp?2016/9/2/260/179906
| Introduction|| |
Patients undergoing lumbar laminectomy experience severe pain in the postoperative period, which may increase the incidence of postoperative morbidity and complications. Adequate pain relief hastens rehabilitation and decreases the incidence of chronic pain .
Stress responses associated with surgical trauma may cause subtle changes in some vital and hormonal parameters. Increased plasma cortisol levels and suppressed anabolic hormones, such as insulin, may have deleterious effects during the perioperative period .
Pre-emptive analgesia has been advocated as an effective way of managing postoperative pain on the basis of the theory of preventing central sensitization after injury; it has been suggested that regional anesthesia and high-dose intravenous opioid injections can reduce the stress response associated with surgical trauma [3,4].
Caudal block is used widely to provide perioperative analgesia in pediatric practice. However, it has only a limited application for some anal surgeries in adults because its success rate is only 70−80%; therefore, Image intensifiers, which are readily available in operating theaters, can be used effectively to verify the accurate position of the hypodermic needle in the caudal epidural space. The advantages of image intensification in accurate placement of caudal epidural needles have been well documented in the literature [5,6].
| Aim of this work|| |
The aim of this study was to evaluate and compare the efficacy of a pre-emptive image-guided caudal epidural morphine versus bupivacaine in providing a postoperative analgesic effect in patients undergoing lumbar laminectomy surgeries.
| Patients and methods|| |
After receiving the approval of the ethical committee and obtaining informed consent from the patients, 90 patients of either sex, American Society of Anaesthesiologists' I and II, 20-50 years of age, scheduled for a single-level lumbar laminectomy by the posterior approach, without posterior spinal instrumentation, in Neuro-Surgical units at Ain Shamis University Hospitals, were enrolled in a double-blind prospective randomized study from October 2012 to November 2013.
Patients with complicated or recurrent lumbar canal compression, emergency post-traumatic lumbar surgeries, patients known to be allergic to the local anesthetic used, patients with a history of coagulation abnormality or bleeding tendency, or those who refused to participate were excluded from the study.
Standard monitoring was carried out, which included ECG, noninvasive blood pressure (BP) measurement, pulse oximetry, and end-tidal capnography. Baseline hemodynamic readings were recorded before starting the technique. General anesthesia was induced after intravenous access by thiopentone at a dose of 5 mg/kg, 0.6 mg/kg rocuronium bromide, and 100 mg fentanyl was established for all groups of patients. Anesthesia was maintained with oxygen, isoflurane 1-2%, and rocuronium bromide 0.15 mg/kg. Another 100 mg of fentanyl intravenously was administered to all groups after induction of anesthesia and before skin incision. Patients were placed prone on a Relton-Hall frame or padded bolsters. A 21 G hypodermic needle was then introduced into the caudal epidural space after sterilization using povidone iodine 10%. Accurate placement was also confirmed by an injection of 3 ml of nonionic myelography-approved iodinated contrast material (Omnipaque; GE Healthcare, Little Chalfont, UK) and using the image intensifier C-arm (OEC flourostar; GE Healthcare) used in OR for lumbar laminectomy surgeries.
After radiologically confirming the position of the needle in the caudal epidural space and a negative aspiration of blood or cerebrospinal fluid, the patients were allocated randomly by a sealed envelope technique into three equal groups (30 each): previously prepared 30 ml of bupivacaine 0.125% was administered caudally in the study group A, 50 mg/kg of preservative-free morphine added to 30 ml of a sodium chloride 0.9% solution was administered caudally to the study group B, and 30 ml of a sodium chloride 0.9% solution was administered caudally to the control group (group C).
The time interval between this injection and the surgical incision was never less than 20 min. This provided enough time for the drug to accumulate to the nerve roots, leading to effective pre-emptive analgesia.
Dose adjustment of isoflurane concentration and intraoperative rescue analgesia (fentanyl 0.5 mg/kg intravenously) were performed on the basis of clinical signs and hemodynamic measurements. Signs of inadequate analgesia were defined as an increase in heart rate (HR) and BP greater than 20% from baseline. This was treated by 0.5 mg/kg of fentanyl intravenously as a top-up dose and increasing isoflurane concentration in case of inadequate response to intravenous fentanyl.
If there was a decrease in BP greater than 20% from baseline, the patient received a 500 ml saline infusion and if there was no response, 5 mg ephedrine was administered. If HR decreased to 45 beats/min, atropine 0.01 mg/kg was administered.
