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Review of Recent Advances in Pain Management for Pediatric Spinal Fusion

  • Pediatric Anesthesia (J Lerman, Section Editor)
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Abstract

Pain management for children after posterior spinal fusion is complex. This has been attributed to several factors including severe postoperative pain and treating a heterogeneous group of patients who range in disease severity from healthy adolescents to severely handicapped children with underlying neuromuscular disease or syndrome with minimal respiratory and cardiac reserve. The goals for pain management include minimizing the duration of severe pain, reducing opioid consumption, minimizing opioid-associated side effects, and rapid return to oral feeds and physical function. Optimal analgesia commences with preoperative nonpharmacological interventions such as pain coping skills. Multimodal analgesia comprises the basis of successful pain management. The expected pain trajectory shows that two-thirds of patients require opioids for pain control for 2–6 weeks postoperatively. With the prolonged period of postoperative pain, the pain management plan should continue after discharge from hospital. About one third of patients still require opioids 6 weeks postoperatively and 20% suffer pain at or above preoperative levels at 6 months postoperatively. The latter group of patients can benefit from early follow-up in a pediatric pain clinic.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lee BH, Park J-O, Suk K-S, Kim T-H, Lee H-M, Park M-S, et al. Pre-emptive and multi-modal perioperative pain management may improve quality of life in patients undergoing spinal surgery. Pain Physician. 2013;16(3):E217–26.

    PubMed  Google Scholar 

  2. •• Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci. 2015;22(6):930–8. Multimodal pain management has been demonstrated to improve postoperative pain outcomes and reduce opioid consumption. This comprehensive literature review grades the level of evidence for commonly used agents in multimodal pain management and provide a best practice guideline.

    Article  PubMed  Google Scholar 

  3. Kwan MK, Chiu CK, Chan TS, Chong KI, Mohamad SM, Hasan MS, et al. Trajectory of post-operative wound pain within the first two weeks following posterior spinal fusion surgery in adolescent idiopathic scoliosis patients. Spine. 2016.

  4. • Connelly M, Fulmer RD, Prohaska J, Anson L, Dryer L, Thomas V, et al. Predictors of postoperative pain trajectories in adolescent idiopathic scoliosis. Spine. 2014;39(3):E174–81. Describes the pain trajectory after spinal fusion in adolescent idiopathic scoliosis, which is longer than after many other surgeries. The article describes variables that change trajectories towards worse or better pain outcomes.

    Article  PubMed  Google Scholar 

  5. •• Sieberg CB, Simons LE, Edelstein MR, DeAngelis MR, Pielech M, Sethna N, et al. Pain prevalence and trajectories following pediatric spinal fusion surgery. J Pain. 2013;14(12):1694–702. This study examines longitudinal pediatric pain trajectories and factors contributing to pain following spinal fusion for patients with adolescent idiopathic scoliosis. Five pain trajectories were identified and were distinguishable on presurgical characteristics of age, mental health and self-image.

    Article  PubMed  Google Scholar 

  6. Rhodes L, Nash C, Moisan A, Scott DC, Barkoh K, Warner WC, et al. Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop. 2015;35(3):276–9.

    Article  PubMed  Google Scholar 

  7. Taylor CP, Angelotti T, Fauman E. Pharmacology and mechanism of action of pregabalin: the calcium channel alpha2-delta (alpha2-delta) subunit as a target for antiepileptic drug discovery. Epilepsy Res. 2007;73(2):137–50.

    Article  CAS  PubMed  Google Scholar 

  8. Mayell A, Srinivasan I, Campbell F, Peliowski A. Analgesic effects of gabapentin after scoliosis surgery in children: a randomized controlled trial. Paediatr Anaesth. 2014;24(12):1239–44.

    Article  PubMed  Google Scholar 

  9. Rusy LM, Troshynski TJ, Weisman SJ. Gabapentin in phantom limb pain management in children and young adults: report of seven cases. … of pain and symptom management. 2001.

  10. Jirarattanaphochai K, Jung S. Nonsteroidal antiinflammatory drugs for postoperative pain management after lumbar spine surgery: a meta-analysis of randomized controlled trials. J Neurosurg Spine. 2008;9(1):22–31.

