Perioperative Local Infiltration of Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail Reduces Opioid Use and Length-of-Stay Following Spinal Fusion Surgery

Introduction: Ropivacaine-Epinephrine-Clonidine-Ketorolac (RECK) cocktail can improve postoperative pain control in patients undergoing total knee arthroplasty and lumbar decompression surgery. We aimed to investigate whether RECK is effective at reducing opioid requirements, length-of-stay, and long-term opioid utilization following spinal fusion surgery.

Methods: In this single-institution retrospective cohort study of patients undergoing spinal fusion surgery from June 2019-June 2021, we utilized multivariable regression to analyze whether age, sex, diabetes, tobacco use, chronic steroids, disease-modifying antirheumatic drugs, body mass index, levels fused, use of percutaneous techniques, fusion regions, use of interbody or corpectomy cages, operative length, intraoperative durotomy, preoperative opioid use, elective nature of cases, RECK administration, and whether surgery was performed for trauma or spinal tumors were associated with postoperative opioid utilization, length-of-stay, readmissions within 90 days, and complications. Levels of surgery were re-classified to 1 (1 level), 2 (2-3 levels), and 3 (4+ levels).

Results: Of 162 patients meeting study criteria, 49 received RECK (30.2%). Decreased total and daily inpatient opioid oral morphine equivalents was only significantly associated with RECK administration in multivariable linear regression (B=-159.3, p=0.002 and B=-27.9, p=0.01, respectively). Length-of-stay duration of 3 days or less was associated with RECK administration (OR 4.1, 95% CI:1.4–13.2, p=0.01) and was negatively associated with surgery levels (OR 0.4, 95% CI:0.2–0.7, p=0.005) and durotomy (OR 0.02, 95% CI:0.0009–0.1, p< 0.001). RECK was not significantly associated with readmissions within 90 days or complications. Prolonged opioid utilization >90 days was associated with opioid use (OR 3.8, 95% CI:1.8–8.3, p< 0.001) and was negatively associated with RECK administration (OR 0.4, 95% CI:0.2–0.9, p=0.04) and fusion constructs extending to the pelvis (OR 0.07, 95% CI: 0.004-0.4, p=0.02).

Conclusion : In patients undergoing spinal fusion, RECK can reduce postoperative opioid utilization, including prolonged utilization at 3-months postoperatively and was not associated with increased readmissions or complications.