Degenerative lumbar spinal disease is a common condition associated with reduced quality of life for individuals and economic strain on healthcare systems. Due to a growing population of elderly patients with degenerative lumbar conditions, both the volume and complexity of spine surgery have increased in recent decades, with a particular rise in lumbar spinal instrumentation procedures.1,2 Given these circumstances, identification of modifiable factors influencing postoperative patient outcomes has become imperative.
Poor postoperative pain control has been associated with prolonged hospitalization, elevated risk of chronic pain, increased complication rates, and overall healthcare costs.3,4 Therefore, interventions targeted toward reducing postoperative pain are not only beneficial to individual patients, by improving postsurgical suffering and reducing complications, but also to the healthcare system as a whole by maximizing surgical efficiency and optimizing patient flow. This has motivated many advances in the field, such as minimally invasive approaches, application of enhanced recovery after surgery principles, and multimodal nonopioid analgesia strategies.
One intervention that has shown effectiveness in improving postoperative pain after lumbar spine surgery is the intraoperative application of topical epidural steroids. Although most of the existing literature focuses on microdiscectomy, in the current issue of the Journal of Neurosurgery: Spine, Tavanaei et al. investigate the role of this treatment in the context of lumbar instrumented fusion.5 Specifically, they report on a randomized placebo-controlled double-blind trial recruiting 100 patients with degenerative lumbar pathology who, at the conclusion of surgery, received epidural Gelfoam soaked in either triamcinolone acetonide or normal saline. Surgical intervention involved single or multilevel posterolateral fusion (no interbody fusion) coupled with posterior decompression.
The primary outcome was defined as visual analog scale leg pain scores at multiple time points within the first postoperative day, with primary analysis demonstrating no significant difference in pain scores between treatment and control groups during this early postoperative period. There was also no change in secondary outcome measures including disability index scores, opiate requirements, length of stay, or complications (although there was a nonsignificantly increased skin and soft-tissue infection rate in the steroid cohort). Strengths of this study include the randomized and placebo-controlled methodology as well as the high rates of clinical follow-up. Potential weaknesses include the lack of fusion outcomes and the single-center, single-surgeon design. The group highlights the fact that larger multicenter and multisurgeon collaborations would be necessary in the future to continue to explore this clinical question.
Although the current study was negative, the literature is replete with studies demonstrating improvement in postoperative outcomes, including decreased morphine consumption, length of stay, and visual analog scale pain scores with topical steroid administration following microdiscectomy.6–9 Interestingly, similar benefits have been demonstrated in single-level lumbar discectomy cases with intravenous steroid administration.10 Arirachakaran et al. corroborated these findings in lumbar microdiscectomy cases by performing a systematic review and meta-analysis comparing randomized trials assessing epidural steroid versus placebo in lumbar microdiscectomy.11 Their review showed reduced postoperative back pain, morphine consumption, and length of stay in the topical steroid group compared to placebo, particularly in open compared to minimally invasive cases. Specifically, they showed a pooled mean 8.47-mg reduction in morphine consumption in the first 24 hours postoperatively and a 0.89-day shorter hospitalization in patients treated with intraoperative epidural steroids. Furthermore, they demonstrated there was no difference in surgical infections between groups.
There is a strong biological rationale for topical steroid use in surgery for degenerative lumbar pathologies. After lumbar microdiscectomy, the mechanism for persistent postoperative pain may be driven by direct nerve root manipulation, as well as by further inflammation associated with resultant peridural fibrosis and scarring.8,12 Immediate intraoperative steroid administration is believed to interrupt these secondary inflammatory pathways, thus reducing the magnitude of dural reaction following surgery.
Given evidence to support the role of intraoperative topical corticosteroid administration following microdiscectomy, it is somewhat surprising that the study by Tavanaei et al. failed to find an effect within the context of lumbar fusion. The rationale for Gelfoam as a vehicle for steroid in the epidural space was to minimize the loss of local steroid flowing to the dependent disc space as well as to reduce dilution by blood products and fluids during wound closure.13,14 However, given the known propensity of Gelfoam to swell in the postoperative period, one wonders if such swelling could impact outcomes by contributing to persistent neural element compression following decompression. From a dosing perspective, the selection of 40-mg triamcinolone acetate was made based on demonstrations of efficacy in the microdiscectomy literature.6,9 The optimal dose and delivery vehicle to the epidural space following lumbar fusion remains unknown and there is a paucity of current literature comparing specific steroid types (dexamethasone compared to triamcinolone acetate or methylprednisolone) and doses.
Beyond the drug delivery, there are surgical differences between lumbar microdiscectomy and posterolateral lumbar fusion that may diminish the utility of topical epidural steroids. A major operative difference is the extent of muscle dissection and soft-tissue injury. The effect of topical epidural steroids for the increased pain following lumbar fusion may be inconsequential given that these patients often require patient-controlled analgesia and increased opiate utilization perioperatively. It is possible that one or several of the factors listed above could have contributed to the absence of effect seen in the current study.
In summary, despite a strong biological rationale and supporting evidence for their application in microdiscectomy, the current study does not support the use of topical steroids in lumbar fusion. In spite of this, Tavanaei et al. should be commended for their important contribution to the literature and, in particular, for the rigorous study methods they used to help answer this question. In light of the aforementioned possibilities explaining the lack of observed effect, additional studies would be useful in this domain, perhaps exploring different modes of topical delivery (not involving the use of Gelfoam) or consideration of different steroid formulations or dosages. Certainly, given the large burden of disease and the volume of lumbar fusions completed annually, even incremental improvements in postoperative outcomes discovered with this therapy in the future could have a significant impact at both the patient and healthcare system levels.
Disclosures
Dr. Wilson is a consultant for Stryker. Dr. Wilson would also like to acknowledge support from the Labatt Family Endowed Chair in Neurosurgery at St. Michael’s Hospital, University of Toronto.
References
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