Effects of local intraoperative epidural use of triamcinolone acetonide–soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial

Roozbeh TavanaeiFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Pooria AhmadiFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Bahador MalekipourFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Bijan Herfedoust BiazarFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Mohsen KeikhaeeFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Kaveh Oraii YazdaniDepartment of Cardiovascular Diseases, Zahedan University of Medical Science, Zahedan, Iran

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Alireza ZaliFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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Saeed Oraee-YazdaniFunctional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and

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OBJECTIVE

Prior evidence has supported the use of local intraoperative epidural steroids in lumbar discectomy for improvements in postoperative pain and outcomes. However, currently there is a paucity of data regarding the efficacy of local epidural steroids in spinal fusion procedures. The present investigation aimed to evaluate the impact of local epidural administration of triamcinolone acetonide–soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly divided into two groups (treatment and control). Patients in the treatment group received a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg), which was placed over the nerve roots in the epidural space before the closure. Patients in the control group received a Gelfoam carrier soaked in normal saline in a similar fashion to the treatment group. Patients were followed up during their hospital stay and at 4 and 12 weeks postoperatively. The primary outcome measure was early postoperative visual analog scale (VAS) scores for pain both at rest and with movement.

RESULTS

A total of 100 patients were recruited in this study and were randomly allocated to the treatment or control group. No significant difference was found in baseline demographic, clinical, and surgical characteristics between the two groups. Postoperative VAS scores for pain both at rest and with movement were comparable between the treatment and control groups. Cumulative morphine consumption, length of hospital stay, and incidence of postoperative complications such as surgical site infection were also similar between the two groups. There was no significant difference in patient-reported outcomes including VAS scores for back and leg pain as well as the Oswestry Disability Index at 4 and 12 weeks postoperatively. The proportion of patients who achieved a minimum clinically important difference for patient-reported outcomes were also similar between the two groups.

CONCLUSIONS

In contrast to the existing literature on the beneficial use of local intraoperative epidural steroids in conventional lumbar discectomy, the present study did not demonstrate such significant efficacy for the use of local epidural steroids in instrumented posterolateral lumbar spinal fusion. However, there is still a lack of evidence in this regard and further high-quality clinical trials are required to evaluate the efficacy of local epidural steroids in this group of patients.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; CONSORT = Consolidated Standards for Reporting of Trials; IRR = incidence rate ratio; LOS = length of hospital stay; MCID = minimum clinically important difference; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; PONV = postoperative nausea and vomiting; SSI = surgical site infection; VAS = visual analog scale.

OBJECTIVE

Prior evidence has supported the use of local intraoperative epidural steroids in lumbar discectomy for improvements in postoperative pain and outcomes. However, currently there is a paucity of data regarding the efficacy of local epidural steroids in spinal fusion procedures. The present investigation aimed to evaluate the impact of local epidural administration of triamcinolone acetonide–soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly divided into two groups (treatment and control). Patients in the treatment group received a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg), which was placed over the nerve roots in the epidural space before the closure. Patients in the control group received a Gelfoam carrier soaked in normal saline in a similar fashion to the treatment group. Patients were followed up during their hospital stay and at 4 and 12 weeks postoperatively. The primary outcome measure was early postoperative visual analog scale (VAS) scores for pain both at rest and with movement.

RESULTS

A total of 100 patients were recruited in this study and were randomly allocated to the treatment or control group. No significant difference was found in baseline demographic, clinical, and surgical characteristics between the two groups. Postoperative VAS scores for pain both at rest and with movement were comparable between the treatment and control groups. Cumulative morphine consumption, length of hospital stay, and incidence of postoperative complications such as surgical site infection were also similar between the two groups. There was no significant difference in patient-reported outcomes including VAS scores for back and leg pain as well as the Oswestry Disability Index at 4 and 12 weeks postoperatively. The proportion of patients who achieved a minimum clinically important difference for patient-reported outcomes were also similar between the two groups.

CONCLUSIONS

In contrast to the existing literature on the beneficial use of local intraoperative epidural steroids in conventional lumbar discectomy, the present study did not demonstrate such significant efficacy for the use of local epidural steroids in instrumented posterolateral lumbar spinal fusion. However, there is still a lack of evidence in this regard and further high-quality clinical trials are required to evaluate the efficacy of local epidural steroids in this group of patients.

In Brief

This study aimed to evaluate the impact of local epidural administration of triamcinolone acetonide–soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion. Local intraoperative epidural administration of steroids using a Gelfoam carrier did not affect the study outcome measures significantly in instrumented posterolateral lumbar spinal fusion. This study was the first to evaluate the efficacy of local intraoperative epidural use of triamcinolone acetonide–soaked Gelfoam in posterolateral lumbar spinal fusion.

Postoperative pain management is one of the milestones of fast-track or enhanced recovery after surgery clinical pathways, which has received growing attention in recent years, especially for spinal procedures.1 Significant pain in the early postoperative course is a common finding among patients undergoing lumbar spine surgery.2 In addition to delayed mobilization and a resultant prolonged hospital stay, poorly controlled postoperative pain could result in cardiovascular, pulmonary, and cerebrovascular complications as well as an increased risk of chronic pain.3–7 Therefore, effective strategies to reduce postoperative pain in lumbar spinal procedures are in high demand.