    Article  PubMed  Google Scholar 

  11. Dodwell ER, Latorre JG, Parisini E, Zwettler E, Chandra D, Mulpuri K, et al. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87(3):193–202.

    Article  CAS  PubMed  Google Scholar 

  12. Kay RM, Directo MP, Leathers M, Myung K, Skaggs DL. Complications of ketorolac use in children undergoing operative fracture care. J Pediatr Orthop. 2010;30(7):655–8.

    Article  PubMed  Google Scholar 

  13. Rowe E, Cooper TE, McNicol ED. Ketorolac for postoperative pain in children. John Wiley & Sons, Ltd: The Cochrane Library; 2016.

    Book  Google Scholar 

  14. Moriarty C, Carroll W. Paracetamol: pharmacology, prescribing and controversies. Arch Dis Child Educ Pract Ed. BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health; 2016;101(6):331–4.

  15. Hiller A, Helenius I, Nurmi E, Neuvonen PJ, Kaukonen M, Hartikainen T, et al. Acetaminophen improves analgesia but does not reduce opioid requirement after major spine surgery in children and adolescents. Spine. 2012;37(20):E1225–31.

    Article  PubMed  Google Scholar 

  16. Fentanyl Sparing Effects of Combined Ketorolac and Acetaminophen for Outpatient Inguinal Hernia Repair in Children. Elsevier Inc; 2010;183(4):1551–5.

  17. • Wong I, St John Green C, Walker SM. Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children. Paediatr Anaesth. 2013;23(6):475–95. Pediatric perioperative pain can be effectively managed with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or paracetamol while reducing opioid consumption.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. British Journal of Anaesthesia. Oxford University Press; 2014;112(6):991–1004.

  19. Rivosecchi RM, Rice MJ, Smithburger PL, Buckley MS, Coons JC, Kane-Gill SL. An evidence based systematic review of remifentanil associated opioid-induced hyperalgesia. Expert Opin Drug Saf. 2014;13(5):587–603.

    Article  CAS  PubMed  Google Scholar 

  20. Tripi PA, Kuestner ME, Poe-Kochert CS, Rubin K, Son-Hing JP, Thompson GH, et al. Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents. J Pain Res. 2015;8:637–40.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. McDonnell C, Zaarour C, Hull R, Thalayasingam P, PEHORA C, Ahier J, et al. Pre-treatment with morphine does not prevent the development of remifentanil-induced hyperalgesia. Can J Anesth/J Can Anesth. 2008;55(12):813–8.

    Article  Google Scholar 

  22. Blackman RG, Reynolds J, Shively J. Intrathecal morphine: dosage and efficacy in younger patients for control of postoperative pain following spinal fusion. Orthopedics. 1991;14(5):555–7.

    Article  CAS  PubMed  Google Scholar 

  23. Goodarzi M. The advantages of intrathecal opioids for spinal fusion in children. Paediatr Anaesth. 1998;8(2):131–4.

    Article  CAS  PubMed  Google Scholar 

  24. Tripi PA, Poe-Kochert C, Potzman J, Son-Hing JP, Thompson GH. Intrathecal morphine for postoperative analgesia in patients with idiopathic scoliosis undergoing posterior spinal fusion. Spine. 2008;33(20):2248–51.

    Article  PubMed  Google Scholar 

  25. Eschertzhuber S, Hohlrieder M, Keller C, Oswald E, Kuehbacher G, Innerhofer P. Comparison of high- and low-dose intrathecal morphine for spinal fusion in children. Br J Anaesth. 2008;100(4):538–43.

    Article  CAS  PubMed  Google Scholar 

  26. •• Jitpakdee T, Mandee S. Strategies for preventing side effects of systemic opioid in postoperative pediatric patients. Paediatr Anaesth. 2014;24(6):561–8. Reviews strategies that prevent or reduce opioid induced side effects in children during the post-operative period, including the use of multimodal analgesia, local anesthetics, opioid titration and providing the specific prophylaxis for each side effect

    Article  PubMed  Google Scholar 

  27. Goodarzi M, Shier NH, Grogan DP. Effect of intrathecal opioids on somatosensory-evoked potentials during spinal fusion in children. Spine. 1996;21(13):1565–8.

