title: Peri-operative pain management in children with cerebral palsy: comparative efficacy of epidural vs systemic analgesia protocols.
abstract: BACKGROUND
  Selective Dorsal Rhizotomy (SDR) is the only surgical intervention with class I evidence supporting permanent reduction in spasticity for children with cerebral palsy (Paediatr Anaesth, 12, 2002, 296; Neurosurg Focus, 21, 2006, e2). Postoperatively, adequate analgesia can be difficult to achieve (J Neurosurg, 105, 2006, 8; Childs Nerv Syst, 17, 2001, 556; Pediatr Neurosurg, 43, 2007, 107; Anesth Analg, 79, 1994, 340; Reg Anesth Pain Med, 24, 1999, 438; Pediatr Anesth, 19, 2009, 1213). This study examines a novel regimen utilizing the combination of epidurally infused ropivacaine - hydromorphone and scheduled ketorolac. This regimen was compared to a protocol utilizing systemic fentanyl and diazepam.
  
  
  METHODS
  Following IRB approval, 31 patients receiving epidural analgesia were compared with 41 patients who received systemic analgesia. All surgeries were performed by one surgeon with standardized anesthetic and nursing care. Studied outcomes included: pain scores; episodes of severe pain; nausea, itching; oxygen desaturation; and ICU admission. Data were analyzed using Mann-Whitney U-test, CHI square, and Fisher exact test where indicated with P < 0.05 considered significant.
  
  
  RESULTS
  Studied groups had similar demographics, biometrics and disease burdens. Patients in the epidural group had statistically and clinically significant reductions in peak recorded pain scores for each 4-h period in the first 24 postoperative hours. Severe pain (score >5) was markedly reduced in the epidural group with 9% of epidural patients vs. 68% of systemic patients experiencing at least one episode. Fewer epidural patients experienced oxygen desaturation during the first two postoperative days (6.5% vs. 41%, 6.5% vs. 39%).
  
  
  CONCLUSIONS
  Epidural analgesia resulted in substantial improvements in pain control and safety. The data supports the superiority of a multimodal analgesia approach centered on epidural analgesia. A similar protocol should be considered following simple laminectomies or procedures associated with lower-extremity muscle spasm.
authors.affiliation: Division of Pediatric Anesthesiology, Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA. moorero@anest.wustl.edu
authors.forename: Robert P
authors.initials: RP
authors.lastname: Moore
authors.forename: Tracy
authors.initials: T
authors.lastname: Wester
authors.forename: Rani
authors.initials: R
authors.lastname: Sunder
authors.forename: Charles
authors.initials: C
authors.lastname: Schrock
authors.forename: Tae S
authors.initials: TS
authors.lastname: Park
mesh_terms: D000698:Analgesia / Q000009:adverse effects / Q000379:methods*; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects; D002547:Cerebral Palsy / Q000150:complications*; D002648:Child; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D019635:Neurosurgical Procedures; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy; D061214:Patient Safety; D019990:Perioperative Care / Q000379:methods*; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology / Q000628:therapy; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy; D012189:Retrospective Studies; D019051:Rhizotomy
chemical_list: D000701:Analgesics, Opioid
keywords: acute; drugs; local anesthetics; neurological disease; neurosurgery; pain; regional