With great anticipation, we read the study by Maheshwari et al.1  and congratulate the authors for a prominently featured article and infographic on the cover of Anesthesiology. We were interested to see that the results of the study suggest that multimodal analgesia, as administered in this protocol, did not benefit participants’ postoperative quality of recovery, opioid consumption, or pain scores after spine surgery. However, with closer scrutiny, we found several elements of the experimental design that were, perhaps, not well-suited to properly explore the study aim and hypothesis in the context of the primary outcome measure. Surprisingly, the authors did not control for intraoperative analgesic strategies such as surgeon-administered epidural analgesia or local anesthetic wound infiltration. Even more concerning, the authors did not control for postoperative multimodal analgesic medications. Postoperative acetaminophen, gabapentin, tramadol, and ketorolac were not limited to the experimental group. In nearly identical numbers, both groups consumed the same postoperative analgesics for the first 48 h after surgery.

The authors found it surprising that the multimodal analgesic regimen proved ineffective in their patients. We politely disagree. Measuring the Quality of Recovery score 3 days after surgery, as well as other postsurgical pain measures, is confounded when both the experimental and control groups received multimodal analgesics during and after surgery. If the goal of the study was to examine the quality of recovery outcome 3 days after a single preoperative dose of acetaminophen and gabapentin with intraoperative ketamine and lidocaine infusions, then both groups should have received identical multimodal-free medication regimens after surgery. If, however, the objective was to examine multimodal versus opioid-only strategies, the control group should have been restricted from nonopioid analgesics during the pre-, intra-, and postoperative periods.

We recognize the challenge in designing studies that restrict therapies that are possibly beneficial to patients. However, we believe that the data presented in this study are inadequate to support the authors’ conclusion that “this combination of four analgesics was not beneficial for patients having multilevel spine surgery.” We agree with the authors that multimodal analgesia should be formally tested in each clinical context but disagree that the data presented here suggest a lack of benefit in spine surgery patients.

Dr. Johnson has previously received financial support from the American Board of Anesthesiology (Raleigh, North Carolina), Applied Medical Visualizations (Salt Lake City, Utah), IARS – Anesthesia & Analgesia Editorial Board (San Francisco, California), and the American Society of Anesthesiologists (Schaumburg, Illinois); however, none of these funding sources had any direct conflict of interest pertaining to the content of this letter. The other authors declare no competing interests.

1.
Maheshwari
K
,
Avitsian
R
,
Sessler
DI
,
Makarova
N
,
Tanios
M
,
Raza
S
,
Traul
D
,
Rajan
S
,
Manlapaz
M
,
Machado
S
,
Krishnaney
A
,
Machado
A
,
Rosenquist
R
,
Kurz
A
.
Multimodal analgesic regimen for spine surgery: A randomized placebo-controlled trial.
Anesthesiology
.
2020
;
132
:
992
1002