Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia.

STUDY DESIGN A prospective, randomized, double-blind clinical trial. OBJECTIVE To compare the efficacy of postoperative continuous epidural analgesia versus patient-controlled analgesia in patients undergoing lumbar fusion. SUMMARY OF BACKGROUND DATA Controversy remains regarding the optimal strategy for postoperative pain control. METHODS Fifty-four patients were divided into two treatment groups. There was no difference between the groups with respect to age, levels fused, estimated blood loss, and use of spinal instrumentation. Patient-controlled analgesia or epidural analgesia was administered in a double-blind manner for a 3-day postoperative course. Each patient received both an epidural and a patient-controlled analgesia delivery system; 26 received the epidural active agent and 28 received patient-controlled analgesia. Postoperative time to liquids and solid food, ambulation, length of stay, and side effects was recorded. Pain was evaluated by a visual analog scale on postoperative days 1, 2, and 3. RESULTS Results showed no difference between the groups with reference to diet, ambulation, length of stay, and visual analog scale scores. Minor side effects occurred in 71% of patients in both groups. No major complications occurred. Epidural catheter dislodgment occurred in 11% of patients. The total cost for epidural analgesia was approximately $550 more than that for patient-controlled analgesia for a 3-day postoperative course. CONCLUSIONS These data suggest that there is no clinical advantage of epidural opiate/local anesthetic analgesia over systemic opiate by patient-controlled analgesia for spinal fusion patients. However, possible technical limitations (namely, the low dosage of bupivacaine and placement of the catheter tip) may have prevented adequate delivery of anesthetic to the involved segments. Although the incidence of side effects is similar, cost factors and a high incidence of epidural catheter dislodgment favor use of patient-controlled analgesia.