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Benes GA, Hunsberger JB, Dietz HC, Sponseller PD. Opioid Utilization After Scoliosis Surgery is Greater in Marfan Syndrome Than Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2024; 49:E80-E86. [PMID: 37294802 DOI: 10.1097/brs.0000000000004741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/29/2023] [Indexed: 06/11/2023]
Abstract
STUDY DESIGN Retrospective matched case cohort. OBJECTIVE Compare postoperative opioid utilization and prescribing behaviors between patients with Marfan syndrome (MFS) and adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA Opioids are an essential component of pain management after PSF. However, due to the potential for opioid use disorder and dependence, current analgesic strategies aim to minimize their use, especially in younger patients. Limited information exists on opioid utilization after PSF for syndromic scoliosis. PATIENTS AND METHODS Twenty adolescents undergoing PSF with MFS were matched with patients with AIS (ratio, 1:2) by age, sex, degree of spinal deformity, and the number of vertebral levels fused. Inpatient and outpatient pharmaceutical data were reviewed for the quantity and duration of opioid and adjunct medications. Prescriptions were converted to morphine milligram equivalents (MMEs) using CDC's standard conversion factor. RESULTS Compared with patients with AIS, patients with MFS had significantly greater total inpatient MME use (4.9 vs . 2.1 mg/kg, P ≤ 0.001) and longer duration of intravenous patient-controlled anesthesia (3.4 vs . 2.5 d, P = 0.001). Within the first 2 postop days, MFS patients had more patient-controlled anesthesia boluses (91 vs . 52 boluses, P = 0.01) despite similar pain scores and greater use of adjunct medications. After accounting for prior opioid use, MFS was the only significant predictor of requesting an opioid prescription after discharge (odds ratio: 4.1, 95% CI: 1.1-14.9, P = 0.03). Patients with MFS were also more likely to be discharged with a more potent prescription (1.0 vs . 0.72 MME per day/kg, P ≤ 0.001) and to receive a longer-duration prescription (13 vs . 8 d, P = 0.005) with a greater MME/kg (11.6 vs . 5.6 mg/kg, P ≤ 0.001) as outpatients. CONCLUSION Despite a similar intervention, patients with MFS and AIS seem to differ in their postoperative opioid usage after PSF, presenting an opportunity for further research to assist clinicians in better anticipating the analgesic needs of individual patients, particularly in light of the ongoing opioid epidemic.
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Affiliation(s)
- Gregory A Benes
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Joann B Hunsberger
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD
| | - Harry C Dietz
- Institute of Genetic Medicine, The Johns Hopkins University, Baltimore, MD
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD
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Hammon DE, Chidambaran V, Templeton TW, Pestieau SR. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Paediatr Anaesth 2023; 33:894-904. [PMID: 37528658 DOI: 10.1111/pan.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.
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Affiliation(s)
- Dudley E Hammon
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sophie R Pestieau
- Department of Anesthesiology, Washington National, Washington, DC, USA
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Hozack BA, Kistler JM, Vaccaro AR, Beredjiklian PK. Benzodiazepines and Related Drugs in Orthopaedics. J Bone Joint Surg Am 2022; 104:2204-2210. [PMID: 36223476 DOI: 10.2106/jbjs.22.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants. ➤ The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic. ➤ Benzodiazepines can increase the risk of prolonged opioid use and abuse. ➤ Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications. ➤ Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.
