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ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 685-689  

Study of wound instillation technique for effective postoperative analgesia using ropivacaine in lumbar spine surgery


Department of Anaesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India

Date of Web Publication11-Sep-2018

Correspondence Address:
Dr. Urvashi Yadav
Department of Anaesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_87_18

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   Abstract 

Background: Instillation of local anaesthetics over incision site is a simple technique done as a part of multimodal analgesia targetting incisional pain for post-operative pain relief following lumbar laminectomy. Aim: To determine postoperative analgesic effect of ropivacaine in wound instillation for lumbar laminectomy. Study Design: Prospective, randomised, double blind study. Methodology: Forty patients scheduled for elective lumbar laminectomy under general anaesthesia were enrolled and randomly allocated into two groups namely Group R (n=20 receiving 20ml of 0.25% ropivacaine) and Group N (n=20 receiving 20ml normal saline) as instillation over incision site. If the NRS exceeded '4' at any point of time, rescue analgesia with inj. Diclofenac 75 mg deep intramuscular was administered. Post- operative pain score, duration of analgesia and total rescue analgesic required in 24 h were compared between the groups. Results: The pain score was less in ropivacaine group as compared to normal saline group (p value 0.0001). Duration of analgesia in normal saline group (N) is 4.3± 1.03 and in ropivacaine group(R) is 12.15±1.49. Mean amount of rescue analgesic required in normal saline group was 191.25± 38.28mg and in ropivacaine group was 97.5± 35.26 mg. Conclusion: The patients who received ropivacaine wound instillation had better pain control, longer duration of analgesia and less analgesic requirement as compared to patients who received normal saline wound instillation.

Keywords: Analgesia, Lumbar Laminectomy, Ropivacaine, Wound Instillation


How to cite this article:
Saini D, Yadav U. Study of wound instillation technique for effective postoperative analgesia using ropivacaine in lumbar spine surgery. Anesth Essays Res 2018;12:685-9

How to cite this URL:
Saini D, Yadav U. Study of wound instillation technique for effective postoperative analgesia using ropivacaine in lumbar spine surgery. Anesth Essays Res [serial online] 2018 [cited 2018 Dec 13];12:685-9. Available from: http://www.aeronline.org/text.asp?2018/12/3/685/240879


   Introduction Top


Lumbar laminectomy is a commonly performed procedure in neurosurgical and orthopedic practice.[1] Postoperative pain relief helps in early mobilization, initiation of physiotherapy, provides satisfaction to the patients, preventing the development of chronic pain, and plays an important role in reducing the morbidity and mortality.[2] Currently, several postoperative analgesic options such as intravenous (iv) opioids, nonsteroidal anti-inflammatory drugs, intrathecal opioids, and local anesthetics have been evaluated. Regional techniques offer many advantages as follows: pain is cured at close to damaged tissue, and when local anesthetics are used, they provide analgesia and substantially reduce the need for opioids. Most of these techniques may be limited by potentially high-failure rates, high cost, technically challenging, labor-intensive, and procedure-related complications.[3],[4] Wound site infiltration is an efficient method, but has a potential theoretical risk of wound site infection.[5],[6]

Wound instillation with local anesthetics had been used in the past in various surgical procedures and shown better postoperative pain relief.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] We aim to evaluate the duration and analgesic efficacy of ropivacaine wound instillation in lumbar laminectomy.


   Methods Top


The current study was conducted over a period of 1 year. Approval from the Institutional Ethics Committee and written informed consent was obtained from all 40 patients. Patients of the physical status American society of anesthesiologists classes I and II, aged 18–60 years of either sex, scheduled for lumbar laminectomy who were planned to have single-level lumbar disc surgery under general anesthesia were enrolled for this trial. Exclusion criteria included patients with spinal stenosis, who underwent prior lumbar disc surgery, prior neurological deficits; preoperative opioid use or any history of substance abuse or on steroids; had known local anesthetics allergy, intraoperative cerebrospinal fluid leak, or requiring the placement of a drain were excluded. Patients were randomly allocated to two groups of 20 each using sealed opaque envelopes.

  • Group R (study group) received wound site instillation with 20 ml of 0.25% ropivacaine (n = 20)
  • Group N (control group) received wound site instillation with 20 ml normal saline (n = 20).