    Article  CAS  PubMed  Google Scholar 

  28. Stricker PA, Sestokas AK, Schwartz D, Bhalodia V, Pahwa A, Dormans JP, et al. Effects of intrathecal morphine on transcranial electric motor-evoked potentials in adolescents undergoing posterior spinal fusion. Anesth Analg. 2012;115(1):160–9.

    Article  CAS  PubMed  Google Scholar 

  29. Schmitz A, Salgo B, Weiss M, Dillier CM, Frotzler A, Gerber AC. Intrathecal opioid medication for perioperative analgesia in severely handicapped children undergoing spinal operations. Anaesthesist. 2010;59(7):614–20.

    Article  CAS  PubMed  Google Scholar 

  30. Ibach BW, Loeber C, Shukry M, Hagemann TM, Harrison D, Johnson PN. Duration of intrathecal morphine effect in children with idiopathic scoliosis undergoing posterior spinal fusion. J Opioid Manag. 2015;11(4):295–303.

    Article  PubMed  Google Scholar 

  31. Hong RA, Gibbons KM, Li GY, Holman A, Voepel-Lewis T. A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis. Paediatr Anaesth. 2016.

  32. Hong R, Gauger V, Caird MS, Burke C. Narcotic-only epidural infusion for posterior spinal fusion patients: a single-center, retrospective review. J Pediatr Orthop. 2015:1.

  33. Erdogan MA, Ozgul U, Uçar M, Korkmaz MF, Aydogan MS, Ozkan AS, et al. Patient-controlled intermittent epidural bolus versus epidural infusion for posterior spinal fusion after adolescent idiopathic scoliosis: prospective randomized double-blinded study. Spine. 2016;1

  34. Saudan S, Habre W, Ceroni D, Meyer P-A, Greenberg RS, Kaelin A, et al. Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery. Paediatr Anaesth. 2008;18(2):132–9.

    PubMed  Google Scholar 

  35. Borgeat A, Blumenthal S. Postoperative pain management following scoliosis surgery. Curr Opin Anaesthesiol. 2008;21(3):313–6.

    Article  PubMed  Google Scholar 

  36. Lavelle ED, Lavelle WF, Goodwin R, Gurd D, Kuivila T, Youssef G, et al. Epidural analgesia for postoperative pain control after adolescent spinal fusion procedures which violated the epidural space. J Spinal Disord Tech. 2010;23(5):347–50.

    Article  PubMed  Google Scholar 

  37. Ravish M, Muldowney B, Becker A, Hetzel S, McCarthy JJ, Nemeth BA, et al. Pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion: combined intrathecal morphine and continuous epidural versus PCA. J Pediatr Orthop. 2012;32(8):799–804.

    Article  PubMed  Google Scholar 

  38. Li Y, Lu S, Ma S-C, Fan H-W, Zhao G-Q. Effects of patient-controlled epidural analgesia and patient-controlled intravenous analgesia on analgesia in patients undergoing spinal fusion surgery. Am J Ther. 2016;23(6):e1806–12.

    Article  PubMed  Google Scholar 

  39. Milbrandt TA, Singhal M, Minter C, McClung A, Talwalkar VR, Iwinski HJ, et al. A comparison of three methods of pain control for posterior spinal fusions in adolescent idiopathic scoliosis. Spine. 2009;34(14):1499–503.

    Article  PubMed  Google Scholar 

  40. Wenk M, Ertmer C, Weber TP, Liljenqvist UR, Popping DM, Mollmann M, et al. Feasibility and efficacy of preoperative epidural catheter placement for anterior scoliosis surgery. Anesthesiology. 2010;113(2):353–9.

    Article  PubMed  Google Scholar 

  41. Gauger VT, Voepel-Lewis TD, Burke CN, Kostrzewa AJ, Caird MS, Wagner DS, et al. Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion. J Pediatr Orthop. 2009;29(6):588–93.