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Affiliation(s)
- Bryan A Hozack
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Makino H, Seki S, Kamei K, Yahara Y, Kawaguchi Y. Efficacy of surgeon-directed postoperative local injection with an analgesic mixture in posterior fusion surgery for adolescent idiopathic scoliosis. BMC Musculoskelet Disord 2022; 23:208. [PMID: 35246097 PMCID: PMC8897906 DOI: 10.1186/s12891-022-05158-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background Severe postsurgical pain in posterior spinal fusion is common. Multimodality analgesia, including opioid-based patient-controlled analgesia (PCA), is commonly used, but opioid-related adverse events such as nausea and vomiting are sometimes a problem. We used a ropivacaine-epinephrine-dexamethasone mixture given as one-time local bilateral submyofascial injections at the operated levels added to conventional multimodality analgesia including PCA for postoperative pain control in one group of patients to confirm whether administration of this mixture reduced postoperative pain and opioid use status post posterior spinal fusion. Methods We retrospectively reviewed 67 consecutive patients who had undergone posterior fusion surgery for adolescent idiopathic scoliosis (AIS), 35 of whom were treated with conventional analgesia that consisted mainly of PCA (control group) and 32 of whom were treated with one-time submyofascial injections of a ropivacaine-epinephrine-dexamethasone mixture (submyofascial injection group) added to conventional multimodality analgesia. We compared postsurgical pain levels and the amount of opioid use over the first 48 h after surgery, as well as physical activity levels and adverse events 2 weeks after surgery. Results Postsurgical pain quantified by a numeric rating scale (1–10) in the submyofascial injection group was significantly lower than that in the control group. The amount of fentanyl use was significantly less in the submyofascial injection group at 24 h, 48 h, and all subsequent periods after surgery. In addition, Walking Recovery Time (WRT) defined as the number of days until the first event of ambulation was significantly less in the submyofascial injection group (3.3 d vs 4.1 d, P = 0.0007)). Laxative use was significantly less in the submyofascial injection group (0.3 times vs 1.3 times, P = 0.02). Conclusions One-time submyofascial injections at the operated levels with a ropivacaine-epinephrine-dexamethasone mixture after spinal fusion surgery reduced pain, opioid consumption, and opioid-related adverse events. This technique can contribute significantly to postoperative analgesia.
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Affiliation(s)
- Hiroto Makino
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Shoji Seki
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Katsuhiko Kamei
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Yasuhito Yahara
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, University of Toyama, Faculty of Medicine, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Controlled Study. J Am Acad Orthop Surg 2021; 29:e1407-e1416. [PMID: 34047723 DOI: 10.5435/jaaos-d-20-01432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/26/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR. METHODS Adult patients undergoing arthroscopic RCR were prospectively enrolled and randomized to one of two groups. The control received our institution's standard-of-care pain protocol, including oxycodone-acetaminophen 5 to 325 mg on discharge. The ketorolac group received the standard-of-care protocol, intravenous ketorolac at the completion of the procedure, and oral ketorolac on discharge. Pain and functional outcome scores and narcotic utilization were recorded three times per day for the first 5 days after surgery. Repeat magnetic resonance imaging was done at least 6 months postoperatively. RESULTS In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7 ± 10.6 years, and 66.7% of patients were male. No differences were observed in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 versus 8.82, P < 0.001). No difference was observed in functional outcome scores at up to 6 weeks postoperatively between the two groups. No difference was observed in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. Twenty-two of 39 patients underwent repeat magnetic resonance imaging at a mean of 7.9 months postoperatively, of which 5 (22%) demonstrated a retear of their rotator cuff. No significant difference was observed between the ketorolac and control groups in the rate of retear (P = 1.00). DISCUSSION Adjunctive ketorolac substantially reduces narcotic utilization after arthroscopic RCR.
