**8.1 Multimodal analgesia**

Multimodal analgesia (MMA) includes more than one pain-control modality (pharmacological and nonpharmacological)(**Figure 5**) to achieve optimal analgesia [26]. The additive or synergistic effects of these modalities act on various sites of the pain pathways to enhance pain control. It also helps to minimize any side effects that are associated with a single agent. Pharmacological agents include acetaminophen, nonsteroidal anti-inflammatories, steroids, narcotics, N-methyl-D-aspartate (NMDA) receptor antagonists (ketamine or dextromethorphan), and antiseizure medications (gabapentinoids, particularly gabapentin and pregabalin). Nonpharmacological adjuncts include immersive virtual reality, acupuncture, injections (trigger point injections and epidural steroid injections), other neuroexperimental modalities, cryotherapy, transcutaneous electrical nerve stimulation units, and various regional analgesia techniques.

The regional analgesia (RA) techniques play an essential role as an adjunct to MMA by interrupting pain transmission and sensitization (central and peripheral) processes. MMA also includes pre-emptive analgesia, which also plays an essential role in decreasing peripheral and central sensitization. Various studies recommend the MMA as the best approach for any postsurgical pain. Unaddressed postsurgical

**Figure 5.** *Multimodal analgesia components.*

pain initiates several neuroendocrine stress responses - leading to secretion of various hormones [27] like ACTH, catecholamines, and ADH - resulting in an increase in blood pressure, heart rate, prolonged recovery, and infections.
