Table 12: Postoperative (+/- before end of surgery) lumbar epidural opioid versus placebo or systemic analgesia

Study

n treatment/

Control

Comparison

Supplemental analgesic

VAS scores and type of pain, where specified

Time to first analgesic request

Use of supplemental analgesic

Other important outcomes

Hendolin 1996

(LoE 1)

10/11

IM saline pre-op and postop epidural morphine (4 mg) + 3 mg 10 h later (EpOp) vs. IM saline pre-op and epidural saline postop and 10 h later (Cont)

Postop: PCA-fentanyl, IV

EpOp superior during the 1^st 6 h (p<0.001), but NS at 6–20 h

__

Mean PCA-fentanyl consumption: EpOp superior during the 1^st 6 h (p<0.01) and at 14–20 h; cumulative fentanyl consumption over 20 h: EpOp superior (p<0.01)

PONV

NS

Complications

Pruritus, urinary retention, respiratory depression: NS

Klasen 1999

(LoE 1)

10/10

Postop epidural boluses of morphine (2.5 mg), on request (EpOp) vs. PCA-morphine, IV only (Cont)

Not reported

NS over 24 h postop

__

Morphine consumption: EpOp superior at 24 h (mean EpOp requirement was 17% of Cont requirement; p value not reported)

PONV

NS

Complications

Dizziness, pruritus: NS

Nielsen 1989

(LoE 1)

9/10

Epidural morphine (2–6 mg), 3 times daily for 10 days (EpOp) vs. IM ketobemidone for 5 days (Cont)

Postop: oral paracetamol (1 g), 4 times daily

EpOp superior on days 1 and 10 (p<0.05, in both cases)

__

Not reported

PONV

3 patients vs. 1

Functional outcomes

Range of motion: NS

Complications

Pruritus: 1 patient vs. 0; urinary retention: 2 patients vs. 0

Weller 1991

(LoE 2)

15/15

Epidural morphine (3 ml 0.1%) + saline (2 ml), 1 h before end of surgery + 0.1% morphine (2 ml) in recovery room if required, repeated 12 h later (EpOp) vs. IV morphine in recovery room until VAS<4 then PCA-morphine IV (Cont)

Postop: PCA-morphine, IV

VAS score for pain at time of assessment (i.e. at 6, 18 and 24 h):

NS; VAS score for pain (recalled) since time of last assessment: EpOp superior (p<0.05)

__

Loading dose of morphine required for VAS<4 in recovery room: EpOp superior (p<0.05); 24 h total morphine consumption: EpOp superior (p<0.05)

PONV

NS

Complications

Sedation: NS; pruritus: Cont superior (p<0.05); minimum respiratory rate: Cont superior (p<0.05), but no clinically important respiratory depression in EpOp

*Study*	*n treatment/* *Control*	*Comparison*	*Supplemental analgesic*	*VAS scores and type of pain, where specified*	*Time to first analgesic request*	*Use of supplemental analgesic*	*Other important outcomes*
Hendolin 1996 (LoE 1)	10/11	IM saline pre-op and postop epidural morphine (4 mg) + 3 mg 10 h later (EpOp) *vs.* IM saline pre-op and epidural saline postop and 10 h later (Cont)	Postop: PCA-fentanyl, IV	EpOp superior during the 1^st 6 h (p<0.001), but NS at 6–20 h	__	Mean PCA-fentanyl consumption: EpOp superior during the 1^st 6 h (p<0.01) and at 14–20 h; cumulative fentanyl consumption over 20 h: EpOp superior (p<0.01)	PONV NS Complications Pruritus, urinary retention, respiratory depression: NS
Klasen 1999 (LoE 1)	10/10	Postop epidural boluses of morphine (2.5 mg), on request (EpOp) *vs.* PCA-morphine, IV only (Cont)	Not reported	NS over 24 h postop	__	Morphine consumption: EpOp superior at 24 h (mean EpOp requirement was 17% of Cont requirement; p value not reported)	PONV NS Complications Dizziness, pruritus: NS
Nielsen 1989 (LoE 1)	9/10	Epidural morphine (2–6 mg), 3 times daily for 10 days (EpOp) *vs.* IM ketobemidone for 5 days (Cont)	Postop: oral paracetamol (1 g), 4 times daily	EpOp superior on days 1 and 10 (p<0.05, in both cases)	__	Not reported	PONV 3 patients vs. 1 Functional outcomes Range of motion: NS Complications Pruritus: 1 patient vs. 0; urinary retention: 2 patients vs. 0
Weller 1991 (LoE 2)	15/15	Epidural morphine (3 ml 0.1%) + saline (2 ml), 1 h before end of surgery + 0.1% morphine (2 ml) in recovery room if required, repeated 12 h later (EpOp) *vs.* IV morphine in recovery room until VAS<4 then PCA-morphine IV (Cont)	Postop: PCA-morphine, IV	VAS score for pain at time of assessment (i.e. at 6, 18 and 24 h): NS; VAS score for pain (recalled) since time of last assessment: EpOp superior (p<0.05)	__	Loading dose of morphine required for VAS<4 in recovery room: EpOp superior (p<0.05); 24 h total morphine consumption: EpOp superior (p<0.05)	PONV NS Complications Sedation: NS; pruritus: Cont superior (p<0.05); minimum respiratory rate: Cont superior (p<0.05), but no clinically important respiratory depression in EpOp