Various strategies for postoperative pain management in lumbar spine surgery have been implemented, one of which is the use of epidural steroids.3,4 Prior studies have demonstrated significant improvements in postoperative visual analog scale (VAS) scores (both back and leg), reductions in length of hospital stay (LOS), and postoperative cumulative morphine consumption following the use of epidural steroids in patients undergoing lumbar discectomy and laminectomy.8–15 The observed effects are possibly attributable to the antiinflammatory properties of corticosteroids that prevent the subsequent fibrosis and resultant chronic pain.16 Although this modality has been widely investigated in lumbar discectomy, currently there is scarce information regarding its efficacy in lumbar spinal fusion surgery.

Hence, due to the paucity of data, the present randomized, double-blind, controlled trial was designed to evaluate the efficacy of intraoperative local administration of corticosteroids in postoperative pain management and patient-reported outcomes in patients undergoing posterolateral lumbar spinal fusion surgery.

Methods

Trial Design

This study was a randomized, double-blind, placebo-controlled, parallel-group trial approved by the institutional review board of the Shohada Tajrish Hospital and the ethics committee of Shahid Beheshti University of Medical Sciences. This study was registered with the Iranian Registry of Clinical Trials database (https://www.irct.ir/), and its registration no. is IRCT20200502047277N6. All patients undergoing elective, instrumented posterior lumbar spinal fusion surgery between July 2020 and July 2021 were assessed for eligibility. Written informed consent was obtained from all participants following the recruitment process. In order to improve the reporting of results, this trial was conducted in accordance with the Consolidated Standards for Reporting of Trials (CONSORT) guidelines.

Inclusion criteria were age > 18 years, degenerative indications (e.g., spondylolisthesis, spinal stenosis, disc herniation, or spondylosis) for elective posterior instrumented lumbar spinal fusion surgery, and written informed consent. Patients who were scheduled to undergo posterior lumbar spinal fusion for nondegenerative pathologies (e.g., tumor, trauma, deformity, or infection); had a prior history of hypersensitivity or anaphylactic reaction to the study drug; had previously undergone lumbar spinal fusion surgery; or had severe concurrent comorbidity (defined as American Society of Anesthesiologists [ASA] physical status > II) or psychiatric disorder were excluded from the study.

Patients were randomly assigned (a 1:1 ratio) to one of two groups (treatment or control) via computer-generated block randomization performed using SPSS version 24 (IBM Corp.) on the day of surgery, before the operation. The person who performed the preoperative randomization was not part of the study. Sealed opaque envelopes were used for allocation concealment. One surgeon who was not blind to the patients’ allocation and study intervention in each group performed all the operations in the study. The surgeon, however, did not take part in the data collection and investigation processes after the operation. Patients, the principal investigator, outcome assessors, and data analyzers were merely informed of the study group number (1 or 2) and remained blind to the intervention performed in each study group throughout the course of the study.

Interventions

All patients in this study underwent posterolateral lumbar spinal fusion surgery performed by the same surgeon and surgical team. Following the intubation, patients were placed in the prone position, and one midline incision was made, the length of which was adjusted according to the number of levels of fusion anticipated preoperatively. After the complete bony dissection, nerve roots were decompressed in a posterolateral fashion. Depending on each case, multilevel laminectomy, facetectomy, foraminotomy, and discectomy were also performed; however, no patient in this study underwent posterior lumbar interbody fusion. Next, the conventional method of pedicle screw-rod instrumentation was used, and harvested autologous bone grafts mixed with allograft bone chips were placed bilaterally on the transverse processes and laminae. In the treatment group, a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg) for 5 minutes was placed over the nerve roots at the epidural space before the closure. The size of the Gelfoam was adjusted based on the epidural space, and for each pair of nerve roots, 1 ml of triamcinolone acetonide was used. The same was performed for patients in the control group, except that this was done via a Gelfoam carrier soaked in 1 ml of normal saline. The drain was fixed, and the wound closure was performed in a layered fashion.

For anesthesia and perioperative pain management, the same process was applied to both study groups. Thirty minutes before the end of the surgery, paracetamol 1 g, ondansetron 4 mg, and morphine 0.1 mg/kg were administered. All patients were also instructed preoperatively how to use the patient-controlled analgesia device, which was attached to them at the end of surgery. The patient-controlled analgesia device was set to deliver morphine 20 µg/kg and ondansetron 12 mg (in 150 ml of normal saline) at a basal rate of 2 ml/hr and 1 ml per patient’s demand (10-minute lockout period). Meperidine 50 mg and ondansetron 4 mg were used as additional analgesia and antiemetic agents, respectively, at the patient’s request.

Outcome Measures

Patients were assessed at the following time points: at baseline; at 2, 4, 6, 12, 24, and 48 hours postoperatively; and at 4 and 12 weeks after the surgery to evaluate the study outcome measures. The primary outcome measure of the study was postoperative leg pain based on the 10-cm VAS score (0 = no pain, 10 = worst imaginable pain) for leg pain both at rest and with movement during the first postoperative day at 2, 4, 6, 12, 24, and 48 hours postoperatively. Secondary outcome measures of the present study included VAS scores for leg and back pain at 4 and 12 weeks postoperatively, cumulative postoperative 24-hour morphine consumption, Oswestry Disability Index (ODI), LOS, postoperative nausea and vomiting (PONV), and the incidence of postoperative complications. Moreover, demographic, clinical, and surgical characteristics were recorded. Patient-reported outcomes, including VAS scores (in addition to acute postoperative values) for back and leg pain, along with ODI, were recorded at 4 and 12 weeks postoperatively.

