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

Comparison of preemptive and preventive intravenous acetaminophen on opioid consumption in pediatrics undergoing posterior spinal fusion surgery: a randomized controlled trial

BACKGROUND

Posterior spinal fusion (PSF), commonly used for adolescent idiopathic scoliosis (AIS), causes severe postoperative pain. Intravenous (IV) administration of acetaminophen has shown promise for opioid-sparing analgesia; however, its analgesic effect and optimal timing for its standard use remain unclear. Our study aimed to evaluate the analgesic effect and optimal timing of IV acetaminophen administration in pediatric and adolescent patients undergoing PSF and requiring adequate pain control.

METHODS

This prospective, randomized, triple-blind trial was conducted in patients aged 11-20 undergoing PSF. Participants were randomized into three groups: the preemptive group (received IV acetaminophen 15 mg/kg after anesthetic induction/before surgical incision), the preventive group (received IV acetaminophen 15 mg/kg at the end of surgery/before skin closure), and the placebo group. The primary outcome was cumulative opioid consumption during the first 24 h postoperatively.

RESULTS

Among the 99 enrolled patients, the mean ± standard deviation (SD) amount of opioid consumption during the postoperative 24 h was 60.66 ± 23.84, 52.23 ± 22.43, and 66.70 ± 23.01 mg in the preemptive, preventive, and placebo groups, respectively (overall P = 0.043). A post hoc analysis revealed that the preventive group had significantly lower opioid consumption than the placebo group (P = 0.013). However, no significant differences between the groups were observed for the secondary outcomes.

CONCLUSIONS

The preventive administration of scheduled IV acetaminophen reduces cumulative opioid consumption without increasing the incidence of drug-induced adverse events in pediatric and adolescent patients undergoing PSF.

PCA-pump for analgesia following pediatric scoliosis surgery: bolus administration with/without basal infusion

OBJECTIVES

The aim of this study is to compare the use of two different opioid delivery systems (bolus PCA with/without basal infusion) to control postoperative pain and evaluate the side effect profile in pediatric patients undergoing scoliosis surgery.

PATIENTS AND METHODS

38 patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis were included in the study. Patients were randomly divided into 2 groups by the computer. Patients who received only bolus PCA were named Group 1, and patients who received bolus PCA with basal infusion were named Group 2.Morphine consumption, postoperative pain assessmentduring rest, movement and coughing with numeric rating scale (NRS) and the Wong -Baker pain scale, heart rate and average blood pressure, sedation levels withRamsey sedation scale and side effects such as nausea, vomiting, itching, desaturation, and urinary retention were recorded.

RESULTS

Total mean morphine consumption (mg) was 32.7 ± 9.7 in Group 1 and 43.4 ± 9.1 in Group 2. The mean morphine consumption (mg) at 12-24 hours and 0-48 hours in Group 1 was statistically lower than Group 2 (p = 0.001). There was no significant difference between the groups in terms of median NRS scores (p = 0.55). There was no statistically significant difference in the evaluation of the groups in terms of Wong-Baker pain scale. Wong-Baker pain scale is p:0.66 at the 2nd hour, p:0.951 at the 12th hour and p:0.467 at the 24th hour.There was no statistically significant difference in Ramsay Sedation Scale evaluation between groups during each follow-up time (p > 0.05). The Ramsay Sedation Scale was p: 0.94 at the 2nd hour, p:1.0 at the 12th hour, and p:1.0 at the 24th hour. The duration of vomiting between 0-2 h, 2-24 h and 0-48 h was higher in Group 2 (p = 0.001, p = 0.024, p = 0.001).

CONCLUSION

The two administration settings of morphine sulphate by PCA pump have shown to be equally effective in the treatment of postoperative pain following PSF. In addition, PCA with basal infusion administration causes more opioid consumption and more systemic side effects. Therefore, the use of only bolus PCA in pediatric scoliosis surgery should be encouraged.

LEVEL OF EVIDENCE

Level II, Randomized Controlled Trial.

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

Analgesic options for anterior approach to scoliosis repair: a scoping review

PURPOSE

The ideal analgesic regimen for the anterior approach to scoliosis repair is not clearly defined. The purpose of the study was to summarize and identify gaps in the current literature specific to the anterior approach to scoliosis repair.

METHODS

A scoping review was conducted in July 2022 utilizing PubMed, Cochrane, and Scopus databases guided by the PRISMA-ScR framework.

RESULTS

The database search generated 641 possible articles, 13 of which met all inclusion criteria. All articles focused on the effectiveness and safety of regional anesthetic techniques, while a minority also provided both opioid and non-opioid medication frameworks.

CONCLUSION

Continuous Epidural Analgesia (CEA) is the most well-studied intervention for pain control in anterior scoliosis repair, but other, more novel regional anesthetic techniques offer safe and effective potential alternatives. More research is indicated to compare the effectiveness of different regional techniques and perioperative medication regimens specific to anterior scoliosis repair.

Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion

PURPOSE

The goal of this study was to compare our institution's recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores.

METHODS

This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis.

RESULTS

We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P<0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P < 0.01). We found no difference in pain scores between the two groups.

CONCLUSION

Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients.

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.

