Background: Postoperative pain after spine surgery has traditionally been managed with opioids, but opioid-related adverse effects, complications, and long-term dependence have driven interest in opioid-sparing strategies. Multimodal analgesia (MMA) and Enhanced Recovery After Surgery (ERAS) pathways aim to improve perioperative pain control while reducing opioid exposure, yet the evidence base remains difficult to apply due to heterogeneous protocols and inconsistent reporting. This review maps current MMA approaches in adult spine surgery, summarizes outcomes, and identifies implementation and research gaps.
Methods: This review synthesized English-language clinical studies, case reports, and guidelines published from January 2010 through July 2025 evaluating perioperative MMA strategies in adult spine surgery. A comprehensive search was performed across PubMed, Embase, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. Studies were excluded if they involved pediatric populations, non-surgical spine pain, single-agent analgesia, or non-English publications. Records were screened by title/abstract followed by full-text review, with discrepancies resolved by consensus. Extracted data included surgical type, MMA components, and outcomes including pain scores, opioid consumption, mobilization time, length of stay, and complications.
Results: MMA protocols commonly combined systemic non-opioid agents with regional techniques, targeting multiple pain pathways to reduce opioid requirements. Across studies, multimodal regimens were frequently associated with lower inpatient opioid use and earlier mobilization, with some cohorts demonstrating shorter hospital stays, particularly when MMA was integrated into ERAS pathways. Regional adjuncts such as ESPB showed more consistent opioid-sparing benefits in invasive procedures (e.g., lumbar fusion and multilevel surgery), whereas systemic MMA alone produced mixed effects in randomized trials. Substantial variability in medication selection, dosing, timing, and block technique limited cross-study comparisons, and post-discharge opioid use and long-term outcomes were rarely reported. High-risk populations (obesity, obstructive sleep apnea, chronic opioid use) were underrepresented, reducing generalizability and limiting guidance for individualized perioperative planning.
Conclusions: MMA in adult spine surgery is a promising opioid-sparing approach, especially when tailored to surgical invasiveness and combined with ERAS protocols, but outcomes remain inconsistent due to protocol heterogeneity and limited long-term follow-up. Future research should prioritize standardized, procedure-specific MMA bundles, bundle-versus-bundle comparisons, inclusion of high-risk populations, and consistent reporting of short- and long-term outcomes. Strengthening implementation science and ERAS compliance tracking will be critical to translating MMA evidence into reproducible, real-world spine surgery pathway
Methods: This review synthesized English-language clinical studies, case reports, and guidelines published from January 2010 through July 2025 evaluating perioperative MMA strategies in adult spine surgery. A comprehensive search was performed across PubMed, Embase, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. Studies were excluded if they involved pediatric populations, non-surgical spine pain, single-agent analgesia, or non-English publications. Records were screened by title/abstract followed by full-text review, with discrepancies resolved by consensus. Extracted data included surgical type, MMA components, and outcomes including pain scores, opioid consumption, mobilization time, length of stay, and complications.
Results: MMA protocols commonly combined systemic non-opioid agents with regional techniques, targeting multiple pain pathways to reduce opioid requirements. Across studies, multimodal regimens were frequently associated with lower inpatient opioid use and earlier mobilization, with some cohorts demonstrating shorter hospital stays, particularly when MMA was integrated into ERAS pathways. Regional adjuncts such as ESPB showed more consistent opioid-sparing benefits in invasive procedures (e.g., lumbar fusion and multilevel surgery), whereas systemic MMA alone produced mixed effects in randomized trials. Substantial variability in medication selection, dosing, timing, and block technique limited cross-study comparisons, and post-discharge opioid use and long-term outcomes were rarely reported. High-risk populations (obesity, obstructive sleep apnea, chronic opioid use) were underrepresented, reducing generalizability and limiting guidance for individualized perioperative planning.
Conclusions: MMA in adult spine surgery is a promising opioid-sparing approach, especially when tailored to surgical invasiveness and combined with ERAS protocols, but outcomes remain inconsistent due to protocol heterogeneity and limited long-term follow-up. Future research should prioritize standardized, procedure-specific MMA bundles, bundle-versus-bundle comparisons, inclusion of high-risk populations, and consistent reporting of short- and long-term outcomes. Strengthening implementation science and ERAS compliance tracking will be critical to translating MMA evidence into reproducible, real-world spine surgery pathway