Orthopedic surgeons at Andrews Sports Medicine and Orthopaedic Center in Birmingham are using a multimodal pain management regimen in certain surgeries to reduce pain and lessen patient recovery time. The principle of the therapy is to target several phases along the pain pathway to control pain more effectively with fewer side effects.
Surgeon Benton A. Emblom, MD says they have been using the therapy for about three months with good success in soft-tissue procedures such as sports hernia repairs, and in orthopedic surgeries such as knee and shoulder replacements. “Basically, multimodal pain management is essentially the use of different types of anesthesia used at once. The concept became popular when we developed the ability to use a tri-cocktail to manage a patient’s pain after a surgical procedure,” he says. “The patient gets general anesthesia, pre-op pain relieving medications, anti-inflammatory drugs, and then an intra-operative anesthesia.”
That intra-operative medicine, a new drug called Exparel, is the key to the success of this pain management system. “The issue in the early stages of trying to develop techniques for this regimen was with the medicines we were using,” Emblom says. “We could only use a certain amount of each drug, and you needed higher doses of some to be effective. Toxicity could potentially be a problem in those cases, and a lot of the medicines couldn’t be used together because of the chance of some sort of adverse reaction or incompatibility. Exparel is an extremely long-acting local anesthetic that’s like a multi-day acting lidocaine.”
Exparel is long-acting because it is housed in a lipid layer, like a layer of fat, so when it is injected in the soft tissue, it is hidden in fat globules, “kind of like Italian dressing,” Emblom says. “The body is aqueous so anything that’s water soluble will dissolve and be metabolized. That’s why most of the medicines we used didn’t last long. This medicine is an extremely long-acting local anesthetic that can be used in combination with other medications, because it doesn’t interact and is shielded in its liposomal form.”
According to Emblom, the standard procedure for using multimodal pain management during surgery begins in pre-op. “In pre-op, we give the patient an oral pain medication – a narcotic – and also an oral anti-inflammatory drug. We also inject a medication that reduces bleeding at the time of surgery, because bleeding can generate pain as well,” he says.
Next, the patient receives a peripheral nerve block that controls the sensation to the surgical area, followed by general anesthesia to put the patient to sleep. “While in surgery, we use the local soft tissue block which is the new cocktail of these different meds that allows for decreased pain, decreased inflammation, decreased bleeding, and allows patients to wake up without any discomfort,” Emblom says. “The effects of the regimen have been lasting anywhere from three to five days. By the time the patient’s discomfort creeps back up, they’re already up and eating and able to take pain medication as needed. Because they don’t need as many of the narcotic pain relievers, they have less chance of the side effects like nausea, vomiting and constipation caused by narcotic drugs.”
Fewer drugs also means less effect on a patient’s cognitive function which means they are not altered and get up and out of bed sooner. “They are able to begin rehabilitation sooner and are able to rehab better; therefore, they can go home sooner,” Emblom says. “They’re not having pain so they are able to function and walk and can recover in the comfort of their own homes with out-patient physical therapy. This concept allows people to get back to life quicker with less pain.”
Risks are minimal with this treatment, Emblom points out. “The main risk is an unknown allergy to one of the medications, but most of the medicines are common drugs and most people would know if they are allergic,” he says. “If a patient is allergic to one or two of the medicines, we just remove those ingredients from the cocktail. The benefits for patients include diminished pain levels, decreased use of narcotics, and a reduced risk of dependence on pain medications.”
Multimodal pain management is also being used in some general surgery applications and in plastic surgery, but it is in orthopedic surgery where the technique has evolved. “We have fine-tuned it, particularly in regards to the sequence of administration, the components that we administer, and the location of where we inject them. That’s what we really have revolutionized in our practice in the last few months,” Emblom says. “This is now part of our standard protocol with knee and shoulder replacements.”
Emblom has had a handful of patients with invasive knee surgeries who return to his office after two weeks and say they haven’t had any pain. “I think that in those cases the different meds in combination tricked the nerves, masking the stimulus for pain,” he says. “I’ve had half-dozen patients who had no pain after two weeks and never even took a pain pill. Those cases are not the norm but are the ultra-success stories, the ones that surprise you. That’s the kind of thing you hope for.”