Mini-dose esketamine-dexmedetomidine combination to supplement analgesia for patients after scoliosis correction surgery: a double-blind randomised trial

BACKGROUND

Patients often experience severe pain after scoliosis correction surgery. Esketamine and dexmedetomidine each improves analgesia but can produce side-effects. We therefore tested the hypothesis that a mini-dose esketamine-dexmedetomidine combination safely improves analgesia.

METHODS

Two hundred male and female adults having scoliosis correction surgery were randomised to patient-controlled sufentanil analgesia (4 μg kg^-1 in normal saline) with either a combined supplement (esketamine 0.25 mg ml^-1 and dexmedetomidine 1 μg ml^-1) or placebo. The primary outcome was the incidence of moderate-to-severe pain within 72 h, defined as a numeric rating scale (NRS: 0=no pain and 10=worst pain) score ≥4 at any of seven time points. Amongst secondary outcomes, subjective sleep quality was assessed with an NRS score (0=best sleep and 10=worst sleep) for the first five postoperative nights.

RESULTS

There were 199 subjects included in the intention-to-treat analysis. Mean infusion rates were 5.5 μg kg^-1 h^-1 for esketamine and 0.02 μg kg^-1 h^-1 for dexmedetomidine. The primary outcome incidence was lower with the combined supplement (65.7% [65/99]) than with placebo (86.0% [86/100]; relative risk 0.76; 95% confidence interval: 0.65-0.90; P=0.001). Subjects given the combined supplement had lower pain intensity at rest at five time points (median difference -1 point; P≤0.005), lower pain intensity with movement at six time points (median difference -1 point; P≤0.001), and better subjective sleep quality for the first 5 postoperative nights (median difference -2 to -1 points; P<0.001). Adverse events did not differ between groups.

CONCLUSIONS

The mini-dose esketamine-dexmedetomidine combination safely improved analgesia and subjective sleep quality after scoliosis correction surgery.

CLINICAL TRIAL REGISTRATION

NCT04791059.

Anesthesia and Perioperative Management for Surgical Correction of Neuromuscular Scoliosis in Children: A Narrative Review

Scoliosis is the most frequent spinal deformity in children. It is defined as a spine deviation of more than 10° in the frontal plane. Neuromuscular scoliosis is associated with a heterogeneous spectrum of muscular or neurological symptoms. Anesthesia and surgery for neuromuscular scoliosis have a higher risk of perioperative complications than for idiopathic scoliosis. However, patients and their relatives report improved quality of life after the surgery. The challenges for the anesthetic team result from the specifics of the anesthesia, the scoliosis surgery itself, or factors associated with neuromuscular disorders. This article includes details of preanesthetic evaluation, intraoperative management, and postoperative care in the intensive care unit from an anesthetic view. In summary, adequate care for patients who have neuromuscular scoliosis requires interdisciplinary cooperation. This comprehensive review covers information about the perioperative management of neuromuscular scoliosis for all healthcare providers who take care of these patients during the perioperative period, with an emphasis on anesthesia management.

Rapid recovery pathway without epidural catheter analgesia for surgical treatment of adolescent idiopathic scoliosis: a comparative study

PURPOSE

To assess effectiveness of a rapid recovery pathway (RRP) without epidural catheter analgesia (ECA) or intravenous patient controlled analgesia (PCA) in accelerating recovery and decreasing opioid consumption in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF).

METHODS

A retrospective cohort study included collection of demographics, ECA use, IV PCA, postoperative opioid consumption, postoperative pain scores, and reoperation rate. Opioid consumption was calculated using morphine milligram equivalents (MME). Hospital length of stay (HLOS) and first reported ambulation with physical therapy (PT) were also recorded.

RESULTS

53 patients were included, with 18 in the RRP group. Patient characteristics were comparable between the groups, except in ECA use and BMI. The RRP group consumed less total MME from postoperative day (POD) 0 to 2 (mean difference 61.6 MME; 95% CI 37.1-86.1 MME; p < 0.001). In addition, the RRP group had significantly shorter HLOS (2.5 vs 4.0 days; p < 0.001). There were no differences in VAS scores between the two groups. A subset analysis comparing patients who did and did not receive ECA showed that ECA resulted in overall higher inpatient MME and HLOS. A prediction model was developed using multiple regression based on the different medications used for multimodal analgesia (MMA) in the RRP.

CONCLUSIONS

An RRP without the use of ECA or IV PCA can provide adequate analgesia in patients with AIS undergoing PSF while lowering inpatient narcotic consumption and accelerating immediate postoperative recovery.

Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA

OBJECTIVES

Excessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery.

METHODS

We developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants' evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis.

RESULTS

Eighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0-10 pills (mean=5.9); Paediatrics: 6-30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time.

CONCLUSIONS

In this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients' opioid use and providers' prescription patterns.

Paediatric Spinal Deformity Surgery: Complications and Their Management

Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.

