A commentary on ‘Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial’

Dear Editor,

The recent research paper ‘Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial’ published in the International Journal of Surgery caught our attention¹. Multimodal cocktails are widely used for local infiltration analgesia following various types of surgeries. However, there is currently no consensus on which drugs to use. Shrestha et al. conducted a randomized, double-blind, and prospective study analyzing the efficacy of combining betamethasone with ropivacaine for postoperative pain management after spinal laminectomy and laminoplasty procedures. This study analyzed 116 patients who underwent laminectomy or laminoplasty between September 2021 and March 2022. Patients were randomly assigned to two groups in a 1:1 ratio. The Betamethasone-Ropivacaine (BR) group received a local infiltration of betamethasone with ropivacaine and saline for pain management, while the Ropivacaine (R) group received a local infiltration of ropivacaine and saline. The results indicated that the BR group had a lower cumulative opioid consumption within 48 h postsurgery. The visual analog scale score at movement and rest was significantly lower until 3 months and 6 weeks, respectively. It was concluded that local infiltration analgesia with betamethasone and ropivacaine provides better postoperative pain management following laminoplasty and laminectomy, compared to ropivacaine alone. This study innovatively utilized the long-acting corticosteroid, betamethasone, providing a meaningful option for selecting multimodal cocktail drugs. Moreover, the use of a double-blind, randomized design has made the research results more credible. While profoundly appreciating this study’s rigorous efforts and valuable contributions, some constructive suggestions are also offered for further refinement.

Firstly, this study adopts a randomized, double-blind grouping method to control bias, which is commendable. However, it is a single-center study with a relatively small sample size, leading to single-center bias². For instance, this study was conducted at one of China’s top hospitals, with researchers being renowned neurosurgeons whose high technical expertise could influence patients’ postoperative pain experiences, potentially limiting the generalizability of the study results. By adopting a multicenter research model, the sample size can be significantly expanded to include patients from different regions, which not only helps to enhance research efficiency but also facilitates increased interaction and exchange among researchers from various areas³.

Secondly, potential confounding factors. The study is commendable for adjusting several vital covariates, including sex, age, BMI, and duration of surgery. However, considering other potential confounding factors such as blood loss during surgery and postoperative rehabilitation protocols could further enhance the reliability of the research findings⁴.

Finally, the location and timing of local infiltration injection. The study determined that the injection time is before the closure of the incision, which provides a reliable basis for clinical application and is worth learning. However, previous studies have found that multimodal analgesic cocktails can produce different therapeutic effects due to differences in injection sites, timing, and drug composition^5,6. In future research, if intraoperative fluoroscopy is used to ensure the same injection site, it would better reflect the significance of the study.

Overall, this study has significant implications for selecting multimodal analgesic cocktail drugs. Local infiltration analgesia is a simple, minimally invasive, and effective postoperative pain management technique. This method is widely used for various surgeries, not exclusively for laminoplasty or laminectomy, but also for total knee and hip arthroplasty and others. A superior multimodal cocktail formulation could effectively enhance the postoperative pain experience for patients across different types of surgeries, facilitate early recovery, and substantially increase patient satisfaction with the operation. Our suggestions are merely aimed at further refining an already outstanding study. We eagerly anticipate more innovative work from the authors in the future.

Ethical approval

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Consent

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Sources of funding

This work was supported by a grant from the Zhejiang Provincial Administration of Traditional Chinese Medicine (No.2021ZX009), 2024 ‘spearhead’ and ‘leading wild goose’ research and development plan of Zhejiang Province (2024C03213).

Author contribution

C.Z., X.Y., and L.W.: put forward the conception and design of the study; C.Z. and X.Y.: collected and analyzed the data; C.Z. and X.Y.: writed the paper. All the authors drafted and revised the paper. All authors read and approved the final manuscript.

Conflicts of interest disclosure

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Research registration unique identifying number (UIN)

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Guarantor

Lianguo Wu accept full responsibility for the work and/or the conduct of the study.

Data availability statement

This manuscript is a comment. Do not need data availability statement. But all the data during the current study are publicly available.

Provenance and peer review

Not applicable.