The use of NSAIDs in pediatric scoliosis surgery - a survey of physicians' prescribing practice

Perioperative pain protocols following surgery for adolescent idiopathic scoliosis: a snapshot of current treatments utilized by attending orthopedic surgeons

PURPOSE

Perioperative management after adolescent idiopathic scoliosis (AIS) surgery varies extensively between surgeons and institutions. We devised a questionnaire to assess surgeon baseline characteristics, practice settings, and pain regimens to assess what factors contribute to perioperative pain protocols.

METHODS

A multiple-choice questionnaire including 130 independent variables regarding baseline characteristics, practice environments, and pain regimen protocols was distributed to elicit information among surgeons performing AIS fusion surgery. Pairwise bivariate analysis between practice location, length of practice, and practice environment vs. type of post-operative analgesia was completed using two-tailed Fisher's exact test.

RESULTS

85 respondents participated, all identified as practicing orthopedic surgeons. The largest group of respondents reported 20-40% of their total practice was dedicated to AIS (36%). Respondents were predominantly hospital-employed academic physicians (67%). The most common pain medication administered preoperatively was gabapentin (54%). Postoperative regimens were highly varied. Discharge pain regimens most commonly included short-acting opiates (89%), acetaminophen (86%), antispasmodics (59%), and NSAIDs (51%). Bivariate analysis revealed that fentanyl PCA was significantly associated with practice location (p < 0.05). Utilization of NSAIDs was significantly associated with length in training, with older physicians utilizing anti-inflammatories more regularly than younger physicians (p < 0.05).

CONCLUSION

This study identifies common perioperative regimens utilized in AIS surgery. Of interest, younger surgeons are less likely to prescribe NSAIDs post-operatively than surgeons who have been in practice for longer periods of time, which may represent a bias against anti-inflammatory medications in younger surgeons.

Methadone-based Multimodal Analgesia Provides the Best-in-class Acute Surgical Pain Control and Functional Outcomes With Lower Opioid Use Following Major Posterior Fusion Surgery in Adolescents With Idiopathic Scoliosis

Introduction:

Posterior spinal fusion for idiopathic scoliosis is extremely painful, with no superior single analgesic modality. We introduced a methadone-based multimodal analgesia protocol, aiming to decrease the length of hospital stay (LOS), improve pain control, and decrease the need for additional opioids.

Methods:

We analyzed 122 idiopathic scoliosis patients with posterior instrumented spinal fusion. They were matched by age, sex, surgeon, and the number of levels fused before and after the implementation of the new protocol. This analysis included 61 controls (intrathecal morphine, gabapentin, intravenous opioids, and adjuncts) and 61 patients on the new protocol (scheduled methadone, methocarbamol, ketorolac/ibuprofen, acetaminophen, and oxycodone with intravenous opioids as needed). The primary outcome was LOS. Secondary outcomes included pain scores, total opioid use (morphine milligram equivalents), time to a first bowel movement, and postdischarge phone calls.

Results:

New protocol patients were discharged earlier (median LOS, 2 days) compared with control patients (3 days; P < 0.001). Total inpatient morphine consumption was lower in the protocol group (P < 0.001). Pain scores were higher in the protocol group on the day of surgery, similar on postoperative day (POD) 1, and lower by POD 2 (P = 0.01). The new protocol also reduced the median time to first bowel movement (P < 0.001), and the number of postdischarge pain-related phone calls (P < 0.006).

Conclusion:

Methadone-based multimodal analgesia resulted in significantly lower LOS compared with the conventional regimen. It also provided improved pain control, reduced total opioid consumption, and early bowel movement compared with the control group.

Current Trends in Pediatric Spine Deformity Surgery: Multimodal Pain Management and Rapid Recovery

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose of this article is to perform a review of the literature assessing the efficacy of opioid alternatives, multimodal pain regimens, and rapid recovery in pediatric spine surgery.

METHODS

A literature search utilizing PubMed database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease postoperative pain and expedite recovery after posterior spinal fusion in adolescent idiopathic scoliosis patients have been provided based on results of studies with the highest level of evidence.

RESULTS

Refining perioperative pain management to lessen opioid consumption with multimodal regimens may be useful to decrease recovery time, pain, and complications. Nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, neuraxial blockades, and local anesthesia alone offer benefits for postoperative pain management, but their combination in multimodal regimens and rapid recovery pathways may contribute to faster recovery time, improved pain levels, and lower reduction in total opioid consumption.

CONCLUSION

A rapid recovery pathway using the multimodal approach for pediatric scoliosis correction may offer superior postoperative pain management and faster recovery than traditional opioid only pain protocols.

Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction

STUDY DESIGN

Prospective double-blind, randomized controlled trial.

OBJECTIVES

The objective of this study was to validate the efficacy of gabapentin as part of a multimodal pain regimen in a double-blind, randomized controlled trial for patients aged 10-19 years with idiopathic scoliosis undergoing posterior spinal fusion. Perioperative pain management represents a challenge for patients undergoing surgical correction of adolescent spinal deformity. Gabapentin has been shown to decrease postoperative pain and opioid use after spine surgery, but it has not yet been investigated as part of a multimodal pain regimen intended to decrease the perioperative use of opioids.

METHODS

Fifty patients were randomized to receive gabapentin or placebo pre- and postoperatively in addition to a standardized medication regime including scheduled ketorolac and as-needed acetaminophen, hydromorphone, and oxycodone. Patients were monitored in the pre-, peri-, and postoperative periods for pain levels, medication dosing, side effects, adverse events, hospitalization length of stay, and parent satisfaction.