At the end of the surgery, residual muscle paralysis was antagonized by a mixture of 0.01 mg/kg atropine and 0.05 mg/kg neostigmine. In the postoperative period, after full recovery (modified Aldrete score of 9-10), the postoperative pain was assessed using verbal rating scale (VRS) starting from 0 h (patient's full recovery in the postanesthesia care unit) and then every 2 h for the next 24 h.
Serum cortisol level was tested preoperatively (1 h before induction of general anesthesia), intraoperatively (30 min postsurgical stimulus), and then 24 h postoperatively.
The total dose of intraoperative rescue analgesic consumption (intravenous fentanyl) was recorded. Vital data were recorded in the form of systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR every 2 h in the first 24 h.
Analgesic efficacy using the VRS was assessed after surgery when the patient had completely recovered and regained consciousness from general anesthesia (0 h), and subsequently every 2 h, rescue analgesia was administered (pethidine 50 mg intramuscularly, every 6 h) whenever the patients' pain score was higher than 4 for the three groups of patients; the total dose of rescue analgesia was recorded for all patients in the first 24 h and the time of the first rescue analgesia was also recorded.
The time of the patient's ambulation (time interval between the end of surgery until first ambulation) was recorded.
Adverse effects such as itching, urinary retention, postoperative nausea, and vomiting were recorded and treated. Nausea was treated by 10 mg metoclopramide intravenously, vomiting was treated by 4 mg ondansatron intravenously, and itching was treated by pheniramine maleate (45.5 mg/2 ml) intravenously. We used urinary catheterization for urinary retention.
The expected success rates in the study group A, study group B, and control group C were 85, 65, and 45%, respectively; the ratio in the two study groups being 1 : 1, for a risk of 5% and a study power of 90, the sample size for each group was 26. An additional four patients were included in each group to compensate for any dropouts.
Data were analyzed using statistical package for social science, version 18.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean ± SD. Qualitative data were expressed as frequency and percentage.
The following tests were performed:
- Independent-samples t-test of significance was used to compare two means.
- c2 -test of significance was used to compare the proportions between two qualitative parameters.
- Probability (P-value)
- A P-value of less than 0.05 was considered significant.
- A P-value of 0.01 was considered highly significant.
| Results|| |
In terms of age, sex, American Society of Anaesthesiologists' classification, and duration of surgery, no statistically significant difference was found between any of the groups (P > 0.05) [Table 1].
For intraoperative vital data (systolic and diastolic blood pressure, heart rate), there was a significant difference (P < 0.05) between the study groups A, B on the one hand and the control group C on the other, being lower in the study groups than the control group; otherwise, there was no significant difference between the two study groups A and B [Table 2].
In terms of arterial oxygen saturation for the three groups studied at the time of induction, intraoperatively, and postoperatively as shown in [Table 3], no significant difference was found (P > 0.05).
|Table 3 Intraoperative and postoperative arterial oxygen saturation (SpO2) monitoring|
Click here to view
There was a statistically significant difference between the three groups in VRS starting from the fourth hour postoperatively, being lower in both group A and group B than the control group C, but from the eight hour and beyond, the difference became significantly lower in group B than both groups A and C, P-value less than 0.05 [Table 4].
The total amount of intraoperative fentanyl consumption was not statistically significant between the bupivacaine group A (90 ± 15.5 mg) and the morphine group B (78 ± 11.3 mg), but was significantly higher in the saline group C (181 ± 26.2 mg).
For postoperative analgesia (pethidine intramuscularly), the mean time of the first rescue analgesia needed was significantly longer in the study group B (morphine group) (9.68 ± 3.52 h) compared with either group A (bupivacaine group) (6.30 ± 1.15 h) or group C (1.16 ± 0.81).
The total pethidine consumption postoperatively showed a statistically significant difference among the three groups, being the highest in group C and the lowest in group B [Table 5].
In terms of the time of patients' ambulation, it was observed that the patients in group B were the earliest to start ambulation, with a significant difference from the other two groups, P-value less than 0.05. Also, patients in group A (bupivacaine group) showed a delayed ambulation compared with the other two groups, with a significant time difference from group B [Table 6].
As shown in [Table 7], there was no significant difference between the three groups in itching (P > 0.05), but for postoperative urinary retention (evidenced by the need for postoperative urinary catheterization), there was a significant difference between group A on the one hand and groups B and C on the other, being higher in group A (bupivacaine group), with a longer mean time for first sensation of the need to for micturition than the other two groups. However, it was observed that the incidence of postoperative nausea and vomiting was significantly higher in the control group C than the caudal bupivacaine group A and the caudal morphine group B.