All patients were instructed the day before surgery on how to rate the intensity of pain using numerical rating scale (NRS), a scale of 0–10, where 0 = no pain, and 10 = worst pain.

All patients received ranitidine 150 mg and alprazolam 0.25 mg in the night and at 6:00 a. m. in the morning before surgery. The vital parameters (heart rate, systolic and diastolic blood pressure, SpO2, and respiratory rate) were checked in the preoperative room; Ringer lactate infusion started at 5–10 ml/kg. Monitoring of noninvasive blood pressure (mmHg), electrocardiography, pulse oximetry, and capnography (after intubation) was started and carried out throughout the intraoperative and postoperative period.

All patients were premedicated with glycopyrrolate (0.2 mg), fentanyl (2 μg/kg), and midazolam (0.25 mg/kg). After 3 min of preoxygenation anesthesia was induced with propofol 2 mg/kg and tracheal intubation was facilitated with vecuronium 0.1 mg/kg. Maintenance of anesthesia was carried out using 67%N2O, 33%02, and inspired isoflurane 1% using controlled ventilation. No further opioid supplementation was given intraoperatively.

At the end of the surgical procedure, iv paracetamol 15 mg/kg was administered to all patients for postoperative pain and when hemostasis was achieved, under aseptic conditions, patients in Group R received instillation of 20 ml ropivacaine (0.25%) and in Group N received instillation of 20 ml normal saline and were allowed to remain in the wound for a dwell time of 60 s. The wound was closed in layers without mopping or suctioning. At the end of surgery, the residual neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg iv.

Postoperative pain was assessed by an independent observer blinded to the study by NRS, first at 0 h, i.e., after extubation, when the patient was able to follow commands and then at every 1 h up to first 8 h and then at every 6 h till 24 h.

The duration of analgesia was considered from the time the study drugs (ropivacaine or normal saline) were instilled into the time for the first demand for rescue analgesia. When pain score reach ≥4 point on NRS, diclofenac 75 mg deep intramuscular was given as rescue analgesia. Duration of analgesia, total rescue analgesic requirement, and pain score in 24 h were recorded. Surgical site-related untoward effects such as hematoma, infection, and wound dehiscence were observed clinically until the patient was discharged.

Statistical analysis

The sample size calculated on the basis of a pilot study done in both groups with a difference in total duration of analgesia of 4 h using the power of study 80%, confidence interval 95%, and an alpha error of 0.05. The statistical analysis of data was performed using the SPSS 20 (IBM, Armonk, NY). The statistical analysis of quantitative data (mean ± standard deviation [SD]) between the groups was done uising Student t-test. The statistical analysis of qualitative data (N %) between the groups was done using Fisher exact test. Value of P < 0.05 was considered to be statistically significant. To obtain a composite value for the pain score distributed over a period of 24 h, an area under the curve (AUC) for the pain score of each patient was determined.


   Results Top


Totally 40 patients were recruited for the study, and none were excluded as shown in consort chart [Figure 1]. Both groups were comparable in terms of age, height, weight, sex, duration of surgery, and intraoperative analgesic supplementation [Table 1]. [Figure 2] shows the pattern of NRS pain scores in both groups with respect to time. Mean pain scores as depicted by AUC for NRS was less in the ropivacaine group when compared with a normal saline group [Figure 3] and [Figure 4]. Number of patient's requiring rescue analgesic hourly, number of analgesic demand, and total rescue analgesic required was significantly higher in the normal saline group [Table 2]. Duration of analgesia was significantly less in Group N compared to Group R [Table 2].
Figure 1: Consort flow diagram

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Table 1: Comparison of demographic profile and intraoperative characteristics of patients between two groups



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Figure 2: Bar diagram showing pattern of numerical rating scale with time

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Figure 3: Area under curve in Group N

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Figure 4: Area under curve in Group R

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Table 2: Analgesic requirement and duration of analgesia


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   Discussion Top


In this prospective study, the results showed that patients who received wound instillation with 20 ml of 0.25% ropivacaine experienced better postoperative analgesia as compared with patients who received saline. The pain scores were low at all points of time in the ropivacaine group. The time to first demand of analgesia was prolonged in the ropivacaine group. Cumulative rescue analgesic consumption and some demands for analgesia in the first 24 h were significantly lower in the ropivacaine group. This was similar to other studies using ropivacaine at the incision site.[11],[12],[13],[14],[15],[16]