    Article  PubMed  Google Scholar 

  42. Sunderesan R, Salim F, Oren C. Post-epidural unilateral paralysis of intercostal muscles in child. J Coll Physicians Surg Pak. 2010;20(6):408–9.

    PubMed  Google Scholar 

  43. HAYES J, Dowling JJ, Peliowski A, Crawford MW, Johnston B. Patient-controlled analgesia plus background opioid infusion for postoperative pain in children: a systematic review and meta-analysis of randomized trials. Anesth Analg. 2016;123(4):991–1003.

    Article  CAS  PubMed  Google Scholar 

  44. Van Boerum DH, Smith JT, Curtin MJ. A comparison of the effects of patient-controlled analgesia with intravenous opioids versus epidural analgesia on recovery after surgery for idiopathic scoliosis. Spine. 2000;25(18):2355–7.

    Article  CAS  PubMed  Google Scholar 

  45. Cassady JF, Lederhaas G, Cancel DD. A randomized comparison of the effects of continuous thoracic epidural analgesia and intravenous patient-controlled analgesia after posterior spinal fusion in …. … anesthesia and pain …. 2000.

  46. Tian P, Fu X, Li Z-J, Ma X-L. Comparison of patient-controlled epidural analgesia and patient-controlled intravenous analgesia after spinal fusion surgery: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord BioMed Central. 2015;16(1):388.

    Article  CAS  Google Scholar 

  47. Matava CT, Crawford MW, PEHORA C, Naser B, McDonnell C. Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery. J Opioid Manag. 2014;10(1):39–45.

    Article  PubMed  Google Scholar 

  48. McDonnell C, Pehora C, Crawford MW. PCA-derived factors that may be predictive of postoperative pain in pediatric patients: a possible role for the PCA ratio. J Opioid Manag. 2012;8(1):39–44.

    Article  PubMed  Google Scholar 

  49. Jouguelet-Lacoste J, La Colla L, Schilling D, Chelly JE. The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature. Pain Med. 2015;16(2):383–403.

    Article  PubMed  Google Scholar 

  50. Perelló M, Artés D, Pascuets C, Esteban E, Ey AM. Prolonged Perioperative Low-Dose Ketamine Does Not Improve Short and Long-term Outcomes After Pediatric Idiopathic Scoliosis Surgery. Spine. 2016:1.

  51. Pestieau SR, Finkel JC, Junqueira MM, Cheng Y, Lovejoy JF, Wang J, et al. Prolonged perioperative infusion of low-dose ketamine does not alter opioid use after pediatric scoliosis surgery. Paediatr Anaesth. 2014;24(6):582–90.

    Article  PubMed  Google Scholar 

  52. Engelhardt T, Zaarour C, Crawford MW. Plasma cyclic guanosine 3′,5′-monophosphate levels: a marker of glutamate-nitric oxide-guanyl cyclase activity? J Opioid Manag. 2011;7(6):462–6.

    Article  PubMed  Google Scholar 

  53. Jabbour HJ, Naccache NM, Jawish RJ, Abou Zeid HA, Jabbour KB, Rabbaa-Khabbaz LG, et al. Ketamine and magnesium association reduces morphine consumption after scoliosis surgery: prospective randomised double-blind study. Acta Anaesthesiol Scand. 2014;58(5):572–9.

    Article  CAS  PubMed  Google Scholar 

  54. Maxwell LG, Kaufmann SC, Bitzer S, Jackson EVJ, McGready J, Kost-Byerly S, et al. The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study. Anesth Analg. 2005;100(4):953–8.

    Article  CAS  PubMed  Google Scholar 

  55. Miller JL, Hagemann TM. Use of pure opioid antagonists for management of opioid-induced pruritus. Am J Health Syst Pharm. 2011;68(15):1419–25.

    Article  CAS  PubMed  Google Scholar 

  56. He F, Jiang Y, Li L. The effect of naloxone treatment on opioid-induced side effects: a meta-analysis of randomized and controlled trails. Medicine (Baltimore). 2016;95(37):e4729.

