Review Article: Postoperative pain management following scoliosis surgery
To conclude this week’s review of pain management following scoliosis surgery, here’s an article nicely summarazing the topic. We’ll explore remifenanil’s effects on post-operative pain at a later time.
Curr Opin Anaesthesiol. 2008 Jun;21(3):313-6.
Postoperative pain management following scoliosis surgery.
Department of Anesthesiology, Orthopedic University Clinic Balgrist, Zurich, Switzerland. alain.borgeat@balgrist.ch
PURPOSE OF REVIEW: The control of pain after scoliosis surgery is a real challenge for the anesthesiologist. The first reason is that major spine surgery for correction of scoliosis deformation causes severe postoperative pain, and second that patients undergoing these operations are most often children or adolescents who are known to suffer from increased pain sensation compared with adults. RECENT FINDINGS: A multimodal postoperative pain therapy is a well established procedure to control the pain after scoliosis surgery. Recently, prospective, well controlled studies have emphasized the key role of regional techniques in this context. Epidural analgesia has shown significant benefits regarding pain score, bowel recovery and patients’ satisfaction. However, different modes of epidural analgesia application have been performed. Several issues including local anaesthetic concentration and infusion rate, duration of application and number of catheters placed will be discussed. The safety concerns associated with this type of analgesia will also be emphasized. SUMMARY: Significant improvements have been made in the control of postoperative pain after correction of scoliosis deformation in recent years. The introduction of epidural analgesia has cleared the way for better analgesic techniques in this surgical context. Properly performed and assessed, the addition of epidural analgesia after scoliosis surgery is a safe and effective form of analgesia and the benefits far outweigh the risks.
Postoperative pain management following scoliosis …[Curr Opin Anaesthesiol. 2008] – PubMed Result .
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Brilliant article as you can expect from the Borgeat group.
Epidural is fine, but as everything in Acute Pain Medicine and RA, you can’t expect the block to work on nerves not reached by the local anesthetic agent. One needs really large infusion volumes and rates to cover the large extent of this surgery if only one or not enough catheters are used. I think that is where the controversy comes from.
I have always (and with great success and satisfaction) ascribed to my “Rule of 5’s”: That is one catheter for every 5 segments operated; tread the catheter 5 cm into the epidural space (so it does not dislodge); and infuse 5 mL per hour of a low concentration local anesthetic, with or without hydromorphone (say 10mcg/mL for example) maybe through the middle catheter.
This is anecdotal only based on experience and thus not yet proved standard of practice. We are currently in the process of designing a formal study to evaluate the “Rule of 5’s” and present the evidence (either way).
Thanks for a great blog Patrick.
André P. Boezaart
Nice article. Were i trained we stayed away from epidural in spines just for the reason Dr. Boezaart stated, we tried one epidural cath placed under direct vision by surgery. We found a poor spread of local. We managed our spines with intrathecal morphine on induction, ran a low dose ketamine in fusion 0.1 mg/kg/hr for intraop and 1st 24 hrs, followed by 0.06 mg/kg/hr for another 48 hrs, mith morphine pca with continous infusion, and q 8hr. lorazepam or diazepam for spasms. We found this mix to provide a great deal of pain relief and the patients were up in chair within 24 hours.