title: Pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion: combined intrathecal morphine and continuous epidural versus PCA.
abstract: METHODS
  A retrospective case-comparison study.
  
  
  OBJECTIVE
  Compare efficacy and safety of combined intrathecal morphine (ITM) and epidural analgesia (EPI) to that of conventional intravenous patient-controlled analgesia (IV-PCA) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).
  
  
  BACKGROUND
  Pain control after PSF in AIS has been managed traditionally with IV-PCA. More recently studies have shown improvement in pain control with the use of continuous EPI or intraoperative ITM. No studies to our knowledge have compared the use of both ITM and EPI analgesia to that of IV-PCA.
  
  
  METHODS
  An Institutional Review Board-approved retrospective case-comparison study was performed from 1989 to 2009 of all patients undergoing PSF for AIS. Patients received either IV-PCA or ITM/EPI. Daily pain scores were recorded along with total opioid and benzodiazepine use. Adverse events were recorded for all the patients.
  
  
  RESULTS
  A total of 146 patients were initially included in the study; 95 patients received ITM/EPI and 51 received IV-PCA as a historical control. Eight patients from the ITM/EPI group were excluded from the pain comparison portion of the study. There were no statistical differences in age, sex, weight, or hospital stay between the 2 groups. The ITM/EPI group had, on average, 1 additional level of fusion (P = 0.001). Daily average pain scores were lower in the ITM/EPI group on all hospital days, and statistically lower in days 1 and 3 to 5. Total opioid requirement was significantly lower in the ITM/EPI patients, although oral opioid use was higher among this group. Total benzodiazepine use was lower among the IV-PCA group. A total of 15.7% of the IV-PCA patients had bladder hypotonia, compared with 1.1% of the ITM/EPI group (P = 0.002). The rate of illeus was 15.7% in the IV-PCA patients and 5.7% in the ITM/EPI (P = 0.071). Respiratory depression was reported in 4 ITM/EPI patients, 0 in our PCA group. Technical catheter malfunction was reported in 8.5% of the EPI group.
  
  
  CONCLUSIONS
  The use of ITM/EPI after PSF for AIS is safe and effective, this methodology provided significantly lower pain scores and lowers total opioid use which can lead to urinary and bowel dysfunction.
authors.affiliation: Department of Orthopaedics and Rehabilitation, Department of Anesthesiology, School of Medicine and Public Health, American Family Children's Hospital, University of Wisconsin, Madison, WI, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Ravish
authors.forename: Bridget
authors.initials: B
authors.lastname: Muldowney
authors.forename: Aimee
authors.initials: A
authors.lastname: Becker
authors.forename: Scott
authors.initials: S
authors.lastname: Hetzel
authors.forename: James J
authors.initials: JJ
authors.lastname: McCarthy
authors.forename: Blaise A
authors.initials: BA
authors.lastname: Nemeth
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Noonan
mesh_terms: D000293:Adolescent; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects; D002648:Child; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D008297:Male; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy* / Q000209:etiology; D012189:Retrospective Studies; D012600:Scoliosis / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine