Phase 4 Study in Adult Subjects Undergoing Posterior Lumbar Spine Surgeries
Condition: Postoperative Pain Management
MeSH terms: Pain, Postoperative
Intervention: EXPAREL and Bupivacaine; Standard of Care
Intervention description: Drug: EXPAREL and Bupivacaine HCl 0.5%; Standard of Care
Intervention MeSH terms: Bupivacaine
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 65.0
Sex: All
Minimum age: 18 Years
Maximum age: 75 Years
Healthy volunteers: No

Summary:

      Primary Objective: The primary objective of this study is to compare postsurgical opioid
      consumption through 72 hours postsurgery in patients receiving local infiltration analgesia
      (LIA) with EXPAREL and bupivacaine HCl (EXPAREL group) with that of patients receiving
      standard of care (SOC) (control group) in adult subjects undergoing posterior lumbar spine
      surgeries where both groups are receiving a multimodal pain regimen.

      Secondary Objectives: The secondary objectives of this study are to:

        1. Compare safety and effectiveness outcomes following LIA with EXPAREL and bupivacaine
           hydrochloride (HCl) versus SOC in adult subjects undergoing posterior lumbar spine
           surgeries through 72 hours, including time to first opioid and opioid-related adverse
           events (ORAEs).

        2. Compare health outcomes following LIA with EXPAREL and bupivacaine hydrochloride (HCl)
           versus SOC in adult subjects undergoing posterior lumbar spine surgeries, including
           discharge readiness, hospital (or other facility) length of stay (LOS), discharge
           disposition, hospital readmissions, and health service utilization.
    

Eligibility criteria:

        Inclusion Criteria:

          1. 18-75 years old at the time of screening.

          2. Primary surgical indication is related to spinal degenerative disease, including any
             of the following:

               1. Spinal stenosis

               2. Spondylolisthesis

               3. Radiculopathy/instability disc disorders

               4. Degenerative disc disease

          3. Medically cleared for elective spine surgery.

          4. Scheduled to undergo:

               1. Elective (i.e., not emergency)

               2. Lumbosacral (i.e., L1-S1)

               3. Posterior approach with posterior instrumentation

          5. Cohort 1 - Open only:

             Open or mini-open surgical technique with:

               1. 1-level (i.e., spanning 2 vertebrae) or 2-level (i.e., spanning 3 contiguous
                  vertebrae)

               2. Primary fusion or revision fusion

               3. Open or mini-open surgical technique

          6. Cohort 2 - Tubular or percutaneous cohort only:

               1. 1-level (i.e., spanning 2 vertebrae) or 2-level (i.e., spanning 3 contiguous
                  vertebrae)

               2. Primary fusion or revision fusion

               3. Tubular or percutaneous surgical technique

          7. Cohort 3 - Lumbar decompression without fusion outpatient cohort only:

               1. Radiculopathy

               2. Spinal stenosis

          8. Able to provide informed consent and adhere to all study assessments and visit
             schedule

        Exclusion Criteria:

          1. Serious spinal pathology determined by Investigator that might meaningfully affect
             postsurgical outcomes, including any of the following:

               1. Suspected cauda equina syndrome (e.g., bowel/bladder involvement)

               2. Infection

               3. Tumor

               4. Fracture

               5. Systemic inflammatory spondyloarthropathy

          2. Contraindication to local anesthesia according to the clinical judgment of the
             Investigator and based on the EXPAREL label.

          3. Patients who most likely will require patient-controlled analgesia (PCA) pumps in
             EXPAREL group.

          4. Anterior surgical approaches, including any of the following:

               1. Anterior lumbar interbody fusion (ALIF)

               2. Oblique lumbar interbody fusion (OLIF)

               3. Anterior-posterior or 360º fusion

          5. Lateral surgical approaches, including any of the following:

               1. Extreme lateral interbody fusion (XLIF)

               2. Direct lateral interbody fusion (DLIF)

          6. High-dose presurgical opioid use:

             a) Mean daily intake greater than 100 mg mEq PO in the past 30 days

          7. Known allergy, hypersensitivity, or contraindication to any of the following study
             medications:

               1. Bupivacaine

               2. EXPAREL

               3. Tylenol (acetaminophen)

               4. Robaxin

               5. 2 or more NSAIDs

               6. 2 or more gabapentinoids

               7. 2 or more rescue opioids (e.g., oxycodone, morphine, hydromorphone)

               8. 2 or more medications for postoperative nausea, vomiting, or pruritus (e.g.,
                  dexamethasone, ondansetron)

          8. History of severely impaired renal or hepatic function.

          9. Severe chronic pain that requires analgesic treatment, and in the opinion of the
             principal Investigator, is likely to meaningfully affect postsurgical outcomes.

         10. Subjects that have implanted spinal cord stimulator or intrathecal drug pump.

         11. Any neurologic or psychiatric disorder that might impact postsurgical pain or
             interfere with study assessments per Investigator discretion.

         12. Malignancy in the last 2 years.

         13. History of misuse, abuse, or dependence on opioid analgesics, other prescription
             drugs, illicit drugs, or alcohol as defined in DSM-5 (Diagnostic and Statistical
             Manual of Mental Disorders, Fifth Edition). Dependence or chronic opioid use will be
             defined as use of more than 30 morphine equivalents per day during the prior 90 days.

         14. Currently pregnant, nursing, or planning to become pregnant during the study or within
             1 month after study drug administration.

         15. Body Mass Index < 17 kg/m2 or >44 kg/m2 at screening

         16. Subjects receiving Worker's Compensation for disability or who are involved in other
             litigation related to the spine.

         17. Planned concurrent surgical procedure.

         18. Previous participation in an EXPAREL study.

         19. Administration of any investigational drug within 30 days or 5 elimination half-lives
             of such investigational drug, whichever is longer, prior to study drug administration,
             or planned administration of another investigational product or procedure during the
             subject's participation in this study.

        In addition, the subject might be excluded from the study prior to study drug infiltration
        if one of the following criteria during the surgical procedure is met:

          1. Unable to place planned surgical instrumentation

          2. Poor fixation at the time of surgical instrumentation

        In addition, the subject must be considered an early termination if one of the following
        criteria after the surgical procedure is met:

          1. An incision size >20 cm

          2. Autograft taken from a harvest site other than surgical site (i.e., iliac crest
             autograft)

          3. Intraoperative complications likely to meaningfully affect postsurgical outcomes,
             including any of the following:

               1. Clinically significant and prolonged (i.e., >24 hours) neurologic deficit (e.g.,
                  foot drop)

               2. Dural tear or suspected dural tear requiring bed rest (exception: subject will be
                  allowed if the dural tear is fixed as per SOC of the institution during surgery)

               3. Extensive bleeding (i.e., >1,000 mL blood loss)

               4. Symptomatic epidural hematoma