A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis

Nausea and Vomiting After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review

BACKGROUND

Postoperative nausea and vomiting (PONV) affects patient satisfaction, health care costs, and hospital stay by complicating the postoperative recovery period after adolescent idiopathic scoliosis (AIS) spinal fusion surgery. Our goal was to identify recommendations for optimal management of PONV in AIS patients undergoing posterior spinal fusion (PSF).

METHODS

We performed a systematic review in June 2022, searching the PubMed and Embase electronic databases using search terms "(Adolescent idiopathic scoliosis) AND (Postoperative) AND (Nausea) AND (Vomiting)." Three authors reviewed the 402 abstracts identified from January 1991 to June 2022. Studies that included adolescents or young adults (<21 years) with AIS undergoing PSF were selected for full-text review by consensus. We identified 34 studies reporting on incidence of PONV. Only 6 studies examined PONV as the primary outcome, whereas remaining were reported PONV as a secondary outcome. Journal of Bone and Joint Surgery Grades of recommendation were assigned to potential interventions or clinical practice influencing incidence of PONV with respect to operative period (preoperative, intraoperative, and postoperative period) on the basis that potential guidelines/interventions for PONV can be targeted at those periods.

RESULTS

A total of 11 factors were graded, 5 of which were related to intervention and 6 were clinical practice-related. Eight factors could be classified into the operative period-1 in the intraoperative period and 7 in the postoperative period, whereas the remaining 3 recommendations had overlapping periods. The majority of grades of recommendations given were inconclusive or conflicting. The statement that neuraxial and postoperative systemic-only opioid therapy have a similar incidence of PONV was supported by good (Grade A) evidence. There was fair (Grade B) and poor evidence (Grade C) to avoid opioid antagonists and nonopioid local analgesia using wound catheters as PONV-reducing measures.

CONCLUSION

Although outcomes after spinal fusion for AIS have been studied extensively, the literature on PONV outcomes is scarce and incomplete. PONV is most commonly included as a secondary outcome in studies related to pain management. This study is the first to specifically identify evidence and recommendations for interventions or clinical practice that influence PONV in AIS patients undergoing PSF. Most interventions and clinical practices have conflicting or limited data to support them, whereas others have low-level evidence as to whether the intervention/clinical practice influences the incidence of PONV. We have identified the need for expanded research using PONV as a primary outcome in patients with AIS undergoing spinal fusion surgery.

Safety and efficacy of intrathecal morphine in early onset scoliosis surgery

Intrathecal morphine (IM) is a popular adjunct for pain management in spinal deformity surgery for idiopathic scoliosis. It has not been studied in patients with early onset scoliosis (EOS). We retrospectively reviewed EOS patients undergoing growth-friendly surgery who received IM or did not receive IM (non-IM). Data from initial insertion and final fusion procedures were studied. IM was not used for lengthening procedures, short procedures (<3 h), patients with significant underlying respiratory issues, paraplegia, unsuccessful access and anesthesiologist discretion. We assessed pediatric ICU (PICU) admission and IM complications (respiratory depression, pruritus and nausea/vomiting), time to first postoperative opiate, and pain scores. There were 97 patients including 97 initial insertions (26 IM and 71 non-IM) and 74 patients with final fusions (17 IM and 57 non-IM). The first dose of opioids following insertion and final fusion occurred at 16.8 ± 3.8 and 16.8 ± 3.1 h postoperatively in the IM group compared to 5.5 ± 2.8 and 8.3 ± 3.2 h in the non-IM group, respectively ( P  < 0.001). Postoperative pain scores were lower in the IM groups ( P  = 0.001). Two patients with IM developed mild respiratory depression following initial insertion ( P  = 0.01) but did not require PICU admission. The rate of respiratory depression was not different between the final fusion groups. There was no difference between pruritus and nausea/vomiting at the final fusion. Preincision IM can provide well-tolerated and effective initial postoperative analgesia in select children with EOS undergoing spinal deformity surgery.

Continuous Epidural Analgesia (CEA) via Single Catheter Providing Profound Analgesia for Pediatric Patients Following Posterior Spinal Fusion (PSF) in Adolescent Idiopathic Scoliosis (AIS)

INTRODUCTION

Posterior spinal fusion (PSF) is a commonly performed orthopedic procedure to correct scoliosis in children. Continuous epidural analgesia (CEA) is a proposed means of providing analgesia following PSF. Whether a single epidural catheter with the tip in the upper thorax can provide adequate analgesia for PSF, which often spans the upper thoracic to lower lumbar regions, is unresolved in the literature.