Statistical Analysis

A number of previous studies have demonstrated the efficacy of epidural steroids in reducing pain after a lumbar discectomy.14 Therefore, according to their findings, by assuming a mean VAS score of 3.2 for the control group at 24 hours postoperatively and an SD of 1.7, a minimum of 94 patients (47 in each arm) would be required to observe a change of 1 point in the mean VAS score with a power of 0.80 and a 2-sided significance level of 0.05. After anticipating a dropout rate of 6%, a total of 100 (50 in each arm) was estimated for this study.

Data were analyzed using an intention-to-treat approach. Quantitative data were expressed as the mean ± SD, and qualitative data were presented as frequency and percentage in the present study. The Mann-Whitney U-test was used to compare the continuous data between the two groups (treatment and control) at each time point. Moreover, the changes in postoperative outcome measures (postoperative value − baseline value) were also compared between the two groups using the Mann-Whitney U-test. A backward stepwise multiple linear regression analysis was performed to assess the differences in changes in patient-reported outcome measures (VAS, ODI, and cumulative morphine consumption as the response variable) between the two groups while adjusting for sex, the number of fused levels, and preoperative pain. Similarly, Poisson regression was also carried out to evaluate the impact of study intervention on the percentage of patients who reached the minimum clinically important difference (MCID) while controlling for the aforementioned confounders. The incidence rate ratio (IRR) of the study groups was also estimated by performing the Poisson regression. The goodness of fit of the Poisson regression model was checked using the chi-square goodness-of-fit test. In order to compare the categorical data between the two groups, either the chi-square or Fisher’s exact test was used. Probability values less than 0.05 were considered statistically significant. All statistical analyses in this study were performed using SPSS version 24. Poisson regression was performed using Stata version 15 (StataCorp).

Results

Patient Characteristics

Between July 2020 and July 2021, a total of 168 patients were screened for eligibility. Among them, 52 patients did not meet the study criteria and 16 refused to participate. Thus, a total of 100 patients were recruited in this study and randomly allocated to receive either intraoperative local epidural corticosteroid or placebo. All patients in both study groups received their assigned intervention, and no dropouts occurred during the study period (Fig. 1).

FIG. 1.
FIG. 1.

Data on participants in study, prepared using the CONSORT 2010 Flow Diagram template (available at http://www.consort-statement.org/). Figure is available in color online only.

Regarding the patients’ baseline characteristics, no significant difference was found (p > 0.05) between the two groups in age, sex, BMI, smoking status, comorbidities, preoperative indications for surgery, ASA physical status, VAS scores (for both back and leg pain), and ODI. Surgical information, including the number of levels of fusion, duration of operation, and estimated intraoperative blood loss, was also similar (p > 0.05) in both study groups. Table 1 demonstrates the differences in demographic, clinical, and surgical characteristics of the two study groups (treatment and control).

TABLE 1.

Demographic, clinical, and surgical characteristics of 100 patients who underwent spinal fusion

CharacteristicTreatment, n = 50Control, n = 50p Value
Age in yrs, mean (SD)51.7 (11.7)48.5 (12.5)0.189
Sex, no. (%)0.405
 Male16 (32.0%)20 (40.0%)
 Female34 (68.0%)30 (60.0%)
BMI, mean (SD)28.1 (4.8)28.7 (4.1)0.550
Smoking status, no. (%)0.298
 Smoker7 (14.0%)11 (22.0%)
 Nonsmoker43 (86.0%)39 (78.0%)
Comorbidities, no. (%)
 Diabetes mellitus3 (6.0%)5 (10.0%)0.715
 Hypertension9 (18.0%)13 (26.0%)0.334
 Pulmonary disease0 (0.0%)1 (2.0%)1.00
Prior lumbar decompression, no. (%)4 (8.0%)6 (12.0%)0.505
Diagnosis, no. (%)
 Spondylolisthesis38 (76.0%)33 (66.0%)0.271
 Spinal stenosis44 (88.0%)42 (84.0%)0.564
 Disc herniation7 (14.0%)5 (10.0%)0.538
 Spondylosis18 (36.0%)15 (30.0%)0.523
ASA class, no. (%)0.230
 I29 (58.0%)23 (46.0%)
 II21 (42.0%)27 (54.0%)
Baseline scores, mean (SD)
 VAS for back pain5.7 (1.6)5.8 (1.7)0.594
 VAS for leg pain6.2 (1.7)6.3 (1.8)0.734
 ODI35.4 (9.7)36.8 (10.6)0.367
No. of levels of fusion, mean (SD)3.9 (1.2)3.7 (1.0)0.565
Duration of surgery in mins, mean (SD)243.6 (37.1)234.9 (35.6)0.206
Estimated blood loss in ml, mean (SD)525.7 (270.6)572.0 (279.0)0.381

Primary Outcome Measure

Table 2 shows changes in the value of the VAS score during the first and second postoperative days. There was no significant difference between the two groups in VAS scores for leg pain both at rest (treatment: 5.3 ± 1.6 vs control: 5.1 ± 1.6, p = 0.407) and with movement (treatment: 6.4 ± 1.2 vs control: 6.2 ± 1.1, p = 0.393) at 24 hours postoperatively (Fig. 2). Similarly, the two groups were comparable (p > 0.05) in terms of VAS scores for leg pain both at rest and with movement at 2, 4, 6, 12, and 48 hours postoperatively (Fig. 2). No significant difference in changes in VAS score for leg pain both at rest (treatment: −0.9 ± 2.3 vs control: −1.3 ± 2.5, p = 0.487) and with movement (treatment: 0.2 ± 1.9 vs control: −0.1 ± 2.2, p = 0.497) was found. Changes in VAS scores for leg pain both at rest and with movement at each time point are depicted in Table 2. Similar to univariate analyses, multiple linear regression controlled for sex, preoperative VAS score for leg pain, and the number of fused levels found no significant difference between the study groups and changes in the VAS score of leg pain both at rest (B = 0.035 and p = 0.588) and with movement (B = 0.048 and p = 0.401) at 24 hours postoperatively.