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Li Y, Swallow J, Robbins C, Caird MS, Leis A, Hong RA. Gabapentin and intrathecal morphine combination therapy results in decreased oral narcotic use and more consistent pain scores after posterior spinal fusion for adolescent idiopathic scoliosis. J Orthop Surg Res 2021; 16:672. [PMID: 34781972 PMCID: PMC8594153 DOI: 10.1186/s13018-021-02525-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background Gabapentin and intravenous patient-controlled analgesia (PCA) can reduce postoperative pain scores, postoperative opioid use, and time to completing physical therapy compared to PCA alone after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Gabapentin combined with intrathecal morphine has not been studied. The primary purpose of this retrospective study was to evaluate whether perioperative gabapentin and intrathecal morphine provide more effective pain control than intrathecal morphine alone after PSF for AIS. Methods Patients aged 11 to 18 years who underwent PSF for AIS were identified. Patients who received intrathecal morphine only (ITM group) were matched by age and sex to patients who received intrathecal morphine and perioperative gabapentin (ITM+GABA group). The ITM+GABA group received gabapentin preoperatively and for up to 2 days postoperatively. Both groups received oxycodone and the same non-narcotic adjuvant medications. Results Our final study group consisted of 50 patients (25 ITM, 25 ITM+GABA). The ITM+GABA group had significantly lower mean total oxycodone consumption during the hospitalization (0.798 vs 1.036 mg/kg, P<0.015). While the ITM group had a lower mean pain score between midnight and 8 am on POD 1 (2.4 vs 3.7, P=0.026), pain scores were significantly more consistent throughout the postoperative period in ITM+GABA group. The ITM+GABA group experienced less nausea/vomiting (52% vs 84%, P=0.032) and pruritus (44% vs 72%, P=0.045). Time to physical therapy discharge and length of hospital stay were similar. Conclusion Addition of gabapentin resulted in reduced oral opioid consumption and more consistent postoperative pain scores after PSF for AIS. The patients who received intrathecal morphine and gabapentin also experienced a lower rate of nausea/vomiting and pruritus. Trial registration All data was collected retrospectively from chart review, with institutional IRB approval. Trial registration is not applicable.
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Affiliation(s)
- Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Jennylee Swallow
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Christopher Robbins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Aleda Leis
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca A Hong
- Department of Anesthesiology, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Drive, SPC 4245, Ann Arbor, MI, 48109-4245, USA.
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Johnson MA, Andras LM, Andras LE, Ellington MD, Upasani VV, Shah AS. What's New in Pain Management for Pediatric Orthopaedic Surgery. J Pediatr Orthop 2021; 41:e923-e928. [PMID: 34469397 DOI: 10.1097/bpo.0000000000001956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE Level IV-literature review.
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Affiliation(s)
- Mitchell A Johnson
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Matthew D Ellington
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX
| | | | - Apurva S Shah
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Introduction of an enhanced recovery pathway results in decreased length of stay in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion: A description of implementation strategies and retrospective before-and-after study of outcomes. J Clin Anesth 2021; 75:110493. [PMID: 34482261 DOI: 10.1016/j.jclinane.2021.110493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE This study assessed whether implementation of an enhanced recovery-based pathway decreased length of stay without increasing readmissions among patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. DESIGN Retrospective observational before-and-after study. SETTING A tertiary children's hospital. PATIENTS A total of 117 patients were studied, 78 in the pre-intervention group and 39 in the post-intervention group. All patients underwent posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) in the same institution with one of two spine surgeons. Age, sex, American Society of Anesthesiologists physical status, and Cobb angle were comparable between the two groups. INTERVENTIONS Between the pre- and post-intervention groups an enhanced recovery protocol was developed. The pathway included standardized use of nonopioid analgesics, proactive transition to oral analgesics, scheduled antiemetics, plans for diet advancement, and specific physical therapy goals. MEASUREMENTS Outcome measurements included hospital length of stay, cumulative opioid doses in the first two postoperative days, and time to discontinuation of urinary catheter and patient-controlled analgesia. Postoperative emergency department visits, hospital readmissions and chronic pain management referrals were also measured. Pain scores on postoperative days one through four were recorded. MAIN RESULTS Hospital length of stay decreased from 4.6 days to 3.8 days. Patient-controlled analgesia (PCA) was discontinued one day earlier on average following pathway implementation. Average cumulative postoperative opioid use, in morphine equivalents, decreased in the first two postoperative days from 2.5 to 2.2 mg/kg. There was no change in hospital readmission rate or postoperative chronic pain referral. CONCLUSIONS Patients undergoing PSF for AIS experienced shorter hospital stays without increased readmissions following the implementation of an enhanced recovery pathway. Development of this pathway required buy-in from multiple stakeholders and significant coordination among services. The principles used to develop this pathway may be applied in other institutions and to other patient populations using the model outlined here.
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Pennington Z, Cottrill E, Lubelski D, Ehresman J, Lehner K, Groves ML, Sponseller P, Sciubba DM. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. J Neurosurg Pediatr 2021; 27:225-238. [PMID: 33254141 DOI: 10.3171/2020.7.peds20444] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery. METHODS The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores. RESULTS Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences. CONCLUSIONS The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.