The risk of delayed spinal cord injury in pediatric spinal deformity surgery

Delayed spinal cord injury (SCI) hours or days after surgery, with uneventful monitoring and initial normal postoperative neurological examination, is a rare complication. Based on anecdotal evidence, the risk of delayed spinal cord injury might be higher than previously assumed. Therefore the aim of this study was to determine the risk of delayed SCI after pediatric spinal deformity surgery between 2013-2019 in the Netherlands. The total number of pediatric spinal deformity surgeries performed for scoliosis or kyphosis between 2013-2019 was obtained from the Dutch National Registration of Hospital Care. All eleven Dutch hospitals that perform pediatric spinal deformity surgery were contacted for occurrence of delayed SCI. From the identified patients with delayed SCI, the following data were collected: patient characteristics, details about the SCI, the surgical procedure, management and degree of improvement.2884 pediatric deformity surgeries were identified between 2013-2019. Seven patients (0.24%) with delayed SCI were reported: 3 idiopathic, 2 neuromuscular (including 1 kypho-scoliosis) and 2 syndromic scoliosis. The risk of delayed SCI after pediatric deformity surgery was 1:595 in idiopathic scoliosis, 1:214 in syndromic scoliosis, 1:201 in neuromuscular scoliosis. All seven patients had a documented normal neurological examination in the first postoperative period; neurological deficits were first diagnosed at a median 16h (range 2.5-40) after surgery. The risk of delayed SCI after pediatric deformity surgery is higher than previously reported, especially in patients with non-idiopathic scoliosis. Regular postoperative testing for late neurologic deficit should be performed for timely diagnosis and management of this devastating complication.

Investigation of the analgesic efficacy of ultrasound-guided thoracolumbar interfacial plane block in vertebral surgery: A prospective randomized clinical study

OBJECTIVES

To investigate the effect of thoracolumbar interfacial plane block (TLIP) on analgesic consumption and pain score in vertebral surgery.

METHODS

All patients (64 patients undergoing vertebral surgery) were randomly allocated as Group T (patients with block, n=32) and Group C (patients without block, n=32). After surgery, patient-controlled analgesia using tramadol was administered to all patients. Pain intensity was evaluated with visual analogue scale (VAS; recovery room at 1, 2, 6, 12, and 24 hours postoperative), and as rescue analgesia, morphine was administered to patients with VAS scores of >4. In this study, total tramadol consumption, the number of patients requiring morphine, VAS score, and Quality of Recovery-40 of all patients questionnaire was evaluated.

RESULTS

There were important differences between the 2 groups according to mean postoperative tramadol consumption (Group T and Group C; 180 mg [100-260] vs. 210 mg [100-300]; p=0.001) and the number of patients requiring additional analgesia (n=4; 12.5% vs. n=24; 75%, p=0.000). There were important differences between the 2 groups according to the postoperative VAS pain score (p=0.000).

CONCLUSION

Ultrasound-TLIP reduces analgesic consumption and pain severity after vertebral surgery. Therefore, it is an important regional analgesia technique. CLINICALTRIALSGOV GRANT NO: NCT04548076.

Effect of Sufentanil Combined with Gabapentin on Acute Postoperative Pain in Patients Undergoing Intraspinal Tumor Resection: Study Protocol for a Randomized Controlled Trial

Purpose

Patients undergoing intraspinal tumor resection usually experience severe postoperative pain. Inadequate postoperative analgesia usually leads to severe postsurgical pain, which could cause patients to suffer from many other related complications. Recently, an increasing number of studies have found that gabapentin can relieve hyperalgesia, postoperative pain, and postoperative inflammation. However, there have been no reports on the use of gabapentin combined with sufentanil preoperatively for acute pain following intraspinal tumor resection.

Study Design and Methods

This is a protocol for a randomized, placebo-controlled, and double-blinded trial. One-hundred and sixty-eight participants with chronic pain related to the intraspinal tumor will be randomized into the gabapentin and placebo groups in a 1:1 ratio. In the gabapentin group, patients will be given 300 mg gabapentin orally 36 h, 24 h, and 12 h before surgery; the placebo group will receive a placebo orally at the same time points preoperatively. To estimate the efficacy and safety endpoints, all the researchers and patients will be blinded until the completion of this study. The primary outcome will be the consumption of sufentanil within 48 h postoperatively. The secondary outcomes include the visual analog scale pain score and Von Frey mechanical pain threshold 36 h and 24 h before and 24 h and 48 h after surgery, the incidence of postoperative nausea, vomiting, and drowsiness, the length of hospital stay and medical expenses.

Discussion

This trial is to evaluate the efficacy and safety of gabapentin combined with sufentanil for postoperative analgesia in patients who complain of pain before intraspinal tumor resection. The findings will provide a new strategy for multimode perioperative analgesia management in these patients.

Ketamine-induced neurotoxicity is mediated through endoplasmic reticulum stress in vitro in STHdhQ7/Q7 cells