TABLE 2.

Primary and secondary outcome measures in 100 patients who underwent spinal fusion

OutcomeTreatmentControlp Value
Mean ValueChangesMean ValueChangesMean ValueChanges
VAS score for leg pain at rest
 2 hrs6.5 (1.8)0.3 (2.3)6.1 (1.8)−0.2 (2.5)0.2570.238
 4 hrs5.4 (1.8)−0.9 (2.2)5.2 (1.6)−1.2 (2.3)0.5260.549
 6 hrs5.3 (1.5)−0.9 (2.0)5.0 (1.4)−1.4 (2.2)0.2410.439
 12 hrs4.6 (1.0)−1.7 (1.7)4.4 (1.0)−1.9 (2.0)0.3100.458
 24 hrs5.3 (1.6)−0.9 (2.3)5.1 (1.6)−1.3 (2.5)0.4070.487
 48 hrs4.0 (1.3)−2.2 (2.3)3.8 (1.1)−2.5 (2.3)0.5200.710
VAS score for leg pain w/ movement
 2 hrs7.7 (1.8)1.4 (2.3)7.6 (1.6)1.2 (2.4)0.7320.658
 4 hrs6.8 (1.5)0.5 (2.2)6.6 (1.4)0.3 (2.3)0.4900.531
 6 hrs6.3 (1.4)0.1 (2.1)6.2 (1.1)−0.2 (2.3)0.3800.554
 12 hrs5.4 (1.1)−0.8 (1.9)5.3 (1.0)−1.1 (2.1)0.2460.503
 24 hrs6.4 (1.2)0.2 (1.9)6.2 (1.1)−0.1 (2.2)0.3930.497
 48 hrs5.2 (0.9)−1.0 (1.9)4.9 (0.9)−1.5 (2.0)0.1110.329
Cumulative 24-hr morphine consumption, mg38.3 (12.2)NA38.7 (11.2)NA0.839NA
LOS, hrs136.0 (37.3)NA137.0 (31.1)NA0.953NA
PONV, no. (%)13 (26.0%)NA18 (36.0%)NA0.280NA

NA = not applicable.

Unless otherwise indicated, values are expressed as the mean (SD). Changes = postoperative value at each time point – preoperative value.

FIG. 2.
FIG. 2.

Bar graphs showing the mean postoperative pain scores based on a 10-cm VAS for leg pain both at rest (upper) and with movement (lower) at 2, 4, 6, 12, 24, and 48 hours after the surgery.

Secondary Outcome Measures

No significant difference was observed between the two groups in the cumulative morphine consumption at 24 hours postoperatively (treatment: 38.3 ± 12.2 mg vs control: 38.7 ± 11.2 mg, p = 0.839). Multiple linear regression (adjusted for sex, preoperative pain, and the number of fused levels) found no significant difference in cumulative morphine consumption at 24 hours postoperatively (B = −0.17 and p = 0.865) between the two groups. Likewise, LOS was similar in both groups (treatment: 136.0 ± 37.3 vs control: 137.0 ± 31.1, p = 0.953). In regard to the incidence of morphine-related side effects during the first 72 hours after the surgery, 13 (26.0%) and 18 (36.0%) patients experienced PONV in the treatment and control groups, respectively, but this was not statistically significant (p = 0.280).

Changes in the VAS scores for back and leg pain as well as ODI were also assessed at 4 and 12 weeks postoperatively in this study. No statistically significant difference (p > 0.05) was found between the treatment and control groups regarding the changes in VAS scores for both leg and back pain as well as changes in ODI scores at 4 and 12 weeks after the surgery. At each time point, postoperative values of the aforementioned variables were also comparable (p > 0.05) between the study groups. Table 3 illustrates the changes in VAS (for both leg and back pain) and ODI scores at 4 and 12 weeks postoperatively. Multiple linear regressions adjusted for sex, baseline value of outcome measure, and the number of fused levels also found no significant difference between the two groups in VAS for leg pain (B = −0.019 and p = 0.714), VAS for back pain (B = −0.014 and p = 0.746), and ODI score (B = −0.158 and p = 0.117) at 12 weeks postoperatively.

TABLE 3.

Mean values with changes in postoperative patient-reported outcomes in 100 patients who underwent spinal fusion

OutcomeTreatmentControlp Value
Mean ValueChangesMean ValueChangesMean ValueChanges
VAS score for back pain
 Preop5.7 (1.6)NA5.8 (1.7)NA0.594NA
 4 wks3.6 (1.1)−2.1 (1.3)3.8 (0.9)−2.0 (1.6)0.2810.877
 12 wks2.9 (0.8)−2.7 (1.6)2.9 (0.7)−2.9 (1.8)0.6730.650
VAS score for leg pain
 Preop6.2 (1.7)NA6.3 (1.8)NA0.734NA
 4 wks4.2 (1.2)−2.1 (1.3)4.4 (0.9)−1.9 (1.7)0.2430.772
 12 wks3.4 (1.0)−2.8 (1.8)3.5 (0.9)−2.8 (1.8)0.6390.748
ODI
 Preop35.4 (9.7)NA36.8 (10.6)NA0.367NA
 4 wks25.1 (8.7)−10.3 (5.8)26.1 (8.7)−10.7 (4.1)0.6480.208
 12 wks20.7 (6.9)−14.7 (6.7)23.9 (6.6)−12.9 (4.7)0.033*0.384

Values are expressed as the mean (SD). Changes = postoperative value at each time point – preoperative value.

