I recently dove into the article “Perioperative Management for Complex Spine Fusion Surgery” by Carabini et al., featured in the February 2024 issue of Anesthesiology  and I have to say, it really grabbed my attention. Not only does it offer valuable insights into improving the management of acute postoperative pain, but it also drives home a crucial point. I strongly believe that the article could enhance its service to readers in the field of anesthesiology by giving more weight to the limited effectiveness and potential risks associated with gabapentinoids. Previous research, highlighted in a meta-analysis of 281 randomized controlled trials involving gabapentinoids versus placebo in patients undergoing surgery (including 6,549 patients undergoing orthopedic or spinal surgeries), found no clinically significant differences in pain intensity compared to placebo.  Therefore, it is essential to exercise caution when considering their use in complex spine surgery, given the lack of procedure-specific evidence supporting their effectiveness.

Before undergoing complex spine surgery, it is typical for many patients to receive a diagnosis of “radiculopathy.” Consequently, they are often prescribed gabapentinoids (in addition to opioids) both before and after surgery, despite the uncertain clinical benefits. While gabapentinoids are approved for conditions such as neuropathic pain and fibromyalgia, their off-label use, particularly for acute postoperative pain, has seen a notable increase over a 5-yr period, rising from 2 to 5%.  This upward trend is partly driven by the prescribing habits of anesthesiologists and other specialists. Drawing attention to the significant disparity between the purported effectiveness and the documented side effects of gabapentinoids, I firmly believe, would serve as a strong deterrent to their widespread usage.

Recent studies strongly advise against the routine use of gabapentinoids in multimodal pain management strategies for this specific type of surgery due to their associated risks, notably respiratory depression in older patients cognitive impairment including dementia and potential for misuse.  In contrast, simple perioperative interventions such as paracetamol, cyclo-oxygenase-2 specific inhibitors, or short-term non-steroidal anti-inflammatory drugs have demonstrated effectiveness in enhancing postoperative pain control. Immediate-release opioids are reserved solely for in-hospital rescue pain management. 

For certain patients—those battling chronic pain, substance abuse, or a history of multiple prior surgeries—adopting a personalized approach to pain management from the preoperative phase is crucial. This customized strategy enables collaborative goal setting for pain relief, exploration of nonpharmacologic therapies, and meticulous selection of the most appropriate medications to construct a comprehensive multimodal regimen. Our objective must be to facilitate optimal recovery and patient satisfaction while rigorously mitigating the risk of prolonged drug misuse.