Ketamine has traditionally been used as a dissociative anesthetic agent and more recently as a treatment for treatment-resistant depression. However, there is growing concern over the increased use of ketamine in recreational and therapeutic settings due to the potential neurotoxic effects. Recent studies have demonstrated that ketamine is cytotoxic in several cell types, such as fibroblasts, hepatocytes, uroepithelial cells, and adult induced pluripotent stem cells (iPSCs). Ketamine has been shown to dysregulate calcium signalling, increase reactive oxygen species (ROS) production, and impair mitochondrial function, ultimately leading to apoptosis. However, it is unclear whether endoplasmic reticulum (ER) stress plays a role in ketamine associated neurotoxicity in striatal neurons. Disruption to ER homeostasis can initiate ER-mediated cell death, which has been implicated in several neurodegenerative diseases. Thus, the purpose of this study was to determine whether ketamine's neurotoxic effects involve an ER stress-dependent pathway and to elucidate the underlying mechanisms involved in its neurotoxic effects. Mouse striatal cells were treated with various concentrations of ketamine (10 μM, 100 μM, 1 mM) or DMEM for 9-72 hrs. Cell viability was assessed using the MTT assay, and changes in gene expression of ER stress markers were evaluated using RT-qPCR. MTT results revealed that 1 mM ketamine decreased cell viability in striatal cells after 24 h of treatment. Gene expression studies complemented these findings such that ketamine upregulated pro-apoptotic ER stress markers, including X-box binding protein 1 (XBP1), activating transcription factor 4 (ATF4), and C/EBP homologous protein (CHOP) and downregulated pro-survival ER stress proteins such as GRP78, MANF and CDNF. Ketamine activated all three stress sensing pathways including PERK, IRE1, and ATF6. Taken together, our results show that ketamine-induced neurotoxicity is mediated through an ER stress-dependent apoptotic pathway.

Experience and Management of the Adverse Effects of Analgesics After Surgery: A Pediatric Patient Perspective

After surgery, the adverse effects (AEs) of analgesics are common and critical factors influencing the postoperative experience of pediatric patients. Inadequate management of AEs has been found to prolong hospital stay, increase readmission rates and decrease satisfaction with care. The aim of this qualitative descriptive study was to better understand the AEs of analgesics from the perspective of adolescent patients with idiopathic scoliosis after spinal surgery. A total of 7 patients participated in the study. Semistructured interviews were conducted at discharge and 1 week after discharge. Transcribed data were analyzed using qualitative content analysis and themes were identified. Overall, participants most frequently reported gastrointestinal and cognitive AEs, with constipation being the most persistent and bothersome. The pediatric participants used a combination of 3 strategies to mitigate analgesic AEs, namely pharmacologic, nonpharmacologic, and reduction of analgesic intake. Participants demonstrated a lack of understanding of AEs and involvement in their own care. Future studies should be conducted to evaluate the efficacy of nonpharmacological strategies in managing analgesic AEs for pediatric patients after surgery.

Efficacy of surgeon-directed postoperative local injection with an analgesic mixture in posterior fusion surgery for adolescent idiopathic scoliosis

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.

Content validity of Scoliosis Research Society questionnaire-22 revised (SRS-22r) for adolescents with idiopathic scoliosis: protocol for a qualitative study exploring patient's and practitioner's perspectives

INTRODUCTION

Content validity is the most important measurement property for any patient-reported outcome measure (PROM). It being the extent that the PROM measures important concepts that are relevant to the population of interest. Adolescent with idiopathic scoliosis (AIS) is the most common spinal deformity in paediatric populations, with the Scoliosis Research Society questionnaire-22 revised (SRS-22r) a commonly used PROMof quality of life. In the absence of existing evidence, a content validity study for SRS-22r is needed to confirm its suitability for AIS. Thus, this study aims to investigate the content validity of SRS-22r for AIS. A secondary aim is to explore healthcare professional (HCP) perspectives of the barriers and facilitators to using outcome measures in AIS.

METHODS AND ANALYSIS

Qualitative study reported according to COnsolidated criteria for Reporting Qualitative Studies. A purposive sample of AIS (n=10-15, Cobb angle >25°, aged 10-18 years) will be recruited for online semi-structured interviews. A convenience sample (n=10-12) of HCP with clinical and/or research experience in AIS will be recruited for a focus group discussion. Topic guides and age-relevant documents are informed by existing evidence and developed using a framework of concept elicitation and cognitive debriefing. Audio-recordings will be transcribed verbatim, coded, analysed and synthesised using interpretive phenomenology analysis. Themes that generated from the analysis will be used as codes that will then be mapped to the SRS-22r contents.

ETHICS AND DISSEMINATION

The Health Research Authority and Health and Care Research Wales approval have been granted (IRAS 289888). Study findings will be disseminated through publications in peer-reviewed journals and conference presentations.

Thoracic paravertebral nerve catheter reduces postoperative opioid use for vertebral body tethering patients

PURPOSE

Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay.

METHODS

Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated.

RESULTS

69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p < 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632 mg vs. 1630 mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0 days in the TPVB group (p < 0.001). There were no major complications associated with use of the TPVB.

CONCLUSION

In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.

Lidocaine infusions and reduced opioid consumption-Retrospective experience in pediatric hematology and oncology patients with refractory pain

BACKGROUND

Despite a more robust experience with lidocaine infusions for pain management in adults and general pediatric population, there is limited evidence of efficacy of lidocaine infusions for pain management in patients with pediatric hematology and oncology diagnoses.

METHODS

Data pertaining to continuous intravenous lidocaine infusions prescribed between January 2009 and June 2019 were reviewed, including patients' demographic characteristics, hematology/oncology and pain diagnoses, concurrent pain medications, and lidocaine infusion dose regimens and duration. Pain scores and opioid consumption calculations based on morphine equivalent doses (mg/kg/day) of patient-controlled analgesia were collected 1 day before infusion (D1), during infusion (D2), and 1 day after infusion (D3).