Serum cortisol level was measured 1 h preoperatively; it did not show any significant difference. Thirty minutes after surgical incision and 24 h postoperatively, there was a statistically significant difference between the three groups, being lower in groups A and B than group C [Table 8].
| Discussion|| |
The result of the present study showed that a single dose of a pre-emptive caudal block with either morphine or bupivacaine provides adequate and effective analgesia with reduced intraoperative and postoperative analgesic consumption; however, pre-emptive caudal morphine provides superior postoperative analgesia (longer lasting, reduced postoperative pethidine consumption) and early ambulation, with minimal adverse effects in patients undergoing lumber laminectomy.
It is well known that pre-emptive analgesia before the onset of nociceptive stimuli can provide effective postoperative analgesia . Pre-emptive analgesia prevents central sensitization from prolonged pain transmission from peripheral receptors to the central nervous system, which can lead to neuroplasticity and hypersensitivity of cental nervous system, which results in a prolonged and pronounced pain perception, even after cessation of the painful stimulus .
Epidural analgesia can be achieved either by placing an epidural catheter or by administering a single epidural injection with a hypodermic needle. In spine surgeries, it is difficult to place the catheter preoperatively. Although it is easy to place the catheter as soon as the surgical procedure is over, the presence of blood in the epidural space is likely to interfere with the drug action. The presence of a drain tube with or without suction might lead to inadequate retention of the analgesic drug in the epidural space. Safe and secure fixation and retention of the catheter also pose problems .
Image intensifiers, which are readily available at the time of these surgeries, can be effectively used to verify the accurate position of the hypodermic needle in the caudal epidural space. The advantages of image intensification in accurate placement of caudal epidural needles have been well documented in the literature .
Therefore, these limitations associated with the use of an epidural catheter made us choose the technique of producing pre-emptive analgesia using a single caudal epidural injection administered with a hypodermic needle; in addition, the prone position adopted for posterior lumbosacral spinal surgeries is an ideal position for entering the caudal epidural space.
The results of the current study were in agreement with the results reported from the randomized-controlled trial conducted by Kundra et al. . They compared two groups of patients: the study group, which received pre-emptive epidural morphine, and the control group, which received epidural morphine at the end of the surgery. The study showed that pre-emptive epidural morphine is superior to epidural morphine administered postoperatively for pain relief after lumbar laminectomy and as postoperative opioid requirement is also reduced, there were minimum narcotic-induced adverse effects.
Reem et al.  conducted a double-blind prospective study on 78 patients scheduled for single-level lumbar spinal decompression and instrumented posterolateral intertransverse spinal fusion. Patients were divided into three equal groups and were administered a caudal injection of 30 ml saline or 30 ml of 0.25% bupivacaine or 2 mg preservative-free morphine added to 30 ml 0.25% bupivacaine. They concluded that pre-emptive caudal bupivacaine morphine provides prolonged postoperative duration of analgesia with fewer NSAIDs and pethidine analgesic requirements, both intraoperative and postoperative, with earlier patient ambulation without occurrence of any hemodynamic changes or increased incidence of adverse effects, which was in agreement with our study.
Our results are in agreement with those of Sekar et al. , who studied 82 patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation. Patients in the control group received a pre-emptive single caudal epidural injection of 20 ml of normal saline, whereas patients in the study group received a single caudal epidural injection of 20 ml bupivacaine and tramadol. Sekar and colleagues reported that an injection of a cocktail of 0.5% bupivacaine and tramadol into the sacral space provided a significant analgesic effect detected by reduced surgical stress response on vital signs (SBP, DBP, and HR) and serum cortisol level. Also, Sekar and colleagues  used both visual analogue scale and VRS as postoperative pain scores, recorded the total dose of analgesic and the first time for analgesics, and reported the same results as in the present study.
In contrast, Rice et al.  did not advocate pre-emptive analgesia in patients undergoing hernia repair because of inadequate volume of bupivacaine used for caudal anesthesia, similar to other authors who used insufficient concentrations of bupivacaine (0.1%) in knee surgery and a low dose of 2 ml bupivacaine 0.5% in lumbar laminectomy [14,15].
A caudal epidural injection of 1.5-2 ml is required to block a single spinal level. A total volume of 30 ml facilitates analgesia all the way up to the T12-L1 level. This obviates the need to modify the dose in every surgery on the basis of the number of spinal levels required to be blocked .
In terms of the postoperative adverse effects, there were significantly lower incidences of postoperative nausea and vomiting in the morphine group and the bupivacaine group than in the control group, and were reported between 0 and the fourth hour postoperatively. This may be because of the fact that the postoperative narcotic consumption was significantly higher in the control group. Also, a significant number of patients developed urinary retention in the bupivacaine group A (12 cases, 40%) in comparison with the morphine group B and the control group C, which was not significant, with (3 cases, 10%) and (2 cases, 7%), respectively.