Indicates statistically significant at p < 0.05.

With respect to postoperative complications, 4 (8.0%) and 2 (4.0%) patients in the treatment and control groups, respectively, developed superficial surgical site infections (SSIs). However, this difference was not statistically significant (p = 0.678). No significant difference in the percentage of patients who achieved MCID for ODI (treatment: 26 (52.0%) vs control: 31 (62.0%), p = 0.313) and VAS scores for both leg pain (treatment: 38 (76.0%) vs control: 39 (78.0%), p = 0.812) and back pain (treatment: 37 (74.0%) vs control: 38 (76.0%), p = 0.817) was found at 3 months postoperatively. Similarly to univariate analysis, Poisson regression (adjusted for sex, baseline value of outcome measure, and the number of fused levels) found no significant difference in the percentage of patients who achieved MCID for ODI (IRR 0.99 [95% CI 0.58–1.69], p = 0.977) and VAS scores for both back pain (IRR 1.02 [95% CI 0.65–1.62], p = 0.939) and leg pain (IRR 1.02 [95% CI 0.65–1.59], p = 0.923) at 12 weeks postoperatively.

Discussion

According to the results of the present randomized, placebo-controlled trial, intraoperative epidural corticosteroid application did not affect the early postoperative pain significantly in patients who underwent elective posterolateral spinal fusion surgery. Furthermore, postoperative opioid requirements remained unchanged in the group that received epidural steroid in comparison with the control group. Similarly, no significant change was observed in the LOS and postoperative patient-reported outcomes following the administration of epidural corticosteroid in the present study. Moreover, intraoperative epidural use of corticosteroid was not significantly associated with a higher complication rate compared with the placebo. Hence, the findings of the present study do not support the routine use of intraoperative epidural corticosteroids in posterolateral lumbar spinal fusion for better postoperative pain control or improved outcome.

The majority of previous studies have suggested a significant efficacy for epidural use of steroids in reducing postoperative pain, opioid requirement, and LOS in lumbar discectomy procedures.9–14,17,18 In contrast, the present investigation did not demonstrate such a significant impact in posterolateral spinal fusion surgery. According to the most recent systematic review and meta-analysis (level of evidence I), including 12 studies (n = 1006) with either conventional or minimally invasive surgery (MIS) discectomy, application of epidural steroids significantly reduces VAS scores (for both leg and back pain) at 1 week and 1 month postoperatively, as well as reducing morphine consumption and LOS compared with the placebo in patients undergoing lumbar discectomy.14 The subgroup analysis, however, showed that only the conventional discectomy is associated with this significant effect in comparison with the MIS discectomy.

Regarding the method of delivery, most prior studies have used the instillation of the steroid over the epidural space. However, many prior investigations have supported the hypothesis that the use of Gelfoam as a carrier for extended-release epidural administration of various analgesic drugs, such as morphine, buprenorphine, steroids, and levobupivacaine, in lumbar discectomy or laminectomy could prolong the analgesic effect.19–23 Regarding the epidural use of steroids in a sustained-release fashion, although no study has compared it with the instillation method, a number of studies have demonstrated its efficacy in postoperative analgesia. Kumari et al. showed a significant reduction in postoperative tramadol consumption and pain in patients who received Gelfoam soaked in dexamethasone and levobupivacaine compared with those who received Gelfoam soaked in levobupivacaine alone or the control group (normal saline) after lumbar laminectomy.23 Chadduck et al. also found that epidural administration of a piece of autogenous fat soaked in methylprednisolone was associated with significant improvement in postoperative pain following lumbar decompression surgery.19 In addition, a major drawback of drug instillation into the epidural space in comparison with using the Gelfoam carrier is that most of the drug might be lost in the disc space or diluted by tissue fluids or blood. Nevertheless, no study has evaluated the differences in postoperative outcomes between the use of Gelfoam soaked in corticosteroids and instillation of these agents over the epidural space in spinal fusion surgery, and future clinical trials are warranted to assess this topic.

Nevertheless, much of the literature consists of reports on the efficacy of epidural steroids in lumbar discectomy, whereas only a limited number of studies have been devoted to this potential effect in lumbar spinal fusion.12,24 In a prior randomized, double-blind, placebo-controlled trial, Jirarattanaphochai et al. assessed the effects of epidural coadministration of methylprednisolone and bupivacaine on postoperative pain and morphine consumption in patients undergoing lumbar discectomy, decompressive laminectomy, and instrumented lumbar spinal fusion.12 Although their subgroup analysis showed a significant reduction in the postoperative morphine consumption of patients who underwent lumbar discectomy, no such effect was observed for the laminectomy or fusion groups. The findings of this study regarding fusion, however, are limited due mainly to two reasons. First, despite a large study sample size, there is heterogeneity in the type of procedure among the patients, and only 31 patients underwent spinal fusion, with 16 of them in the treatment group. Second, patients in the treatment group received a combination of bupivacaine and methylprednisolone, which might not fully demonstrate the effects of the steroid application given the analgesic effects of local bupivacaine itself.