RESULTS

The mean opioid consumption on D3 was significantly lower than that on D2 (p = .01). The pain scores on D3 were significantly lower than those on D1 when measured as average pain scores per 24 hours (p < .001) or as single pain scores immediately before and after infusions (p < .001). No significant associations were found between cumulative doses of lidocaine (loading dose plus total infusion dose) and either a decrease in the opioid consumption or a decrease in pain scores.

CONCLUSIONS

In this retrospective series of pediatric hematology and oncology cases, we report positive outcomes in reducing opioid consumption and pain scores after lidocaine infusions. Prospective investigations designed in a collaborative, multi-institutional fashion, including a variety of pediatric populations are needed to further investigate the efficacy of lidocaine infusions.

Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of Perioperative Outcomes Between Morning and Afternoon Cases

BACKGROUND

High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes.

METHODS

A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient's weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30.

RESULTS

A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative.

CONCLUSIONS

Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases.

LEVEL OF EVIDENCE

Level II.

Intraoperative Remifentanil Dosage in Surgery for Adolescent Idiopathic Scoliosis Does Not Increase Postoperative Opioid Consumption When Combined With Epidural Analgesia: A Retrospective Cohort Study

Background In adults, high-dose remifentanil during surgery has been reported to increase postoperative opioid consumption, but this has not been well documented in children. Multimodal analgesia is recommended in the perioperative period for adolescent idiopathic scoliosis (AIS), but no report has examined opioid consumption under epidural analgesia, which is one of the most common types of analgesia. Aims To investigate the association between intraoperative remifentanil dosage and postoperative opioid consumption in AIS in the setting of combined epidural analgesia for postoperative multimodal analgesia. Methods In this retrospective cohort study, patients aged 10-18 years who underwent surgery for scoliosis and epidural analgesia for postoperative pain between July 2012 and April 2019 were included. The primary endpoint was the association between intraoperative cumulative weight-adjusted remifentanil dosage and logarithmic transformation of cumulative weight-adjusted fentanyl consumption in the intensive care unit (ICU). Nonopioid analgesics were investigated as secondary endpoints. An epidural catheter was inserted by the surgeon intraoperatively, and a local anesthetic was administered at the end of the surgery. Multivariate linear regression analysis with adjustment for confounders was performed for all analyses. Results In total, 142 patients were included, and the median intraoperative remifentanil dosage for all patients was 0.27 (interquartile range, 0.24-0.34) µg/kg/min. No association was observed between cumulative weight-adjusted intraoperative dosage of remifentanil and fentanyl, even after adjusting for potential confounders (slope = -1.25; 95% confidence interval [CI], -4.35 to 1.85; P = 0.43). No association was observed between nonopioid analgesic use and intraoperative remifentanil dosage. Conclusion No association was noted between remifentanil dosage during surgery for AIS and postoperative opioid consumption with epidural analgesia. However, this study has limitations due to its retrospective design; thus, further prospective studies are warranted.

Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases

PURPOSE

The objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways.

METHODS

Using major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed.

RESULTS

Fourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively.

CONCLUSIONS

Use of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction.

LEVEL OF EVIDENCE III

Meta-analysis of Level 3 studies.

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.

Pregabalin and Persistent Postoperative Pain Following Posterior Spinal Fusion in Children and Adolescents: A Randomized Clinical Trial

BACKGROUND

Surgical correction of spinal deformity requires major surgical intervention with extensive manipulation of the spine and neural elements. Persistent postoperative pain affects patient quality of life and can also cause financial burden for patient families and for society. We aimed to investigate the effect of perioperative pregabalin on the incidence of persistent pain following instrumented spinal fusion.

METHODS

We conducted a randomized, double-blinded, and placebo-controlled single-center clinical trial. Adolescents and children 10 to 21 years old with a spinal deformity who were scheduled for pedicle screw instrumentation and fusion were randomized into either the pregabalin or placebo group. Patients received 2 mg/kg of pregabalin or a placebo twice daily preoperatively and for 5 days postoperatively. The duration of follow-up was 2 years. The primary outcomes were cumulative opioid consumption during the first 48 hours postoperatively and the incidence of persistent postoperative pain over the course of the 2-year follow-up.

RESULTS

Sixty-four of 77 eligible patients were enrolled in the study, with all patients completing the 2-year follow-up. Thirty-three patients were randomized into the pregabalin group and 31 into the placebo group. There was no significant difference in cumulative 48-hour opioid consumption between the study groups. The Scoliosis Research Society 24-Item Questionnaire pain domain score improved significantly, from a mean value of 3.8 in both groups to 4.3 in the pregabalin and 4.0 in the placebo group at 2 years postoperatively, with no differences between the study groups at any time point (p = 0.317). The Scoliosis Research Society total scores of the study groups were similar (p = 0.678). Back pain, as measured with use of a visual analogue scale, improved significantly (p = 0.001) with no significant differences at any time point (preoperatively and 6 months, 1 year, and 2 years postoperatively).

