Archive October 2018 XIX, No. 10

Yes, You Can Perform Opioid-Sparing Surgery

How to go easy on the prescription painkillers - yet still control your patients' pain.

Jeannette Sabatini, Associate Editor


Scott A. Sigman, MD
OPIOID ALTERNATIVES Scott A. Sigman, MD, the "opioid-sparing orthopedic surgeon," relies almost exclusively on non-opioid options to control surgical pain.

The self-proclaimed "opioid-sparing orthopedic surgeon" practices what he preaches. And, boy, does he preach what he practices.

"I have good news: Surgery does not require opioids," says Scott A. Sigman, MD, of Orthopedic Surgical Associates of Lowell (Mass.). "It has been an arduous journey, but I sense there is a paradigm shift occurring on the management of post-operative pain with opioid alternatives."

Dr. Sigman points to a patient who's 12 days out from her total knee replacement who hasn't required a single post-op narcotic pill. She has full knee extension and 115 degrees of knee flexion, he says. And she walked into Dr. Sigman's office for a post-op visit with a cane.

The woman had an Exparel (bupivacaine liposome injectable suspension) field block at the time of surgery and an iovera cryotherapy treatment 4 days before surgery. That's it? Pre-operative iovera cryotherapy treatment followed by intraoperative Exparel? Yes, says Dr. Sigman, that one-two punch gets almost all of his patients through the "storm of pain" that closes in the first 72 hours after surgery.

Brandon Winchester, MD
AROUND THE BLOCK Brandon Winchester, MD, performs thousands of blocks a year.

Cryotherapy is the latest technique Dr. Sigman has incorporated into his opioid-sparing knee surgery. iovera is a cryotherapy device — he calls it his "Freeze Ray Gun" — that temporarily freezes the axons of sensory nerves. The axons redevelop over 6 to 8 weeks after the stimulus of pain from surgery has resolved, says Dr. Sigman, who performs cryotherapy at his surgery center a few days before surgery followed by an Exparel field block at the time of surgery.

Exparel gives excellent initial pain relief followed by long-term pain relief from iovera, he says.

"We use saws and drills on a patient and it hurts like heck, but if you can get them to a softer landing through that first 3 days afterwards," he says, "the pain is not as bad as it was when it first happened because all of the chemicals that create that pain stimulus are washed out of the system."

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