Hernández-Palazón et al.[11] studied wound infusion of 0.25% bupivacaine and 0.25% ropivacaine into the paraspinal muscle and skin before closure of wound following lumbar laminectomy and found that analgesic time was significantly longer in bupivacaine group than in ropivacaine or control group (164 ± 53 min vs. 68 ± 31 and 38 ± 14 min, respectively). Continuous wound infusion with ropivacaine was found to be effective following spinal instrumentation, iliac crest bone graft, and shoulder surgery.[12],[13],[14] All these studies involved infiltration or infusion of the study drug bupivacaine or ropivacaine for analgesia, but the present study involved only instillation of the ropivacaine for a dwell time of 60 s and the analgesia was profound.

A study by Bindra et al.[15] found that total analgesic requirement was significantly less in patients who received intraperitoneal instillation of drug before creation of pneumoperitoneum (1.34 ± 0.52 g paracetamol) than patients who received normal saline (4.7 ± 0.97 g paracetamol). Cu et al.[16] studied the efficacy and safety of 0.75% ropivacaine instillation into inguinal wound on 55 patients who had undergone bilateral microsurgical varicocelectomy by general anesthesia. They found that VAS pain scores and Prince Henry Pain Score in the ropivacaine-instilled operative site were significantly lower compared to those obtained with placebo at 2, 4, and 8 h after surgery (P< 0.05).

Jonnavithula et al.[17] studied the role of wound instillation with bupivacaine through surgical drains for postoperative analgesia in modified radical mastectomy and they found statistically significant difference in total dosage of rescue analgesic tramadol during 24 h time period between the study groups. The rescue analgesic requirement was higher in control Group (C) than bupivacaine (B) Group with mean ± SD 146.2 ± 101 mg and 36 ± 43 mg respectively. The results of the present study were similar to these studies using wound instillation technique.

The rationale for choosing the instillation route is to block the afferent signaling and potentially modifying nociception and provides analgesia. The local anesthetic inhibits nociception by affecting nerve membrane associated proteins and by inhibiting the release and action of prostaglandins and other agents that sensitize or stimulate the nocicepters and contribute to inflammation.[18] However, absorption from meningeal surface may occur, which further contribute to analgesia. Local anesthetics modulate peripheral pain transduction by inhibiting the transmission of noxious impulses from the site of injury.[19] Normal saline producing analgesia was known in gynecological practice for fractional curettage [20] and a similar observation was made with palatal block for postoperative analgesia following cleft palate surgery.[21] In this study, we do not compare saline group with without saline. The probable mechanism being pressure over the nerve endings, thereby blocking the conduction of nerve impulses and producing analgesia Another probable mechanism being washing away or diluting the pain producing substances, and the inflammatory mediators thereby decreasing the postoperative pain.

Limitations of study

We have studied only first 24 h of postoperative period. Pain on movement and during coughing was not tested. Further studies are required with large sample size to clinically extrapolate the results.


   Conclusion Top


The patients who received ropivacaine wound instillation has better pain control at all-time interval as compared to the patients who received normal saline wound instillation. The total amount of analgesic agent used in 24 h was significantly lower in the ropivacaine group as compared to the normal saline group. We believe that wound instillation technique of ropivacaine is a simple, safe, and cost-effective method in the management of acute pain after lumbar laminectomy and it can be used as a useful adjunct in pain management unless contraindicated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Jonnavithula N, Khandekia H, Durga P, Ramachandran G. Role of wound instillation with bupivacaine for postoperative analgesia following lumbar laminectomy. Middle East J Anaesth 2015;23:193-8.  Back to cited text no. 1
    
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Ballantyne JC. Does epidural analgesia improve surgical outcome? Br J Anaesth 2004;92:4-6.  Back to cited text no. 2
    
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Vintar N. Operation-site local anesthetic techniques for postoperative analgesia: Wound infiltration tecniques. Period Boil 2003;3:227-30.  Back to cited text no. 3
    
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Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr., Wu CL, et al. Efficacy of postoperative epidural analgesia: A meta-analysis. JAMA 2003;290:2455-63.  Back to cited text no. 4
    