METHOD

In this single-center, retrospective study, we reviewed 69 consecutive patients undergoing PSF for adolescent idiopathic scoliosis (AIS) with CEA at our institution from October 1, 2020 to May 26, 2022. Data for the entire cohort was divided into two time intervals before and after epidural removal, group epidural (Epi) and group no epidural (No Epi). Daily intravenous and oral opioid morphine equivalents per kilogram (OME/kg) plus mean and maximal visual analogue pain scores (VAS 0-10) were recorded from post-anesthesia care unit (PACU) discharge to the end of postoperative day (POD) three.  Results: 57 patients were included in the study. Opioid usage was 4.5 times greater in the 19 hours following removal of the epidural catheter when compared to the entire period (mean 65 hours) the epidural was in place (Group Epi 0.154 OME/kg vs Group No Epi 0.690 OME/kg, p<0.001). 51% (29/57) of patients did not require opioids (intravenous or oral) while the epidural was in place, all patients required opioids after epidural removal. Mean opioid usage while the epidural was in place was 9.3 OME, equivalent to approximately 6 mg of oxycodone. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3 (mean pain score: Epi 3.4 (1.8) vs No Epi 4.1 (1.7); p<0.001) (max pain score: Epi 4.9 (2.5) vs No Epi 6.3 (2.1); p<0.001).  Conclusions: This is the first study we are aware of to report pain scores and cumulative opioid requirements for PSF patients receiving CEA with a single epidural catheter before and after epidural removal. Opioid usage increased over four times in the 19 hours after epidural removal compared to the total opioid requirements while the epidural was infusing. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3. This study firmly establishes that CEA with a single epidural catheter can provide profound analgesia for patients having PSF for AIS.

Protocolo multimodal farmacológico perioperatorio para la cirugía de columna en pediatría

Introducción: La cirugía de columna es uno de los procedimientos con mayor morbimortalidad dentro de la población pediátrica; el manejo farmacológico del dolor en dicha población aún no se encuentra estandarizado. La analgesia multimodal trata de responder a esta problemática. Objetivo: Sobre la base de una revisión sistemática de la bibliografía, desarrollar un detallado protocolomultimodal farmacológico para el manejo del dolor pre- y posoperatorio intra/extrahospitalario para la cirugía de columna en niños. Materiales y Métodos: Se realizó una revisión sistemática de textos completos en inglés o español en PubMed, Embase, Cochrane Library y LILACS Database publicados entre 2000 y 2021; se aplicó el diagrama de flujo PRISMA. Resultados: De 756 artículos preseleccionados, 38 fueron incluidos en la evaluación final. Dada la dificultad bioética de desarrollar trabajos en formato de ensayos clínicos con fármacos y combinaciones de ellos en la población pediátrica, desarrollamos un protocolo detallado de manejo del dolor pre- y posoperatorio por vía intravenosa/oral, intra- y extrahospitalario, para aplicar en niños sometidos a cirugía de columna. Conclusión: Logramos desarrollar un detallado protocolo multimodal farmacológico para el perioperatorio intra- y extrahospitalario de cirugía de columna en niños, sencillo y reproducible, tendiente a acelerar la recuperación funcional del paciente y disminuir los costos socioeconómicos globales.Nivel de Evidencia: II

The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion

PURPOSE

In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects.

METHODS

The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose).

RESULTS

In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (β =  - 0.83, p < 0.001; β =  - 0.63, p = 0.022) and MED intake for the first two PODs (β =  - 20.8, p = 0.047; β =  - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10).

CONCLUSIONS

In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.

Intravenous ondansetron reduced nausea but not pruritus following intrathecal morphine in children: Interim results of a randomized, double-blinded, placebo-control trial

STUDY OBJECTIVE

This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults.

DESIGN

A double-blinded, randomized placebo-controlled trial.

SETTING

Operating room and first 24 h postoperative inpatient stay at an academic children's hospital.

PATIENTS

Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included.

INTERVENTIONS

Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized.

MEASUREMENTS

Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales.

MAIN RESULTS

The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9].

CONCLUSIONS

This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.

Hydromorphone Prescription for Pain in Children-What Place in Clinical Practice?

While morphine is the gold standard treatment for severe nociceptive pain in children, hydromorphone is increasingly prescribed in this population. This review aims to assess available knowledge about hydromorphone and explore the evidence for its safe and effective prescription in children. Hydromorphone is an opioid analgesic similar to morphine structurally and in its pharmacokinetic and pharmacodynamic properties but 5-7 times more potent. Pediatric pharmacokinetic and pharmacodynamic data on hydromorphone are sorely lacking; they are non-existent in children younger than 6 months of age and for oral administration. The current data do not support any advantage of hydromorphone over morphine, both in terms of efficacy and safety in children. Morphine should remain the treatment of choice for moderate and severe nociceptive pain in children and hydromorphone should be reserved as alternative treatment. Because of the important difference in potency, all strategies should be taken to avoid inadvertent administration of hydromorphone when morphine is intended.

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

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.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA).

SUMMARY OF BACKGROUND DATA

Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication.

METHODS

AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared.

RESULTS

There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation.

