A comparison of three methods of pain control for posterior spinal fusions in adolescent idiopathic scoliosis.
METHODS
Retrospective cohort study.


OBJECTIVE
To compare the efficacy of patient-controlled analgesia (PCA) with morphine alone, a single preoperative intrathecal morphine injection and PCA (IT/PCA), and epidural catheter infusion without PCA (EPI) for postoperative pain control after posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) in adolescent idiopathic scoliosis (AIS).


BACKGROUND
Postoperative pain control after PSF and SSI in AIS can be managed in different ways. EPI provides for a longer period of pain relief but is reliant on the correct placement and maintenance of the catheter in the epidural space. A single preoperative intrathecal morphine injection also provides for long acting analgesia. No direct comparison of these 3 methods of postoperative pain control has been reported.


METHODS
An IRB-approved retrospective chart review was performed at 2 institutions from 1997 to 2005. The medical record was reviewed to determine pain scores after surgery at multiple time periods. The 3 groups were compared using Student t test and chi and significance was defined as P < 0.05.


RESULTS
There was no statistical difference in the gender, age, magnitude of curve, or number of levels fused in the IT/PCA (N = 42), PCA (N = 41), or EPI (N = 55) groups. Postoperative pain scores were lowest in the IT/PCA group in the first 8 hours (P < 0.05) but the pain scores in the EPI group were then lower through 24 hours (P < 0.05). Total morphine use (mg/kg) was lower in the IT/PCA group compared with the PCA group at 12 hours and 24 hours (P = 0.0001). Return to solid food ingestion was quickest in the EPI group (2.0 days) followed by the IT/PCA (2.6 days) and PCA alone (3.2 days) (P < 0.002). Respiratory depression and transient neurologic change occurred most frequently in the EPI group (EPI 11/55 pts vs. 1/42 IT/PCA vs. 0/41 PCA P < 0.001). Pruritus was greatest in the epidural group (11/55 P < 0.05). There were no intraoperative somatosensory-evoked potential changes or permanent neurologic injury recorded in any group.


CONCLUSIONS
An EPI controls postoperative pain for the longest period of time and allows for a quicker return to consumption of solid foods. However, a single preoperative intrathecal morphine injection controls the pain equally for the first 24 hours with less pruritus and with less adverse events thus requiring less nursing and physician intervention after PSF and SSI in AIS. All methods were safe with no neurologic injury recorded.
Milbrandt
Todd A
TA
Shriners Hospital for Children, Lexington, KY 40502, USA. tmilbrandt@shrinenet.org
Singhal
Manuj
M
Minter
Christin
C
McClung
Anna
A
Talwalkar
Vishwas R
VR
Iwinski
Henry J
HJ
Walker
Janet
J
Beimesch
Claire
C
Montgomery
Christopher
C
Sucato
Daniel J
DJ
D000293:Adolescent; D015360:Analgesia, Epidural / Q000295:instrumentation / Q000379:methods; D016058:Analgesia, Patient-Controlled / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D009020:Morphine / Q000008:administration & dosage; D009325:Nausea / Q000209:etiology; D009984:Orthopedic Fixation Devices; D010149:Postoperative Pain / Q000209:etiology / Q000517:prevention & control*; D011183:Postoperative Complications / Q000209:etiology; D011537:Pruritus / Q000209:etiology; D020127:Recovery of Function; D012189:Retrospective Studies; D012600:Scoliosis / Q000503:physiopathology / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D014839:Vomiting / Q000209:etiology
D000701:Analgesics, Opioid; D009020:Morphine