CONCLUSIONS

Perioperative pregabalin does not reduce postoperative opioid consumption or the incidence of persistent postoperative pain following instrumented posterior spinal fusion for spinal deformities in an adolescent population.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Idiopathic scoliosis: general characteristics and analysis of etiological theories (literature review)

Idiopathic scoliosis is a severe pathology of the musculoskeletal system that affects children and adolescents all over the world. The disease occurs in approximately 0.2-0.6% of the general population, and is the largest subgroup of spinal curvature in humans (70-90% of all known scoliosis cases). In idiopathic scoliosis, a threedimensional deformation of the vertebral column is formed, leading to the formation of a rib hump, curvature of the ribs and chest, asymmetry of the pelvis and impaired development of internal organs. The main feature of the disease is the spontaneous development of deformity during the growth of the child and the tendency to progress. Scoliosis is not only an orthopedic disease, but also a ignificant cosmetic, and, consequently, a psychological and social problem. The standard of treatment for scoliotic disease remains unchanged for a long time: observation, corset treatment and surgical correction. The prognosis for the development of pathology varies depending on the degree of deformation. The corset-therapy, hospitalization, surgery and treatment of chronic back pain have a negative impact on the psychoemotional state of children and adolescents. Despite significant advances in the methods of diagnosis of deformity, improvement of surgical treatment methods and in the study of pathogenesis, the etiological factor of pathology is still unknown. The search for the causes of idiopathic scoliosis covers almost all aspects of its possible origin: genetic, environmental, hormonal, metabolic, biochemical, neurological, and others. In recent decades, relevant theories of the development of scoliosis have been formulated, but none of the theories reveals the essence of the pathological process and has no clear justification. The greatest number of supporters is the genetic theory: genetic factors play a key role in the occurrence and development of idiopathic scoliosis. Understanding the underlying factors of the disease will enable prevention, early diagnosis, and identification of the risk groups of the patients in question.

Lidocaine Infusions for Pain Management in Pediatrics

Lidocaine is an amino amide with a well-established role as a local anesthetic agent. Systemic intravenous administration expands its clinical use to include acute and chronic pain circumstances, such as postoperative pain, neuropathic pain, postherpetic neuralgia, hyperalgesia, visceral pain, and centrally mediated pain. For refractory pain that has not responded to conventional therapy or if further escalation of treatment is prevented by contraindications or side effects to standard therapies, a continuous infusion of lidocaine may be considered as a single intervention or as a sequence of infusions. Here, we review and evaluate published data reflecting the use of lidocaine continuous infusions for pain management in the pediatric population.

Predictive factors for postoperative ıntensive care unit admission in pediatric patients undergoing scoliosis correction surgery

OBJECTIVE

Postoperative intensive care unit (ICU) admission might be required in adolescent patients following posterior fusion and instrumentation surgery for the treatment of scoliosis. We aimed to evaluate the predictive factors for mechanical ventilation and the characteristics of the patients who required an ICU stay following spinal surgery.

METHODS

We retrospectively reviewed the records of 85 children undergoing primary scoliosis surgery at a university-affiliated general hospital from January 2010 and June 2020 by the same spinal surgeon. The demographic data, pre- and peritoperative variables were collected and recorded. All patients underwent surgery with a combined anesthesia protocol of fentanyl and remifentanil.

RESULTS

There were 31 males (36.5%) and 54 females (63.5%). In the postoperative period, 13 patients (15.3%) were admitted to the ICU, and six of them required mechanical ventilation. Among these, three patients (50%) were extubated within the postoperative 0-12 hours, two (33.3%) within postoperative 12-24 hours, and one (16.7) after postoperative 24 hours. The major complications included acidosis (4.7%), hemodynamic instability (1.2%), hypercapnia (1.2%), hypoxemia (1.2%), and delayed extubation (1.2%).

CONCLUSIONS

A smaller bodyweight percentile, neuromuscular etiology, abnormal findings in preoperative chest X-ray, additional comorbidities, and preoperative estimated risk for postoperative mechanical ventilation were among the risk factors for postoperative ICU stay. The age, height, weight, degree of the curvature, and the number of operated segments did not have an association with the postoperative outcomes.

Ketamine Use in the Surgical Patient: a Literature Review

PURPOSE OF REVIEW

While ketamine is an established anesthetic, its role in the management of acute surgical pain is less certain. Therefore, a literature review is warranted to examine the role of ketamine in acute pain management.

RECENT FINDINGS

The use of ketamine appears to be most efficacious in larger procedures that lead to increased systemic inflammation or extensive tissue damage. In addition, ketamine seems to be most successful when administered consistently throughout a procedure, such as by an infusion instead of a single bolus, in order to have adequate dosing for an analgesic effect. Therefore, the focus of research should be on procedures that lead to moderate to severe pain using frequent dosing to determine the most effective role of ketamine. Most importantly, the current literature shows that ketamine can be used as a successful part of multimodal anesthesia with few side effects in patients undergoing major procedures associated with moderate to severe pain.

Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVE

To identify national trends in postoperative opioid prescribing practices after posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Opioids are an important component of pain management after PSF for AIS. Given the national opioid crisis, it is important to understand opioid prescribing practices in these patients.

METHODS

Using a commercial prescription drug claims database, we identified AIS patients who underwent PSF from 2010 to 2016 and who were prescribed opioids postoperatively. An initial prescription at hospital discharge of ≥ 90 morphine milligram equivalents daily (MMED) was used to identify patients at risk of overdose according to the US Centers for Disease Control and Prevention (CDC) guidelines. Prescriptions for skeletal muscle relaxants were also identified. α = 0.05.