The present study showed that intraoperative epidural steroid administration does not affect the postoperative pain or patient-reported outcomes in posterolateral spinal fusion. Similar to our findings, Haws et al. found no significant change in postoperative pain, LOS, cumulative morphine consumption, and patient-reported outcomes in patients who received a Gelfoam carrier soaked in 1 ml of methylprednisolone during the MIS transforaminal lumbar interbody fusion compared with the placebo.24 Despite using the MIS approach, this study has been the only clinical trial that assessed the impact of epidural use of steroids on patient outcomes in spinal fusion. Concerning the lumbar discectomy, however, the results have been different. When considering various surgical approaches, conventional discectomy has been significantly effective in improving postoperative patient outcomes.9–12,14,17,18 However, the MIS approach did not lead to the same results in lumbar discectomy.8,14,15,25 Nonetheless, given that there is currently a paucity of data regarding the use of epidural steroids in both conventional and MIS lumbar fusion surgery, further high-quality studies are required.

Changes in patient-reported outcomes, including VAS (for both leg and back pain) and ODI, were not significantly different between the treatment and control groups over 4 and 12 weeks postoperatively in the current study. Likewise, Haws et al. found no significant difference in changes in the aforementioned patient-reported outcomes during 6, 12, and 24 weeks postoperatively.24 By contrast, in the meta-analysis performed by Arirachakaran et al., significant improvements in back and leg VAS scores at 1 and 4 weeks postoperatively were found in patients who underwent lumbar discectomy and received epidural steroids compared with the placebo.14 Jirarattanaphochai et al. showed lower ODI and back and leg VAS scores at 3 months postoperatively in patients who received epidural methylprednisolone and bupivacaine; yet these were not statistically significant.12 Similar to the study performed by Haws et al., no significant difference was observed in the percentage of patients who achieved an MCID for ODI and back and leg VAS scores at 3 months after the surgery in the current study.24

No statistically significant difference was observed in the incidence of postoperative complications between the two groups during the 3 months after the surgery. Nevertheless, although the difference was not statistically significant, a higher incidence of SSI was noted in the group that received triamcinolone acetonide–soaked Gelfoam. In line with this finding, Haws et al. indicated that superficial wound infections tend to be more frequent in patients who received methylprednisolone-soaked Gelfoam and underwent MIS transforaminal lumbar interbody fusion; however, the difference was not significant.24 The most recent meta-analysis mentioned earlier, however, found no significant difference in postoperative complications such as infection between patients who received epidural steroids and those who received placebo (pooled risk ratio 0.92 [95% CI 0.47–1.83]).14 Some prior reports have consistently suggested a significant correlation between the use of the implanted instrument, as well as the performance of spinal fusion, and SSI after spinal procedures.26–28 This might explain the higher rate of SSI in the present investigation compared with prior studies on lumbar discectomy. Therefore, due in part to potential differences in the incidence of postoperative complications between the lumbar discectomy and fusion or between the MIS and conventional approaches, future studies are warranted to assess complications associated with epidural steroids in spinal fusion surgery.

Although the present study was the first to assess the efficacy of epidural triamcinolone acetonide–soaked Gelfoam specifically in patients undergoing posterolateral spinal fusion, there were some limitations. First, all patients were recruited at a single center, and the same surgeon and surgical team performed all operations. Thus, since the same surgical techniques were performed based on the surgeon’s preferences and experience, there might be a potential source of bias that could be addressed by future multicenter clinical trials. Second, patient-reported outcomes such as ODI and VAS as well as complication rates were assessed for 12 weeks postoperatively, which is a relatively short period of time to observe a minimal change in such outcomes. Future high-quality studies are needed to evaluate these outcomes over a long-term follow-up period. Third, the sample size was comparatively small to be used to evaluate the potential association between epidural corticosteroid administration and SSI. Accordingly, a much larger sample size is needed to assess this relationship, given the low incidence of this complication in elective spinal procedures according to prior reports.28,29 Fourth, although the clinical patient-reported outcome measures were not significantly different between the two groups at 12 weeks postoperatively, the effects of local administration of steroids on the rate of fusion were not assessed using radiographic evaluation in the present study. Future investigations are required to evaluate the effects of local administration of steroids on the bone union by performing radiographic studies with a longer follow-up period.

Conclusions

The local intraoperative epidural administration of triamcinolone acetonide did not affect the postoperative pain, cumulative morphine consumption, and patient-reported outcomes in patients undergoing posterolateral lumbar spinal fusion surgery in comparison with the placebo. Therefore, in contrast to current evidence regarding the efficacy of epidural use of steroids in conventional lumbar discectomy, the findings of this randomized controlled trial did not support the regular use of local epidural corticosteroids in posterolateral lumbar spinal fusion surgery. However, further studies are needed in order to validate these findings and evaluate the efficacy of epidural administration of steroids, specifically in patients undergoing spinal fusion.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Oraee-Yazdani, Tavanaei, Ahmadi. Acquisition of data: Tavanaei, Ahmadi, Malekipour, Herfedoust Biazar, Keikhaee. Analysis and interpretation of data: Tavanaei, Ahmadi. Drafting the article: Tavanaei, Ahmadi, Malekipour, Oraii Yazdani. Critically revising the article: Oraee-Yazdani, Tavanaei, Ahmadi. Reviewed submitted version of manuscript: Oraee-Yazdani, Zali. Approved the final version of the manuscript on behalf of all authors: Oraee-Yazdani. Statistical analysis: Tavanaei. Administrative/technical/material support: Oraee-Yazdani, Ahmadi, Zali. Study supervision: Oraee-Yazdani, Zali.