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Thorton PC, Buggy J. Local anaesthetic wound infiltration for acute postoperative pain: A viable option? Br J Anesth 2011;107:656-8.  Back to cited text no. 5
    
6.
Møiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A qualitative systematic review of incisional local anaesthesia for postoperative pain relief after abdominal operations. Br J Anaesth 1998;81:377-83.  Back to cited text no. 6
    
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Pettersson N, Berggren P, Larsson M, Westman B, Hahn RG. Pain relief by wound infiltration with bupivacaine or high-dose ropivacaine after inguinal hernia repair. Reg Anesth Pain Med 1999;24:569-75.  Back to cited text no. 7
    
8.
Mraović B, Jurisić T, Kogler-Majeric V, Sustic A. Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1997;41:193-6.  Back to cited text no. 8
    
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Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Characteristics and prediction of early pain after laparoscopic cholecystectomy. Pain 2001;90:261-9.  Back to cited text no. 9
    
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Kraemer J. Intervertebral Disk Diseases Causes, Diagnosis, Treatment and prophylaxis. Eur J Orthop Surg Traumatol 2010;20.441.  Back to cited text no. 10
    
11.
Hernández-Palazón J, Tortosa Serrano JA, Burguillos López S, Molero Molero E. Infiltration of the surgical wound with local anesthetic for postoperative analgesia in patients operated on for lumbar disc herniation. Comparative study of ropivacaine and bupivacaine. Rev Esp Anestesiol Reanim 2001;48:17-20.  Back to cited text no. 11
    
12.
Bianconi M, Ferraro L, Ricci R, Zanoli G, Antonelli T, Giulia B, et al. The pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg 2004;98:166-72.  Back to cited text no. 12
    
13.
Blumenthal S, Dullenkopf A, Rentsch K, Borgeat A. Continuous infusion of ropivacaine for pain relief after iliac crest bone grafting for shoulder surgery. Anesthesiology 2005;102:392-7.  Back to cited text no. 13
    
14.
Gottschalk A, Burmeister MA, Radtke P, Krieg M, Farokhzad F, Kreissl S, et al. Continuous wound infiltration with ropivacaine reduces pain and analgesic requirement after shoulder surgery. Anesth Analg 2003;97:1086-91.  Back to cited text no. 14
    
15.
Bindra TK, ChawlaD, Kumar P, Parul P. Comparison of intraperitoneal instillation of ropivacaine with normal saline in laparoscopic cholecystectomy. Int J Res Med Sci 2017;5:4924-8.  Back to cited text no. 15
    
16.
Cui WS, Shin YS, You JH, Doo AR, Soni KK, Park JK, et al. Efficacy and safety of 0.75% ropivacaine instillation into subinguinal wound in patients after bilateral microsurgical varicocelectomy: A bi-center, randomized, double-blind, placebo-controlled trial. J Pain Res 2017;10:1515-9.  Back to cited text no. 16
    
17.
Jonnavithula N, Khandelia H, Durga P, Ramachandran G. Role of wound instillation with bupivacaine through surgical drains for postoperative analgesia in modified radical mastectomy. Indian J Anaesth 2015;59:15-20.  Back to cited text no. 17
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18.
Aman Z, Qayum A, Khan K. A study of effectiveness of local bupivacaine infiltration of the wound reducing the post operative parenteral narcotic analgesic requirement. J Postgrad Med Inst 2004;18:7-11.  Back to cited text no. 18
    
19.
Dahl JB, Møiniche S, Kehlet H. Wound infiltration with local anaesthetics for postoperative pain relief. Acta Anaesthesiol Scand 1994;38:7-14.  Back to cited text no. 19
    
20.
Chanrachakul B, Likittanasombut P, O-Prasertsawat P, Herabutya Y. Lidocaine versus plain saline for pain relief in fractional curettage: A randomized controlled trial. Obstet Gynecol 2001;98:592-5.  Back to cited text no. 20
    
21.
Jonnavithula N, Durga P, Madduri V, Ramachandran G, Nuvvula R, Srikanth R, et al. Efficacy of palatal block for analgesia following palatoplasty in children with cleft palate. Paediatr Anaesth 2010;20:727-33.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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