RESULTS

There were statistically significant decreases in early postoperative pain scores and opioid use as well as total postoperative opioid use for the treatment group relative to controls. There were no statistically significant differences in adverse events, medication side effects, or hospitalization length. Parents of patients in both groups were very satisfied with the pain control provided to their children.

CONCLUSIONS

This randomized controlled trial demonstrates that pre- and postoperative administration of gabapentin as part of a multimodal pain management protocol significantly decreases both opioid use and visual analog pain scales in the first two postoperative days after posterior spinal fusion for adolescent idiopathic scoliosis. Gabapentin should be considered as a standard medication for perioperative pain control in this patient population.

LEVEL OF EVIDENCE

Level I.

Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents

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."

[Progress in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery]

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.

Peripheral eosinophilia in children with transient synovitis of the hip: 7-year experience from a single centre in New Zealand

PURPOSE

Hip pain with limping is a common presentation in childhood. The most common diagnosis in young children is transient synovitis of the hip (TSH), a benign and self-limiting condition. In our clinical practice, we observed eosinophilia in children presenting with irritable hip more commonly than would otherwise be expected. The aims of this study were to assess the prevalence of eosinophilia in children with TSH, and to evaluate the clinical outcomes of this sub-group of patients.

METHODS

This study retrospectively examined the data of all paediatric patients admitted to Christchurch Public Hospital, Christchurch, New Zealand. TSH cases were compared with age- and sex-matched controls.

RESULTS

A total of 103 patients were included. Compared with controls, TSH patients had significantly higher eosinophil counts (303 ± 236 vs. 380 ± 337 cells/μL, respectively, p = 0.049). Fourteen patients (15.6 %) had eosinophilia, with a mean eosinophil count of 986 (±321) cells/µL. Children who had eosinophilia did not differ from the rest of the sample in their age (mean 4.6 vs. 4.4 years, p = 0.74) or ethnicity (85.7 vs. 85.5 % European, p = 0.99). Eosinophilic children were not more likely to be atopic (i.e. have history of allergic rhinitis, asthma and/or eczema) than non-eosinophilic children (21.4 vs. 10.5 %, p = 0.37). There was a shorter hospital stay in eosinophilic children (mean 16.3 ± 6 h) than in non-eosinophilic children (mean 21.5 ± 18.8 h), although this was not statistically significant (p = 0.058).

CONCLUSIONS

To the authors' knowledge, this is the first study to explore the relationship between TSH and eosinophilia. We found a sizeable minority (15.6 %) of children with TSH to have eosinophilia. While the difference in hospital stay was not statistically significant, a correlation between peripheral eosinophilia and length of hospital stay of TSH patients is possible. Whether this correlation is clinically meaningful remains to be answered.

LEVEL OF EVIDENCE

Retrospective prognostic study; level II.

Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis

BACKGROUND

Patients undergoing posterior spinal instrumentation and fusion surgery for adolescent idiopathic scoliosis were admitted to the intensive care unit until two years ago, at which time we changed our protocol to admit these patients to the general hospital floor following a brief stay in a postanesthesia care unit. This study compared postoperative management on a hospital floor with that in the intensive care unit for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

METHODS

A retrospective review of 124 consecutive patients with adolescent idiopathic scoliosis treated with spinal fusion from August 2007 to August 2010 was performed. Inclusion criteria were a diagnosis of adolescent idiopathic scoliosis and posterior spinal instrumentation and fusion surgery.

RESULTS

Of 124 patients, sixty-six were managed postoperatively in the intensive care unit and fifty-eight, on the hospital floor. The mean age at the time of surgery was fourteen years. A mean of eleven vertebral levels (range, six to fifteen levels) were fused. No significant difference between the groups was found with respect to the mean age at the time of surgery, mean weight, mean preoperative and postoperative Cobb angles, and mean number of levels fused (p ≥ 0.12). However, the use of analgesic and antianxiety medication, number of postoperative blood tests, days of hospital stay, and number of physical therapy sessions were significantly decreased in the floor group compared with the intensive care unit group (p ≤ 0.05). No patient from the floor group had to be admitted to the intensive care unit. The mean charge was $33,121 for the floor group and $39,252 for the intensive care unit group (p < 0.001).

CONCLUSIONS

Initial postoperative management of patients with adolescent idiopathic scoliosis following a posterior spinal instrumentation and fusion surgery on a general hospital floor, rather than in an intensive care unit, was associated with a shorter hospital stay, fewer blood tests, less analgesic and antianxiety medication usage, and fewer physical therapy sessions at this high-volume, academic, tertiary-care children's hospital. In addition to improved patient outcomes, there was a significant decrease of 16% in hospital charges for the group that did not go to the intensive care unit.

Multimodal pain management after spinal surgery for adolescent idiopathic scoliosis

Corrective surgery for scoliosis is an extensive procedure with well-known problems of postoperative pain control. Additional problems with nausea, vomiting, ileus, and sedation can result in delayed mobilization and a prolonged inpatient hospital stay. At our institution, a multimodal approach to pain management has been used to successfully address these issues. The use of intravenous acetaminophen has been a helpful adjunct to our armamentarium of pain medication in this patient population. We present an illustrative case of our use of multimodal analgesia beginning intraoperatively and continuing during the acute inpatient postoperative period.

Continuous Bupivacaine Infusion Post-Iliac Crest Bone Graft Harvesting in Pediatric Cleft Surgery: Role and Comparison with Ketorolac

Objective

To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids.

Method

A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device.

Main outcome Measure(s)

Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores.

Results

Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac.

Conclusions

Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.