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

Abstract

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. We aimed to investigate whether RECK was an effective local anesthetic for patients undergoing posterior spinal fusion. Single-center retrospective cohort study. Patients who underwent posterior spinal fusion surgery from June 2019 to June 2021. 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 three months postoperatively. Secondary outcomes of interest were rates of discharge to home, complication rates, readmissions within 90 days. 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. 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. 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.