RESULTS

We included 3762 patients (75% female) with a mean (± standard deviation) age of 15 ± 2.1 years. 56% of patients filled only 1 opioid prescription after discharge, and 44% had ≥ 1 refills. 91% of opioid prescriptions were for hydrocodone (median strength, 43 MMED; mean strength, 65 ± 270 MMED) or oxycodone formulations (median strength, 60 MMED; mean strength, 79 ± 174 MMED). 82% of prescriptions complied with CDC guidelines (< 90 MMED). Overall, 612 patients (16%) filled ≥ 1 prescription for skeletal muscle relaxants, the most common being cyclobenzaprine (45%) and methocarbamol (29%). The percentage of patients filling > 1 prescription declined from 54% in 2010 to 31% in 2016 (p < 0.001). The proportion of patients receiving prescriptions for ≥ 90 MMED was highest in the West (29%) and lowest in the South (16%) (p < 0.001).

CONCLUSION

Most opioid prescriptions after PSF in patients with AIS comply with CDC guidelines. Temporal and geographic variations show an opportunity for standardizing opioid prescribing practices in these patients.

LEVEL OF EVIDENCE

III.

Ketamine induces endoplasmic reticulum stress in rats and SV-HUC-1 human uroepithelial cells by activating NLRP3/TXNIP aix

Many clinical studies have been conducted on ketamine-associated cystitis. However, the underlying mechanisms of ketamine-associated cystitis still remain unclear. Bladder tissues of rats were stained by Hematoxylin and Eosin (HE). The viability of human uroepithelial cells (SV-HUC-1 cells) was determined by cell counting kit-8 (CCK-8). Apoptosis and reactive oxygen species (ROS) were examined by flow cytometry. Additionally, the expressions of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-1β and IL-18 were respectively determined by reverse transcription quantitative (RTq)-PCR and enzyme-linked immunosorbent assay (ELISA). The mRNA and protein levels of B-cell lymphoma/leukemia-2 (Bcl2), Bcl-2-associated X protein (Bax), cleaved caspase 3, glucose-regulated protein 78 (GRP78), CCAAT/enhancer binding protein homologous protein (CHOP), NOD-like receptor 3 (NLRP3), thioredoxin-interacting protein (TXNIP), Catalase and MnSOD were examined by RT-qPCR and Western blot. Small interfering RNA target TXNIP transfection was performed using Lipofectamine™ 2000. We found that ketamine effectively damaged bladder tissues of rats and promoted apoptosis through regulating the expression levels of GRP78, CHOP, Bcl-2, Bax and cleaved Caspase-3 proteins in vivo and in vitro. NLRP3 inflammatory body and TXNIP were activated by ketamine, which was supported by the changes in TNF-α, IL-6, IL-1 and IL-18 in vivo and in vitro. Furthermore, knocking down TXNIP reversed the effects of ketamine on apoptosis and NLRP3 inflammatory body in SV-HUC-1 cells. Meanwhile, the changes of Catalase and MnSOD showed that ROS was enhanced by ketamine, however, such an effect was ameliorated by down-regulation of TXNIP in SV-HUC-1 cells. Ketamine promoted cell apoptosis and induced inflammation in vivo and in vitro by regulating NLRP3/TXNIP aix.

An analysis of the safety and efficacy of dexmedetomidine in posterior spinal fusion surgery for adolescent idiopathic scoliosis: a prospective randomized study

PURPOSE

To evaluate whether use of dexmedetomidine, a centrally acting α2 adrenergic agonist, reduces opioid consumption in PSF.

METHODS

Adolescent idiopathic scoliosis patients who underwent PSF were randomized into morphine (M) and dexmedetomidine (D) group. M group received a 10 μg/kg/h IV infusion of morphine for 24 h post-surgery, while the D group received a 0.4 μg/kg/h IV infusion of dexmedetomidine. Trained nursing staffs recorded hourly vital parameters (blood pressure, pulse rate, respiratory rate, and oxygen saturation). Pain, postoperative nausea/vomiting (PONV), and sedation were rated using: the numerical rating scale (NRS), the PONV scale, and sedation status scale (SS). Preemptive analgesia with gabapentin and postoperative analgesia with ketorolac and paracetamol were used in both the groups. Any complications in the study groups were recorded.

RESULTS

No significant difference was noted between the groups (M vs D) with respect to NRS (3.1 ± 0.8 vs 2.7 ± 0.5) (p = 0.07) and breakthrough analgesia requirements (0.78 vs 0.45) (p = 0.17). A significant difference was noted between the groups with respect to the secondary outcome measures of time to ambulation (56.6 ± 12.7 h vs 45.2 ± 7.7 h), time to oral analgesics (84.3 ± 20 h vs 64.0 ± 15.4 h), and time to liquid intake (8.3 ± 1.3 h vs 7.2 ± 1.2 h). The M group had a higher PONV score (0.46 ± 0.3 vs 0.16 ± 0.1) (p < 0.001) and mean time to bowel opening (112.7 ± 28.4 h vs 90.1 ± 20.5 h) (p < 0.001). Additionally, the enema or suppository requirements for bowel opening were significantly more (0.59 ± 0.6 vs 0.26 ± 0.4) (p = 0.01) in the M group.

