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Abstract
Postoperative pain following spinal procedures is a common complaint, with persistent pain even after the immediate convalescent period leading to negative impacts on physical, social, and emotional health (2). On the other hand, sufficient pain management can lead to favorable outcomes such as superior mobility and coordination, quicker recovery, lower risk of complications, and greater patient satisfaction (3-5).
Lidocaine is the only local anesthetic that is safe for intravenous (IV) use. Intraoperative IV lidocaine infusion has been shown to improve pain outcomes, decrease hospital length of stay and has been associated with a decreased 30-day complication rate.(6, 17) Lidocaine IV administration produces an analgesic effect in various pain states, such acute postoperative pain, and neuropathic pain.(21) The analgesia produced by lidocaine may persist after reduction in its plasma levels, favoring the theory of blockade in neuronal conduction.(22) Lidocaine’s metabolite, mono-ethyl-glycine-xylidide (MEGX), may also exert an analgesic effect.(23)
Magnesium sulfate has been found to have anesthetic, analgesic, and muscle relaxation effects and it has been suggested that magnesium may play a role in reducing analgesic requirements during the postoperative period. (31)
We aimed in our study to compare the effect of single-bolus intravenous lidocaine infusion, single-bolus intravenous magnesium sulfate infusion and combination of them on short- and long-term analgesic effects, cognitive function, emotional status (anxiety and depression) and quality of life (QOL) in patients undergoing spine surgery.
Method:
This clinical study was undertaken in Assiut University in one hundred-twenty patients who were randomly assigned to 4 groups:
*group L (Lidocaine): 30 patients received IV lidocaine 4 mg/kg (264) in 50 ml volume over 30 min. plus IV saline 50 ml after induction of anesthesia.
*group M (Magnesium): 30 patients received IV magnesium sulfate 30mg/kg in 50 ml volume over 30 min. plus IV saline 50 ml after induction of anesthesia.
*group LM (combined Lidocaine and Magnesium): 30 patients received IV lidocaine 4 mg/kg in 50 ml volume over 30 min. plus IV magnesium sulfate 30mg/kg in 50 ml volume over 30 min. after induction of anesthesia.
*group C (Control): 30 patients received IV saline 50 ml plus IV saline 50 ml over 30 min. after induction of anesthesia.
Results:
Patients in combined group had the lowest NRS scores, the longest time for first analgesia request and the least in total opioid consumption, followed by lidocaine group then magnesium group, while patients in control group had the highest NRS scores, the shortest time for first analgesia request and the highest in total opioid consumption.
The time for first flatus was reduced significantly in both combined and lidocaine groups, but magnesium and control groups failed to reduce it. Blood loss was significantly lower in combined group than in lidocaine group which was lower than in magnesium group. Intraoperative hypotension was more in combined group than in lidocaine group which was more than magnesium group. Total ephedrine doses were used more in combined than in lidocaine and magnesium groups. Incidence of bradycardia was the same in lidocaine and magnesium groups but was the most in combined group. No statistically significant differences were found between the four studied groups as regarding postoperative side effects.
The combined group and the lidocaine group had lower incidence of postoperative cognitive dysfunction (higher MMSE score) when compared to magnesium group or to control group. However, there was no difference between the combined group and the lidocaine group in postoperative cognitive dysfunction.
Regarding anxiety, statistically significant difference was found at all times postoperative in all studied groups in comparison to control group. Incidence of anxiety in combined group was the lowest at all times. No statistically significant difference between magnesium and lidocaine groups at 6h and 24 hours, but there was statistically significant difference between them at 1w and 4 w where anxiety was lower in lidocaine group.
Depression score was lower in both lidocaine group and combined group when compared to control group at all times postoperative except after 4 weeks postoperative. Depression scores were significantly lower in magnesium group than in control group at all the times. No difference in depression scores between lidocaine and magnesium groups at most of the times. Also there was no difference in depression scores between combined and lidocaine groups at all the times. Depression scores were comparable in the combined group and the magnesium group at most of the times.
Quality of life of patients was the best in the combined group and in the lidocaine group. No differences between the combined group and the lidocaine group. Quality of life of patients in the magnesium group were significantly better than patients in the control group as regarding physical function item only, however no differences were found in the other items.
Numbers of satisfied patients were statistically significantly higher in combined and lidocaine groups than in control or magnesium groups.
In conclusion,
We found a synergistic effect of the combination of lidocaine and magnesium sulfate in peri-operative pain, making this yet another potential strategy in the multimodal analgesia regimen. More studies in the medium and long term are necessary for better evaluation of the impact of intravenous, nonopioid adjuvants. This combination reduces analgesic consumption, anxiety, depression, and improved overall health up to 3 months after a single infusion dose.