Sekar et al.  reported results that were in agreement with our results in terms of postoperative adverse effects, especially for a significant number of patients in the study group who developed transient urinary retention in the postoperative period that was managed properly by catheterization; this may be explained by the use of tramadol in addition to bupivacaine in their study group.
Kundra et al.  recorded minimal narcotic-induced adverse effects with the administration of pre-emptive epidural morphine 60 min before the surgery, followed by epidural placebo at the end of the surgery compared with the control group, which received epidural placebo preoperatively, followed by 3 mg epidural morphine at the end of the surgery.
In terms of the timing of ambulation, patients in the morphine group showed significantly earlier ambulation than those in the bupivacaine group, who already showed earlier ambulation time than the saline group. This might be attributed to proper analgesic effect of morphine given caudally, that made getting the patient out of bed easier. Also, these groups required less pethidine than the saline group, and thus the degree of alertness needed for ambulation was maintained, making ambulation easily achievable.
Ivani et al.  concluded that caudal bupivacaine provides excellent analgesia in the early postoperative period as this technique was preferable from the practical point of view for lumbosacral spine surgeries performed through the posterior approach. The patient was already placed in the knee chest position after general anesthesia, which is ideal for palpation and identification of caudal space, thus reducing the time needed to achieve the same results, and the site of injection is away from the site of surgery, thus decreasing the risk of infection if the dura is opened .
In conclusion, a pre-emptive single caudal epidural injection of morphine is a safe, simple, and effective technique that provides prolonged postoperative analgesia with a lower need for analgesic requirements postoperatively, without occurrence of any hemodynamic changes or increased incidence of adverse effects in lumber laminectomy surgeries.
The study was carried out in Neuro-Surgical units at Ain Shamis University Hospitals from October 2012 to November 2013.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McNeil TW, Anderson GBJ. Postoperative treatment. In: Anderson GBJ, McNeil TW, eds. Lumbar spinal stenosis
. St Louis, MO: Mosby-Year Book; 2002. 475-481.
Burton D, Nicholson G, Hall G. Endocrine and metabolic response to surgery. Contin Edu Anaesth Crit Care Pain 2004; 4:144-147.
Gaitini LA, Somri M, Vaida SJ, Yanovski B, Mogilner G, Sabo E, et al.
Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children? Anesth Analg 2000; 90:1029-1033.
Weismann C. The metabolic response to stress an overview and update. Anesthesiology 1990; 73:308-327.
Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J, Thomas SA. Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil 2001; 80:416-424.
Stitz MY, Sommer HM. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine 1999; 24:1371-1376.
Hong JY, Lim KT. Effect of preemptive epidural analgesia on cytokine response and postoperative pain in laparoscopic radical hysterectomy for cervical cancer. Reg Anesth Pain Med 2008; 33:44-51.
Woolf CJ. Recent advances on the pathophysiology of acute pain. Br J Anaesth 1989; 63:139-146.
Johnson RG, Miller M, Murphy M. Intraspinal narcotic analgesia. A comparison of two methods of postoperative pain relief. Spine 1989; 14:363-366.
Kundra P, Gurnani A, Bhattacharya A. Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy. Anesth Analg 1997; 85:135-138.
Elkabarity R, Abdellatif A, Saoud A. Efficacy of preemptive caudal analgesia in single level lumbar spine decompression and fusion surgery. WScJ 2012; 3:71-79.
Sekar C, Rajasekaran S, Kannan R, Reddy S, Shetty TAP, Pithwa YK. Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial. Spine J 2004; 4:261-264.
Rice LJ, Pudimat MA, Hannallah RS. Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in pediatric ambulatory patients. Can J Anaesth 1990; 37:429-431.
Badner NH, Reimer EJ, Komar WE, Moote CA. Low-dose bupivacaine does not improve postoperative epidural fentanyl analgesia in orthopedic patients. Anesth Analg 1991; 72:337-341.
Cosar A, Daneyemez M, Kurte E, Bilgin F, Çanakçi Z, Gezen F, Süer AH. Pain control following lumbar laminectomy: comparison of epidural morphine plus bupivacaine. Turk Neurosurg 1999; 9:64-67.
Ivani G, Lampngnami E, Torre M, Calevo Maria G, DeNegri P, Borrometi F, et al
. Comparison of ropivacaine and bupivacaine in paediatric caudal block, Br J Anaesth 1998; 81:247-248.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]