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Affiliation(s)
| | | | | | | | | | | | - Paul Sponseller
- 2Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis. Paediatr Drugs 2020; 22:575-601. [PMID: 33094437 DOI: 10.1007/s40272-020-00423-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.
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Abstract
BACKGROUND Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. METHODS Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. RESULTS Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). CONCLUSIONS Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. LEVEL OF EVIDENCE Level II.
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Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents. Clin Spine Surg 2019; 32:210-214. [PMID: 30688677 DOI: 10.1097/bsd.0000000000000783] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS. SUMMARY OF BACKGROUND DATA Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings. METHODS Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications. RESULTS Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure. CONCLUSIONS Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively. LEVEL OF EVIDENCE This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."
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Wang H, Xiu P, Wang L, Song Y. [Progress in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:644-649. [PMID: 31090362 PMCID: PMC8337207 DOI: 10.7507/1002-1892.201810122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/27/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the advances in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery. METHODS Regular analgesics, drug administrations, and analgesic regimens were reviewed and summarized by consulting domestic and overseas related literatures about perioperative pain management of pediatric and adolescent spinal deformity corrective surgery in recent years. RESULTS As for perioperative analgesis regimens of pediatric and adolescent spinal deformity corrective surgery, regular analgesics include non-steroidal anti-inflammatory drugs, opioids, antiepileptic drugs, adrenergic agonists, and local anesthetic, etc. Besides drug administration by mouth, intravenous injection, and intramuscular injection, the administration also includes patient controlled analgesia, epidural injection, and intrathecal injection. Multimodal analgesia is the most important regimen currently. CONCLUSION Heretofore, a number of perioperative pain managements of pediatric and adolescent spinal deformity corrective surgery have been applied clinically, but the ideal regimen has not been developed. To design a safe and effective analgesic regimen needs further investigations.
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Affiliation(s)
- Haozhong Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Peng Xiu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yueming Song
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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14
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Seki H, Ideno S, Ishihara T, Watanabe K, Matsumoto M, Morisaki H. Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review. SCOLIOSIS AND SPINAL DISORDERS 2018; 13:17. [PMID: 30214945 PMCID: PMC6134554 DOI: 10.1186/s13013-018-0165-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/31/2018] [Indexed: 12/12/2022]
Abstract
Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.
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Affiliation(s)
- Hiroyuki Seki
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Satoshi Ideno
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Taiga Ishihara
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Kota Watanabe
- 2Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Morio Matsumoto
- 2Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Hiroshi Morisaki
- 1Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582 Japan
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15
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Sheffer BW, Kelly DM, Rhodes LN, Sawyer JR. Perioperative Pain Management in Pediatric Spine Surgery. Orthop Clin North Am 2017; 48:481-486. [PMID: 28870307 DOI: 10.1016/j.ocl.2017.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pain management after spinal deformity correction surgery for scoliosis in the pediatric population can be difficult. Deformity correction with posterior spinal fusion causes significant tissue trauma. Historically, pain control has been achieved with intravenous opiates. Opiates provide excellent analgesic effect; however, they have serious consequences when used alone. In adult total joint arthroplasty, multimodal pain control has become an increasingly common method to achieve pain control without these sequelae. Recently, the same techniques have been studied in pediatric spinal deformity correction surgery. This article outlines the state of pain management in pediatric spine patients.
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Affiliation(s)
- Benjamin W Sheffer
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA.
| | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
| | - Leslie N Rhodes
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
| | - Jeffrey R Sawyer
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
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16
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Abstract
Effective perioperative pain control in pediatric patients undergoing orthopedic surgery remains a challenge. Developing a successful pain control regimen begins preoperatively with assessment of the patient and discussion with the patient and family regarding expectations. Perioperative pain control regimens are customized based on the type of surgery, patient characteristics, and anticipated severity and duration of the postoperative pain. Recent study focuses on multimodal strategies and regional anesthesia options, allowing for decreased opioid use. This article provides an evidence-based overview of preoperative, intraoperative, and postoperative pain control for the pediatric orthopedic patient.
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