CONCLUSION

This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Effects of 5 µg/kg intrathecal morphine for postoperative analgesia in pediatric patients undergoing major surgery

BACKGROUND

The effects and analgesic adequacy of intrathecal morphine (ITM) administration have been studied less frequently than other regional analgesia techniques in pediatric surgical procedures.

OBJECTIVE

To evaluate the efficacy and adverse event rate of 5 µg/kg ITM administration for postoperative analgesia according to age group.

METHODS

We retrospectively evaluated the medical records of patients who underwent major pediatric surgery and were administered ITM for postoperative analgesia. Patients were divided into three age groups: ≤ 5 years (group I), 5.1-13 years (group II) and > 13 years (group III). All patients received ITM 5 µg/kg (max 300 μg) through the L_4-5 or L₅-S₁ interspace. Postoperative pain (modified pediatric objective pain score > 4), need for rescue analgesics, sleep interruption due to pain, sedation (Ramsay sedation scale score > 3), opioid-related postoperative adverse events (at 0, 4, 8, 12, and 24 h after intervention), hemodynamic data and nurse satisfaction with the analgesic method were compared between groups.

RESULTS

The analysis included 100 children (47 girls, 9 ± 5.4 years). Groups were similar regarding postoperative rescue analgesia consumption and sleep interruption (p = 0.238, p = 0.958), 96% of the children did not require rescue analgesia, and sleep interruption was not observed in 97%. Postoperative adverse events were pruritus in 14 and nausea/vomiting in 9 patients (p = 0.052). Overall, nurses were satisfied or very satisfied in 99% of the cases.

CONCLUSION

Administration of 5 µg/kg ITM can be used for postoperative analgesia in pediatric surgery in all age groups, with no severe adverse events and high nurse satisfaction with analgesic management.

The safety and efficacy of intrathecal morphine in pediatric spinal deformity surgery: a 25-year single-center experience

PURPOSE

Pre-incision intrathecal morphine (IM) is a popular adjunct in adolescent idiopathic spinal deformity surgery. This study represents our 25-year experience with IM in all diagnostic groups undergoing posterior spinal fusion (PSF) and segmental instrumentation (SI).

METHODS

Our prospective Pediatric Orthopaedic Spine Database (1992-2018) identified all patients undergoing PSF and SI. We included patients 21 years of age or less, had a PSF with SSI, and received the recommended IM dose of 9-19 mcg/kg (up to 1 mg) or no IM. We assessed demographics, pain scores, duration of surgery, time to first dose of narcotics, pediatric intensive care unit (PICU) admission, length of hospital stay, and IM complications (respiratory depression, pruritus, nausea/vomiting).

RESULTS

There were 984 patients who met inclusion criteria: 760 patients received IM, 224 did not (non-IM). They were divided into 5 diagnostic groups: idiopathic, neuromuscular, syndromic, and congenital scoliosis and kyphosis. The mean first post-operative opioid following IM administration was at 16.1 h in the IM group compared to 8.7 h in the non-IM group (p =  < 0.001). The post-operative pain scores in the IM groups were significantly lower (p =  < 0.001). Sixteen patients (2%) in the IM group were admitted to the PICU for observation secondary to respiratory depression, none requiring re-intubation. There were no other complications related to IM.

CONCLUSION

Pre-incision IM is a safe adjunct for pain management in select children in all diagnostic groups undergoing spinal deformity surgery. There were no serious complications.

LEVEL OF EVIDENCE

III.

Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature

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.

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.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis

OBJECTIVES

In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR?

STUDY DESIGN

Retrospective cohort.

BACKGROUND

EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued.

METHODS

A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed.

RESULTS

Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204).

CONCLUSION

In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost.

LEVEL OF EVIDENCE

III.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Pain management in neurocritical care; an update

PURPOSE OF REVIEW

Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care.

RECENT FINDINGS

Studies on pain management in neurocritical care continue to explore nonopioid analgesics as part of a multimodal strategy aimed at decreasing overall opioid consumption. Agents including local anesthetics, acetaminophen, ketamine, gabapentinoids, and dexmedetomidine continue to demonstrate efficacy. In addition, the prolonged longitudinal course of many recent trials has also revealed more about the transition from acute to chronic pain following hospitalization.

SUMMARY

In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.

Predictors of Extended Length of Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Segmental Instrumented Fusion: An Analysis of 407 Surgeries Performed at a Large Academic Center

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF).

SUMMARY OF BACKGROUND DATA

Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS.

METHODS

A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS.

RESULTS

Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ± 2 vs. 7 ± 2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ± 548 vs. 488 ± 341 cm, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ± 2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS.

CONCLUSION

Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay.

LEVEL OF EVIDENCE

3.

[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.

Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review

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.

Intrathecal Morphine and Oral Analgesics Provide Safe and Effective Pain Control After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor.

SUMMARY OF BACKGROUND DATA

Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics.

METHODS

We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded.

RESULTS

A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups.

CONCLUSION

ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary.

LEVEL OF EVIDENCE

3.

Pediatric Perioperative Pain Management

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.