Yonsei Med J.  2005 Apr;46(2):245-251. 10.3349/ymj.2005.46.2.245.

The Effects of Ketorolac Injected via Patient Controlled Analgesia Postoperatively on Spinal Fusion

• Park SY
• Moon SH
• Park MS
• Oh KS
• Lee HM

• KMID: 1734051
• DOI: http://doi.org/10.3349/ymj.2005.46.2.245

Abstract

Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.

Keyword

Lumbar spine; spinal fusion; ketorolac

MeSH Terms

Adult
Aged
*Analgesia, Patient-Controlled
Anti-Inflammatory Agents, Non-Steroidal/*administration & dosage/*adverse
Case-Control Studies
Drug Therapy, Combination
Female
Fentanyl/administration & dosage/therapeutic use
Humans
Injections, Intravenous
Ketorolac/*administration & dosage/*adverse effects/therapeutic use
Male
Middle Aged
Postoperative Care/*adverse effects
Research Support, Non-U.S. Gov't
Retrospective Studies
*Spinal Fusion/standards
Treatment Outcome

Reference

1. Moon MS, Ok IY, Lee KS, Yoon HY. A Clinical study of 52 cases of posterolaterally fused lumbar spine. J Korean Orthop Assoc. 1986. 21:585–594.

2. Kwon H, Kim BK, Song JM, Shin BJ, Na SK. Comparative study of fusion rate in the thoracolumbar and lumbar posterolateral fusion using autograft or xenograft lubboc. J Korean Spine Surg. 1997. 4:43–51.

3. Scott DB, Jeffery HS, William CH. An experimental lumbar intertransverse process spinal fusion modelradiographic, histologic, and biomechanical healing characteristics. Spine. 1995. 20:412–420.

4. Kim NH. Anterior interbody fusion in the treatment of the lumbar herniated nucleus pulposus. Yonsei Med J. 1999. 40:256–264.

5. Bassett CA, Creighton DK. A comparison of host response to cortical autograft and processed calf heterograft. J Bone Joint Surg. 1962. 44A:842–846.

6. Toth JM, Seim HB, Schwardt JD, Humphrey WD, Wallskog JA, Turner AS. Direct current electrical stimulation increases the fusion rate of spinal fusion cages. Spine. 2000. 25:2580–2587.

7. Martin GJ, Boden S, Titus L. Recombinant human bone morphogenetic protein-2 overcomes the inhibitory effect of ketoloac, a nonsteroidal anti inflammatory drugs (NSAID), on posterolateral lumbar intertransverse process spine fusion. Spine. 1999. 24:2188–2196.

8. Brown CW, Orme TJ, Richardson HD. The rate of pseudoarthrosis in patients who are smokers and patients who are nonsmokers: A comparison study. Spine. 1986. 11:942–943.

9. Scott SR, Neil RC, Shari L, Margaret K, Charles SG. Dose-response of ketoloac as an adjunct to patient-controlled analgesia morphine in patients after spinal fusion surgery. Anesth Analg. 1998. 87:98–102.

10. Hernandez PJ, Tortosa JA, Martinez LJ, Perz FD. Intravenous administration of propacetamol reduces morphine consumption after spinal fusion surgery. Anesth Analg. 2001. 92:1473–1476.

11. Kjaersgaard-Anderson P, Schmidt SA. Total hip arthroplasty. The role of anti-inflammatory medications in the prevention of heterotopic ossification. Clin Orthop. 1991. 263:78–86.

12. Lebwohl NH, Starr JK, Milne EL, Latta LL, Malini TI. Inhibitory effect of ibuprofen on spinal fusion in rabbits. 1994. Rosemont, IL: AAOS;278.

13. Dimar JR, Ante WA, Zang YP, Glassman SD. The effects of nonsteroidal anti inflammatory drugs on posterior spinal fusions in rat. Spine. 1996. 21:1870–1876.

14. Glassman SD, Rose SM, Dimar JR, Puno RM, Campcell MJ, Johnson JR. The effect of postoperative nonsteroidal anti-inflammatory drugs administration on spinal fusion. Spine. 1998. 23:834–838.

15. Turner DM, Warson JS, Wirt TC, Scalley RD, Cochran RS, Miller KJ. The use of Ketololac in lumbar spine surgery: A cost benefit analysis. J Spinal Disord. 1995. 8:206–212.

16. Lenke LG, Bridwell KH, BUllis DB, Betz RR, Baldus C, Schoenecker PL. Results of in situ fusion for isthmic spondylolisthesis. J Spinal Disord. 1992. 5:433–442.

17. Kim NH, Lee JW. Anterior interbody fusion versus posterolateral fusion with transpedicular fixation for isthmic spondylolithesis. Spine. 1999. 24:812–817.

18. Saag KG, Cowdery JS. Nonsteroidal anti-inflammatory drugs. Balancing benefits and risks. Spine. 1994. 19:1530–1534.

19. Coloma M, White PF, Huber PJ, Kendall TW, Dullye KK, Duffy LL. The effect of ketorolac on recovery after anorectal surgery: Intravenous versus local administration. Anesth Analg. 2000. 90:1107–1110.

20. Daniel R, Jhon L, John R, Stephen L, Timothy K, Kim YJ, et al. Time-dependent inhibitory effects of indomethacin on spine fusion. J Bone Joint Sug. 2003. 85:632–636.

21. Goodman S, Ma T, Trindade M, Ikenoue T. Cox-2 selective NSAID decrease bone growth in vivo. J Orthop Res. 2002. 20:1164–1172.

22. Long J, Lewis S, Kuklo T, Zhu Y, Riew KD. The effect of cyclooxygenase-2 inhibitors on spinal fusion. J Bone Joint Surg. 2002. 84:1763–1768.

23. Reuben SS. Considerations in the use of Cox-2 inhibitors in spinal fusion surgery: In response. Anesth Analg. 2001. 93:803–804.

24. Gerstenfeld LC, Thiede M, Seibert K, Mielke C, Phippard D, Svagr B, et al. Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res. 2003. 21:670–675.

25. Hiroshi M, Ryuichi S, Minoru D, Masahiro K, Kosaku M. The role of cyclooxygenase-2 in lumbar disc herniation. Spine. 2002. 27:2477–2483.

26. Brown KM, Saunders MM, Kirsch T, Donahue HJ, Reid JS. Effect of COX-2-specific inhibition on fracture healing in the rat femur. J Bone Joint Surg. 2004. 86A:116–123.

27. Miyamoto H, Saura R, Doita M, Kurosaka M, Mizuno K. The role of cyclo oxygenase-2 in lumbar disc herniation. Spine. 2002. 27:2477–2483.

28. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation and spinal fusion. Spine. 2000. 25:2608–2615.

29. Depalma AF, Prabhaker M. Posterior-posterobilateral fusion of the lumbosacral spine. Clin Orthop. 1996. 47:165–173.

30. Carpenter MC, Dietz MJW, Leng KYK, Hanscom DA, Wagner TA. Repair of a pseudoarthrosis of lumbar spine. A functional outcome study. J Bone Joint Surg. 1996. 78A:712–720.