    Article  CAS  Google Scholar 

  57. West N, Ansermino JM, Carr RR, Leung K, Zhou G, Lauder GR. A naloxone admixture to prevent opioid-induced pruritus in children: a randomized controlled trial. Can J Anaesth. 2015;62(8):891–900.

    Article  PubMed  Google Scholar 

  58. Firouzian A, Gholipour Baradari A, Alipour A, Emami Zeydi A, Zamani Kiasari A, Emadi SA, et al. Ultra-low-dose naloxone as an adjuvant to patient controlled analgesia (PCA) with morphine for postoperative pain relief following lumber discectomy: a double-blind, randomized, placebo-controlled trial. Journal of Neurosurgical Anesthesiology. 2016.

  59. • Monitto CL, Kost-Byerly S, White E, CKK L, Rudek MA, Thompson C, et al. The optimal dose of prophylactic intravenous naloxone in ameliorating opioid-induced side effects in children receiving intravenous patient-controlled analgesia morphine for moderate to severe pain: a dose finding study. Anesth Analg. 2011;113(4):834–42. Several studies have shown that naloxone is effective to reduce opioid induced side effects in children. This dose finding study helps us optimize dosing to reduce side effects without reducing analgesia.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Burness CB, Keating GM. Oxycodone/naloxone prolonged-release: a review of its use in the management of chronic pain while counteracting opioid-induced constipation. Drugs. 2014;74(3):353–75.

    Article  CAS  PubMed  Google Scholar 

  61. Rozet I, Metzner J, Brown M, Treggiari MM, Slimp JC, Kinney G, et al. Dexmedetomidine does not affect evoked potentials during spine surgery. Anesth Analg. 2015;121(2):492–501.

    Article  CAS  PubMed  Google Scholar 

  62. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Paediatr Anaesth. 2008;18(11):1082–8.

    Article  PubMed  Google Scholar 

  63. Ngwenyama NE, Anderson J, Hoernschemeyer DG, Tobias JD. Effects of dexmedetomidine on propofol and remifentanil infusion rates during total intravenous anesthesia for spine surgery in adolescents. Paediatr Anaesth Blackwell Publishing Ltd. 2008;18(12):1190–5.

    Google Scholar 

  64. Wade Shrader M, Nabar SJ, Jones JS, Falk M, Cotugno R, White GR, et al. Adjunctive pain control methods lower narcotic use and pain scores for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Spine Deformity. 2015;3(1):82–7.

    Article  CAS  PubMed  Google Scholar 

  65. Jones JS, Cotugno RE, Singhal NR, Soares N, Semenova J, Nebar S, et al. Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospective study at a tertiary pediatric hospital. Pediatr Crit Care Med. 2014;15(6):e247–52.

    Article  PubMed  Google Scholar 

  66. Sadhasivam S, Boat A, Mahmoud M. Comparison of patient-controlled analgesia with and without dexmedetomidine following spine surgery in children. J Clin Anesth. 2009;21(7):493–501.

    Article  CAS  PubMed  Google Scholar 

  67. Griffin CE, Kaye AM, Bueno FR, Kaye AD. Benzodiazepine pharmacology and central nervous system-mediated effects. Ochsner J. 2013;13(2):214–23.

    PubMed  PubMed Central  Google Scholar 

  68. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Cochrane back review group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine. 2003;28(17):1978–92.

    Article  PubMed  Google Scholar 

  69. Greze J, Vighetti A, Incagnoli P, Quesada J-L, Albaladejo P, Palombi O, et al. Does continuous wound infiltration enhance baseline intravenous multimodal analgesia after posterior spinal fusion surgery? A randomized, double-blinded, placebo-controlled study. Eur Spine J. Springer Berlin Heidelberg; 2016:1–8.

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  1. Anesthesia, Pain and Intensive Care Division, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel

    Daniel Stocki

  2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Daniel Stocki

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Stocki, D. Review of Recent Advances in Pain Management for Pediatric Spinal Fusion. Curr Anesthesiol Rep 7, 156–163 (2017). https://doi.org/10.1007/s40140-017-0209-6

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