Adjunctive Pain Control Methods Lower Narcotic Use and Pain Scores for Patients With Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion.

STUDY DESIGN: This was a retrospective review of patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF). OBJECTIVES: To determine whether the use of adjunctive pain medications (bupivacaine pump, dexmedetomidine, and ketorolac) will reduce the need for opioids, reduce postoperative pain, and shorten length of hospital stay in patients with AIS undergoing PSF. SUMMARY OF BACKGROUND DATA: Posterior spinal fusion and instrumentation for AIS can cause significant postoperative pain. Adjunctive pain control modalities, including the use of ketorolac, dexmedetomidine, and subcutaneous bupivacaine pumps, all can lessen the effects of postoperative pain. METHODS: Retrospective review of adolescents aged 10-18 years with AIS receiving PSF surgery over the past 10 years at a tertiary care children's hospital. All patients with AIS undergoing PSF were included in the study. Patients older than 18 or younger than 10 years and those undergoing PSF for other diagnoses, including neuromuscular scoliosis, congenital scoliosis, and kyphosis, were excluded from the study. Patients' pain was managed postoperatively with adjunctive medications in addition to intravenous and oral opioids. Variables of interest were local anesthetic bupivacaine delivered through a subcutaneous pump, sedative/analgesic dexmedetomidine, and ketorolac. Primary outcomes analyzed were normalized opioid requirement after surgery, visual analog scale (VAS) pain scores, and length of stay in the hospital. RESULTS: A total of 196 children were analyzed with no significant differences in demographics. Univariate analysis showed that all 3 adjunct medications improved outcomes. A multivariate regression model of the outcomes with respect to the 3 medication variables of interest was built, showing that the bupivacaine pump significantly reduced normalized opioid requirement by 0.98 mg/kg (p = .001) and reduced VAS pain scores by 0.67 points (p = .004). Dexmedetomidine significantly reduced the average VAS pain scores in the first 24 hours by 0.62 points (p = .005). CONCLUSIONS: Use of the bupivacaine pump provided improved analgesia with lower pain scores, lower opioid requirements, and a lower length of stay.

Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospective study at a tertiary pediatric hospital.

OBJECTIVES: This study evaluated the effectiveness of dexmedetomidine in decreasing opioid use in children with adolescent idiopathic scoliosis following posterior spinal fusion surgery at a pediatric tertiary care hospital over the past 10 years. DESIGN: This was a retrospective chart review. Patients were separated into two groups: those that received opioid via patient-controlled analgesia pain therapy alone and those that received opioid via patient-controlled analgesia pain therapy with dexmedetomidine. SETTING: A tertiary pediatric free-standing hospital. The study focused on care administered in the perioperative period, including the operating room, ICU, and general hospital floor. PATIENTS: One hundred sixty-three children with adolescent idiopathic scoliosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measurements included patient demographics, American Society of Anesthesiologists Physical Status Classification System, levels of spinal fusion, length of hospital stay, complications, numeric pain scores, opioid requirement, elastomeric pain pump use, length of time until ambulation, adverse effects, and naloxone use. Data were collected through the first 72 hours of the perioperative period. One hundred six patients received opioids via patient-controlled analgesia therapy with dexmedetomidine and 57 received opioids via patient-controlled analgesia alone. Within the groups, there were 46 patients who received local anesthetic infusions via elastomeric pumps in the patient-controlled analgesia with dexmedetomidine group and 16 patients had pumps in the patient-controlled analgesia-alone group. There was no overall difference in postoperative use of morphine (or equivalents) between the two groups. However, the use of elastomeric pain pumps demonstrated a statistically significant decrease in mean overall opioid consumption (42.6 mg vs 63.1 mg, p < 0.001). CONCLUSIONS: There was no difference in opioid use related to dexmedetomidine on any postoperative day. The only variable showing a significant opioid sparing effect was the use of local anesthetic infusions via elastomeric pumps. Using continuous local anesthetic infusions instead of dexmedetomidine could eliminate the need for ICU admission, require shorter hospital stays, and reduce costs while still providing safe and effective pain control.

Are We Undermedicating Patients With Neuromuscular Scoliosis After Posterior Spinal Fusion?

STUDY DESIGN: Retrospective, matched study of patients with adolescent idiopathic scoliosis (AIS) and patients with cerebral palsy (CP) undergoing (PSF). OBJECTIVES: To compare pain management, through measurement of the amount of narcotic used and pain scores, for patients with neuromuscular (NM) scoliosis undergoing PSF to a cohort of patients with AIS. SUMMARY OF BACKGROUND DATA: Posterior spinal fusion for children with severe NM scoliosis carries a high risk of complications. Appropriate assessment of pain is crucial; undertreatment of pain leads to anxiety whereas overtreatment can lead to respiratory depression and additional complications. METHODS: A series of patients with NM scoliosis was matched for age, gender, and weight with a group of patients with AIS. Data collection included age, curve type and magnitude, and instrumentation type and levels fused. The total opioid used (TOU) was determined by summing all narcotics given during the hospital stay and converting them to morphine equivalent units. The data were then analyzed to determine differences in TOU. RESULTS: A total of 25 patients with NM scoliosis were included in the study. This group was matched with 25 patients with AIS scoliosis. The TOU for the NM group was 1.2 mg morphine/kg (range, 0.28-4.21 mg morphine/kg) whereas the TOU for the AIS group was 3.52 mg morphine/kg (range, 0.71-15.51 mg morphine/kg) (p < .0000001). CONCLUSIONS: In this case-control analysis, patients with AIS undergoing PSF received more than twice the amount of narcotic compared with a matched group of patients with NM scoliosis. These data suggest that NM patients' pain may be undertreated compared with AIS patients. More study is indicated to investigate pain assessment and pain control in this vulnerable patient population to improve care.

Military return to duty and civilian return to work factors following burns with focus on the hand and literature review.

Functional recovery and outcome from severe burns is oftentimes judged by the time required for a person to return to work (RTW) in civilian life. The equivalent in military terms is return to active duty. Many factors have been described in the literature as associated with this outcome. Hand function, in particular, is thought to have a great influence on the resumption of preburn activities. The purpose of this investigation was to compare factors associated with civilian RTW with combat injured military personnel. A review of the literature was performed to assimilate the many factors reported as involved with RTW or duty. Additionally, a focus on the influence of hand burns is included. Thirty-four different parameters influencing RTW have been reported inconsistently in the literature. In a military population of combat burns, TBSA burn, length of hospitalization and intensive care and inhalation injury were found as the most significant factors in determining return to duty status. In previous RTW investigations of civilian populations, there exists a scatter of factors reported to influence patient disposition with a mixture of conflicting results. In neither military nor civilian populations was the presence of a hand burn found as a dominant factor. Variety in patient information collected and statistical approaches used to analyze this information were found to influence the results and deter comparisons between patient populations. There is a need for a consensus data set and corresponding statistical approach used to evaluate RTW and duty outcomes after burn injury.