References

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    Dietz N, Sharma M, Adams S, et al. Enhanced Recovery After Surgery (ERAS) for spine surgery: a systematic review. World Neurosurg. 2019;130:415426.

  • 2

    O’Neill P, Knickenberg C, Bogahalanda S, Booth AE. Use of intrathecal morphine for postoperative pain relief following lumbar spine surgery. J Neurosurg. 1985;63(3):413416.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Wilson-Smith A, Chang N, Lu VM, et al. Epidural steroids at closure after microdiscectomy/laminectomy for reduction of postoperative analgesia: systematic review and meta-analysis. World Neurosurg. 2018;110:e212e221.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):5055.

  • 6

    Gust R, Pecher S, Gust A, Hoffmann V, Böhrer H, Martin E. Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting. Crit Care Med. 1999;27(10):22182223.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):815.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Shin SH, Hwang BW, Keum HJ, Lee SJ, Park SJ, Lee SH. Epidural steroids after a percutaneous endoscopic lumbar discectomy. Spine (Phila Pa 1976). 2015;40(15):E859E865.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Bahari S, El-Dahab M, Cleary M, Sparkes J. Efficacy of triamcinolone acetonide and bupivacaine for pain after lumbar discectomy. Eur Spine J. 2010;19(7):10991103.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Debi R, Halperin N, Mirovsky Y. Local application of steroids following lumbar discectomy. J Spinal Disord Tech. 2002;15(4):273276.

  • 11

    Jamjoom BA, Jamjoom AB. Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskelet Disord. 2014;15(1):146.

  • 12

    Jirarattanaphochai K, Jung S, Thienthong S, Krisanaprakornkit W, Sumananont C. Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial. Spine (Phila Pa 1976). 2007;32(6):609617.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Waqas M, Shallwani H, Shamim MS, Ahmad K. Perioperative steroids for lumbar disc surgery: a meta-analysis of randomized controlled trials. Surg Neurol Int. 2017;8(1):42.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Aljabi Y, El-Shawarby A, Cawley DT, Aherne T. Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy. Surgeon. 2015;13(5):245249.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Liu S, Boutrand JP, Tadie M. Use of a collagen-based sealant to prevent in vivo epidural adhesions in an adult rat laminectomy model. J Neurosurg. 2001;94 (1)(suppl):6167.

    • Search Google Scholar
    • Export Citation
  • 17

    Modi H, Chung KJ, Yoon HS, Yoo HS, Yoo JH. Local application of low-dose Depo-Medrol is effective in reducing immediate postoperative back pain. Int Orthop. 2009;33(3):737743.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Pobereskin LH, Sneyd JR. Does wound irrigation with triamcinolone reduce pain after surgery to the lumbar spine? Br J Anaesth. 2000;84(6):731734.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Chadduck JB, Sneyd JR, Pobereskin LH. The role of bupivacaine in early postoperative pain control after lumbar decompression. J Neurosurg. 1999;90 (1)(suppl):6772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Hassanein A, Ali NS, Saad A. Colloid versus crystalloid soaked gelfoam with morphine for postoperative pain relief after lumbar laminectomy. Egypt J Anaesth. 2016;32(4):495502.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Mastronardi L, Pappagallo M, Tatta C, Roperto R, Elsawaf A, Ferrante L. Prevention of postoperative pain and of epidural fibrosis after lumbar microdiscectomy: pilot study in a series of forty cases treated with epidural vaseline-sterile-oil-morphine compound. Spine (Phila Pa 1976). 2008;33(14):15621566.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Mishra LD, Nath SS, Gairola RL, Verma RK, Mohanty S. Buprenorphine-soaked absorbable gelatin sponge: an alternative method for postlaminectomy pain relief. J Neurosurg Anesthesiol. 2004;16(2):115121.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kumari K, Kamal M, Singariya G, Kishan R, Garg S, Thanvi S. Effect of epidural levobupivacaine with or without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: a double blind, randomised, controlled trial. Indian J Anaesth. 2018;62(7):509515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Haws BE, Khechen B, Patel DV, et al. Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial. J Neurosurg Spine. 2018;30(2):222227.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Lavyne MH, Bilsky MH. Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy. J Neurosurg. 1992;77(1):9095.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Chahoud J, Kanafani Z, Kanj SS. Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front Med (Lausanne). 2014;1:7.

    • Search Google Scholar
    • Export Citation
  • 27

    Ogihara S, Yamazaki T, Inanami H, et al. Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: a prospective multicenter surveillance study with registry of 4027 cases. PLoS One. 2018;13(10):e0205539.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Smith JS, Shaffrey CI, Sansur CA, et al. Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2011;36(7):556563.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Yao R, Zhou H, Choma TJ, Kwon BK, Street J. Surgical site infection in spine surgery: who is at risk? Global Spine J. 2018;8 (4)(suppl):5S30S.

  • Collapse
  • Expand

Images from de Andrada Pereira et al. (pp 525–534).

  • View in gallery
    FIG. 1.

    Data on participants in study, prepared using the CONSORT 2010 Flow Diagram template (available at http://www.consort-statement.org/). Figure is available in color online only.

