Ropivacaine-epinephrine-clonidine-ketorolac is an effective opioid-sparing local anesthetic for patients undergoing posterior spinal fusion

Background context: Ropivacaine-Epinephrine-Clonidine-Ketorolac (RECK) cocktail can improve pain control in patients undergoing lumbar decompression. Given the aging population, rising healthcare costs, the opioid epidemic, and associations of acute pain control with long-term opioid use, effective opioid-sparing analgesia following spinal fusion surgery may impart societal benefits.

Purpose: We aimed to investigate whether RECK was an effective local anesthetic for patients undergoing posterior spinal fusion.

Study design/setting: Single-center retrospective cohort study PATIENT SAMPLE: Patients who underwent posterior spinal fusion surgery from June 2019 to June 2021 OUTCOME MEASURES: Primary outcomes of interest were postoperative pain levels as determined by Visual Analog Scale, in-hospital opioid consumption, length-of-stay <4 days, and long-term opioid utilization at 3-months postoperatively. Secondary outcomes of interest were rates of discharge to home, complication rates, readmissions within 90 days.

Methods: We analyzed whether opioid exposure, patient-specific or surgery-specific factors, and administration of RECK (versus another local anesthetic) were associated with postoperative pain levels, in-hospital opioid consumption, length-of-stay, home discharge, long-term opioid utilization, complications, and readmissions within 90 days using multivariable regression.

Results: Of the 162 patients meeting study criteria, 49 (30.2%) received RECK. RECK was significantly associated with decreased pain levels at 2-, 4-, 6-, and 12-hours postoperatively (p≤.001-.01). RECK was associated with decreased total and daily inpatient opioid utilization (as measured by oral morphine equivalents) in multivariable linear regression (B=-159.6, 95% CI:-255.5- -63.6, p=.002 and B=-27.9, 95% CI:-48.9- -7.0, p=.01, respectively). Length-of-stay duration of <4 days was associated with RECK administration (OR 4.1, 95% CI:1.4-13.2, p=.01) and was negatively associated with levels fused (OR 0.4, 95% CI:0.2-0.7, p=.005) and durotomy (OR 0.02, 95% CI:0.0009-0.1, p<.001). Prolonged postoperative opioid utilization was associated with preoperative opioid prescription (OR 3.6, 95% CI:1.7-7.8, p=.001) and was negatively associated with RECK (OR 0.4, 95% CI:0.2-0.9, p=.04). RECK was not associated with readmissions, complications, or home discharge.

Conclusions: In patients undergoing posterior spinal fusion, RECK was superior to other local anesthetics as it improved pain control, decreased length-of-stay, and decreased opioid utilization. RECK was not associated with increased complications, readmissions, or rates of discharge to home.