Association of perioperative intravenous lidocaine with postoperative pain and opioid use in spine surgery: a systematic review and meta-analysis of randomized clinical trials

Abstract

Background: Effective pain management in spine surgery remains a challenge, often leading to excessive opioid consumption and associated adverse effects. While intravenous lidocaine is a promising analgesic adjunct, current evidence regarding its efficacy specifically in spine surgery is conflicting, necessitating an updated systematic review and meta-analysis. Objective: To assess whether perioperative intravenous lidocaine reduces postoperative pain and opioid use in spine surgery. Methods: This systematic review and meta-analysis followed PRISMA guidelines and included randomized controlled trials comparing perioperative intravenous lidocaine with multimodal analgesia versus standard care in adult patients undergoing spine surgery. Searches were conducted in MEDLINE, Embase, and CENTRAL through February 2026. Primary and secondary outcomes included. Primary and secondary outcomes included postoperative pain scores at 0, 2, 6, and 24 hours (assessed via VAS or NRS), postoperative opioid consumption (fentanyl and 48-hour morphine use), postoperative nausea and vomiting (PONV), length of hospital stay (LOS), patient satisfaction, postoperative mental and physical function, and operative time. Random-effects models generated pooled effect estimates with 95% confidence intervals (CI). Heterogeneity was assessed with I². Sensitivity analyses included leave-one-out procedures. Risk of bias in the included studies was assessed using the RoB 2 tool. Results: We included 1,360 patients from 14 randomized clinical trials. Meta-analysis results showed that perioperative intravenous lidocaine was associated with reduced postoperative pain at 0 hours [mean difference (MD), -1.22; 95% CI, -1.91 to -0.54; P < .001; I² = 46.5%], 2 hours (MD, -1.88; 95% CI, -2.94 to -0.82; P < .001; I² = 72.2%), 6 hours (MD, -1.92; 95% CI, -3.55 to -0.29; P = .021; I² = 92.3%), and 24 hours (MD, -2.10; 95% CI, -3.28 to -0.92; P < .001; I² = 83.1%], and with lower morphine use at 48 hours postoperatively (MD, -8.95; 95% CI, -16.43 to -1.46; P = .019; I² = 95.8%). Intravenous lidocaine was also associated with improved mental function [standardized mean difference (SMD), -0.74; 95% CI, -1.06 to -0.42; P < .001; I² = 42.0%) and higher patient satisfaction (MD, -0.48; 95% CI, -0.81 to -0.16; P = .003; I² = 0.0%). No significant differences were observed for the remaining outcomes. Overall, 71.4% of trials were rated as low risk of bias, while 28.6% presented some concerns. The certainty of evidence ranged from low to moderate according to the GRADE approach, mainly due to statistical heterogeneity. Conclusion: Perioperative intravenous lidocaine appears to be an effective adjunct for pain management in spine surgery, reducing postoperative pain up to 24 hours, opioid consumption, and improving mental function and patient satisfaction. These findings support its role within multimodal analgesia strategies, although factors such as dosing, timing of administration, and clinical implementation may influence the magnitude of benefit.