Protocol for Lumbar Spinal Fusion and Instrumentation

Vietnam - photo by JoAnn Sturman

Scott Sturman, M.D.

Lumbar Spinal Fusion with Instrumentation cases are performed under general anesthesia, but protocols utilizing multimodal therapy and developed for total joint surgery can be applied to more effectively treat pain in the post operative period.

Preoperative Celebrex (200mg vs. 400mg) and pregabalin (300mg in pre op then 150mg po BID during hospitalization --- cut dose in half for patients >70).  Oxycontin 10mg for patients <70.  


1 gm IV acetaminophen intraoperatively by anesthesia.  For patients receiving IV acetaminophen post op in conjunction with oral analgesics containing acetaminophen, care must be taken not to exceed 4 gm per day.

The administration of a long acting narcotic IV or IM in OR prior to arrival in PACU.  Hydromorphone or meperidine with vistaril are preferred.  IM doses suggested: hydromorphone 2-4 mg and meperidine 75-100 mg.  Individually adjust dose for patient's condition.

IV ketamine 100mg intraoperatively at discretion of anesthesiologist.

Infiltration of the wound area with bupivacaine at the conclusion of surgery.
 
Intrathecal narcotics only for select patient, i.e., patients dependent on high dose narcotics with difficult pain control issues.  This therapy is not to be used for routine patients due to problems with urinary retention and the possibility of interfering with the post op neurological exam.

Most pain control problems occur within the first 24 hours following surgery.  By post op day #1, most of these patients have acceptable pain control.  The use of a standardized protocol using multimodal RX should address pain control concerns immediately after surgery.  

 Tiger's Nest, Bhutan - photo by Tom Yanagi, M.D.