CONCLUSION

Dexmedetomidine provided analgesia comparable to morphine with lower PONV scores. It also reduced the opioid requirements in the PSF patients without additional complications and can therefore be incorporated in pain management protocols.

Thoracolumbar Dorsal Ramus Nerve Block Using Continuous Multiorifice Infusion Catheters: A Novel Technique for Postoperative Analgesia After Scoliosis Surgery

Background

This is a brief technical report about a novel regional anesthesia technique in which local anesthetic was deposited around the thoracolumbar dorsal rami nerves via 4 multiorifice pain catheters to obtain analgesia for posterior spinal fusion surgery on scoliosis patients. Scoliosis is the most common deformity of the spine. Currently, most surgeons prefer a dual rod, segmental spinal fixation system that allows multiple anchor points for attachment to the deformed spine. Scoliosis surgery is an extremely painful surgical procedure due to the large incision, surgical trauma to superficial and deep muscles of the back, and the insertion of pedicle screws and metal rods directly into the vertebral column. Postoperative pain management remains very challenging.

Methods

Three patients presented with scoliosis. Intraoperatively, 4 multiorifice catheters were placed lateral to the implanted pedicle screws. Two catheters were placed on each side, and a continuous infusion of 0.2 % ropivacaine was initiated postoperatively to improve the patient's pain control. The catheters remained in place for 48 hours postoperatively and were removed by the surgical team. Gentle traction was applied similar to the way epidural catheters are removed.

Results

All 3 patients reported very low pain scores, low doses of opioid consumption, and satisfaction with their pain control throughout their hospitalization.

Conclusions

Our study results suggest that a thoracolumbar dorsal ramus nerve block using continuous multiorifice infusion catheters significantly improved postoperative comfort and pain and that its implementation into a multimodal analgesic regimen is relatively easy to achieve.

Outcome measures evaluating physical functioning and their measurement properties in adolescent idiopathic scoliosis: a protocol for a systematic review

INTRODUCTION

Physical functioning (PF) is the ability to carry out the physical activity of daily living. It is an important outcome that provides a meaningful evaluation of individuals' life. PF can be assessed using patient-reported outcome measures, performance-based outcome measures or body structure and function measure. Measures need to be valid, reliable and responsive to change to evaluate the effects of an intervention. Adolescent idiopathic scoliosis (AIS) is the most common deformity among the paediatric population and impacts on individuals' lives. This systematic review will appraise evidence on the measurement properties of PF tools in individuals with AIS.

METHODS/ANALYSIS

A protocol for systematic review and meta-analysis informed by Cochrane guidelines is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P. MEDLINE, PsycINFO, EMBASE, CINAHL, SPORTdiscus, Web of Science and PubMed will be searched in two stages, from inception until December 2019. Search 1 will inventory all studies that assessed PF in participants with AIS, without any limitations. The search terms will be scoliosis, adolescent and PF-related terms. Search 2 will include studies which investigated instrument measurement properties in the same population for measures identified in search one. Two reviewers will independently perform study selection, data extraction, risk of bias and overall quality assessment. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias and a modified Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines will be used. A meta-analysis will be conducted if possible, or the evidence will be synthesised and summarised per measurement property per outcome measure per measurement type.

ETHICS AND DISSEMINATION

This review will provide recommendations for practice and future research, considering psychometric properties of outcome measures of PF in AIS. The results of this study will be disseminated through a peer-reviewed publication and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019142335.

The Perioperative Efficacy and Safety of Tranexamic Acid in Adolescent Idiopathic Scoliosis

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) in patients with adolescent idiopathic scoliosis undergoing corrective surgery.

METHODS

A literature search of PubMed, Embase, and Cochrane Library was performed to identify studies published from inception to February 2019. After study selection and data extraction, statistical analysis was performed. Odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (CIs) for all available clinical outcomes were analyzed using fixed-effects or random-effects models.

RESULTS

Twelve studies comprising 2500 patients were included. Intravenous TXA use was associated with significantly fewer patients received blood transfusions (odds ratio, 0.12; 95% CI, 0.06 to 0.22; P < 0.001), less intraoperative estimated blood loss (WMD, -470.07; 95% CI, -645.23 to -294.90; P < 0.001), less intraoperative estimated blood loss per segment (WMD, -27.40; 95% CI, -32.80 to -22.00; P < 0.001), less cell salvage blood transfusion (WMD, -106.02; 95% CI, -170.84 to -41.20; P = 0.001), and shorter surgical time (WMD, -26.18; 95% CI, -46.91 to -5.46; P = 0.010). No significant difference was found in postoperative hemoglobin (WMD, 0.39; 95% CI, -0.07 to 0.86; P = 0.100) and hemoglobin change (WMD, -0.92; 95% CI, -2.90 to 1.07; P = 0.360) between TXA and control groups. No renal, thromboembolic, or other major complications associated with TXA were noted in included studies.

CONCLUSIONS

TXA was effective in reducing surgical time, intraoperative estimated blood loss, and blood transfusion without increasing complications in patients undergoing corrective surgery for adolescent idiopathic scoliosis. TXA had no influence on postoperative hemoglobin and hemoglobin change.