  • View in gallery
    FIG. 2.

    Bar graphs showing the mean postoperative pain scores based on a 10-cm VAS for leg pain both at rest (upper) and with movement (lower) at 2, 4, 6, 12, 24, and 48 hours after the surgery.

  • 1

    Dietz N, Sharma M, Adams S, et al. Enhanced Recovery After Surgery (ERAS) for spine surgery: a systematic review. World Neurosurg. 2019;130:415426.

  • 2

    O’Neill P, Knickenberg C, Bogahalanda S, Booth AE. Use of intrathecal morphine for postoperative pain relief following lumbar spine surgery. J Neurosurg. 1985;63(3):413416.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Ranguis SC, Li D, Webster AC. Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease. A review. J Neurosurg Spine. 2010;13(6):745757.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Wilson-Smith A, Chang N, Lu VM, et al. Epidural steroids at closure after microdiscectomy/laminectomy for reduction of postoperative analgesia: systematic review and meta-analysis. World Neurosurg. 2018;110:e212e221.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12(1):5055.

  • 6

    Gust R, Pecher S, Gust A, Hoffmann V, Böhrer H, Martin E. Effect of patient-controlled analgesia on pulmonary complications after coronary artery bypass grafting. Crit Care Med. 1999;27(10):22182223.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):815.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Shin SH, Hwang BW, Keum HJ, Lee SJ, Park SJ, Lee SH. Epidural steroids after a percutaneous endoscopic lumbar discectomy. Spine (Phila Pa 1976). 2015;40(15):E859E865.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Bahari S, El-Dahab M, Cleary M, Sparkes J. Efficacy of triamcinolone acetonide and bupivacaine for pain after lumbar discectomy. Eur Spine J. 2010;19(7):10991103.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Debi R, Halperin N, Mirovsky Y. Local application of steroids following lumbar discectomy. J Spinal Disord Tech. 2002;15(4):273276.

  • 11

    Jamjoom BA, Jamjoom AB. Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskelet Disord. 2014;15(1):146.

  • 12

    Jirarattanaphochai K, Jung S, Thienthong S, Krisanaprakornkit W, Sumananont C. Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial. Spine (Phila Pa 1976). 2007;32(6):609617.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Waqas M, Shallwani H, Shamim MS, Ahmad K. Perioperative steroids for lumbar disc surgery: a meta-analysis of randomized controlled trials. Surg Neurol Int. 2017;8(1):42.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol. 2018;28(8):15891599.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Aljabi Y, El-Shawarby A, Cawley DT, Aherne T. Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy. Surgeon. 2015;13(5):245249.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Liu S, Boutrand JP, Tadie M. Use of a collagen-based sealant to prevent in vivo epidural adhesions in an adult rat laminectomy model. J Neurosurg. 2001;94 (1)(suppl):6167.

    • Search Google Scholar
    • Export Citation
  • 17

    Modi H, Chung KJ, Yoon HS, Yoo HS, Yoo JH. Local application of low-dose Depo-Medrol is effective in reducing immediate postoperative back pain. Int Orthop. 2009;33(3):737743.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Pobereskin LH, Sneyd JR. Does wound irrigation with triamcinolone reduce pain after surgery to the lumbar spine? Br J Anaesth. 2000;84(6):731734.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Chadduck JB, Sneyd JR, Pobereskin LH. The role of bupivacaine in early postoperative pain control after lumbar decompression. J Neurosurg. 1999;90 (1)(suppl):6772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Hassanein A, Ali NS, Saad A. Colloid versus crystalloid soaked gelfoam with morphine for postoperative pain relief after lumbar laminectomy. Egypt J Anaesth. 2016;32(4):495502.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Mastronardi L, Pappagallo M, Tatta C, Roperto R, Elsawaf A, Ferrante L. Prevention of postoperative pain and of epidural fibrosis after lumbar microdiscectomy: pilot study in a series of forty cases treated with epidural vaseline-sterile-oil-morphine compound. Spine (Phila Pa 1976). 2008;33(14):15621566.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Mishra LD, Nath SS, Gairola RL, Verma RK, Mohanty S. Buprenorphine-soaked absorbable gelatin sponge: an alternative method for postlaminectomy pain relief. J Neurosurg Anesthesiol. 2004;16(2):115121.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kumari K, Kamal M, Singariya G, Kishan R, Garg S, Thanvi S. Effect of epidural levobupivacaine with or without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: a double blind, randomised, controlled trial. Indian J Anaesth. 2018;62(7):509515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Haws BE, Khechen B, Patel DV, et al. Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial. J Neurosurg Spine. 2018;30(2):222227.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Lavyne MH, Bilsky MH. Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy. J Neurosurg. 1992;77(1):9095.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Chahoud J, Kanafani Z, Kanj SS. Surgical site infections following spine surgery: eliminating the controversies in the diagnosis. Front Med (Lausanne). 2014;1:7.

    • Search Google Scholar
    • Export Citation
  • 27

    Ogihara S, Yamazaki T, Inanami H, et al. Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: a prospective multicenter surveillance study with registry of 4027 cases. PLoS One. 2018;13(10):e0205539.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Smith JS, Shaffrey CI, Sansur CA, et al. Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2011;36(7):556563.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Yao R, Zhou H, Choma TJ, Kwon BK, Street J. Surgical site infection in spine surgery: who is at risk? Global Spine J. 2018;8 (4)(suppl):5S30S.

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