Abstract
Study design
Prospective, quality-improvement.
Objectives
To evaluate pain management following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and Scheuermann’s Kyphosis (SK) determine the optimal opioid and benzodiazepine prescription amounts, and implement a multimodal post-operative pain regimen.
Summary of background data
The incidence of prescription opioid abuse is increasing in the United States. Orthopedic spine surgeons often prescribe large quantities of opioids post-operatively for pain control. Previous efforts on pain control have focused on in-patient post-operative regimens after PSF.
Methods
Between 2/1/17 and 5/30/18 patients with AIS or SK were sent home with pain diaries after discharge to document daily narcotic, benzodiazepine, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and gabapentin use following PSF. Diaries were collected at the 4 week post-operative visit. Data from two cohorts were reviewed: pre-intervention and post-intervention. Our prescription intervention went into effect 9/1/17.
Results
Twenty-four (30%) patients returned pain diaries. The pre-intervention cohort consisted of 12 patients (7 female; 5 males; 14.9 years (range 12–19)). Patients were prescribed on average 80 × 5 mg tabs (26–140) of oxycodone but used on average 45 tabs (12–129) over an average of 17.5 days (9–33). They were prescribed an average of 30 × 2 mg tabs (0–150) of diazepam, used on average 4.8 (0–105) tabs over 12.5 (5–25) days. The post-intervention cohort consists of 12 patients (9 female; 3 male; 14.8 years (12–19)). They were prescribed on average 50 × 5 mg tabs (35–80) of oxycodone, used 20.5 (0–39.5) tabs over 8.5 days (3–16). They were prescribed on average 18 × 2 mg tabs of diazepam (0–43), used 5.4 tabs (0–19) over 10 days (5–14).
Conclusions
This analysis has directly impacted clinical practice. Prescribed opioid and benzodiazepine doses have been decreased by over 50%, and more resources are being directed towards determining the disparity between the amount of medications prescribed and consumed in our post-operative patients.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
McCabe SE, West BT, Veliz P et al (2017) Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics 139:e20162387
Harbaugh CM, Lee JS, Hu HM et al (2018) Persistent opioid use among pediatric patients after surgery. Pediatrics 141:e20172439
Gaither JR, Leventhal JM, Ryan SA et al (2016) National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012. JAMA Pediatr 170:1195–1201
Miech R, Johnston L, O’Malley PM et al (2015) Prescription opioids in adolescence and future opioid misuse. Pediatrics 136:e1169–e1177
McCabe SE, West BT, Boyd CJ (2013) Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. J Adolesc Health 52:480–485
Fortuna RJ, Robbins BW, Caiola E et al (2010) Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics 126:1108–1116
Veliz P, Boyd CJ, McCabe SE (2017) Nonmedical use of prescription opioids and heroin use among adolescents involved in competitive sports. J Adolesc Health 60:346–349
Veliz PT, Boyd C, McCabe SE (2013) Playing through pain: sports participation and nonmedical use of opioid medications among adolescents. Am J Public Health 103:e28–e30
Fletcher ND, Glotzbecker MP, Marks M et al (2017) Development of consensus-based best practice guidelines for postoperative care following posterior spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 42:E547–E554
Choudhry DK, Brenn BR, Sacks K, Shah S (2019) Evaluation of gabapentin and clonidine use in children following spinal fusion surgery for idiopathic scoliosis: a retrospective review. J Pediatr Orthop 39(9):e687–e693. https://doi.org/10.1097/BPO.0000000000000989
Jabbour HJ, Naccache NM, Jawish RJ et al (2014) Ketamine and magnesium association reduces morphine consumption after scoliosis surgery: prospective randomised double-blind study. Acta Anaesthesiol Scand 58:572–579
Sieberg CB, Manganella J, Manalo G et al (2017) Predicting postsurgical satisfaction in adolescents with idiopathic scoliosis: the role of presurgical functioning and expectations. J Pediatr Orthop 37:e548–e551
Rhodes L, Nash C, Moisan A et al (2015) Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop 35:276–279
Holman JE, Stoddard GJ, Horwitz DS et al (2014) The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study. J Orthop Trauma 28:502–506
Rullander AC, Lundstrom M, Ostlund U et al (2017) Adolescents’ experiences of scoliosis surgery and the trajectory of self-reported pain: a mixed-methods study. Orthop Nurs 36:414–423
Borgstrom A, Nerfeldt P, Friberg D (2019) Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillectomy in pediatric obstructive sleep apnea: an RCT. Eur Arch Otorhinolaryngol 276:3231–3238
Group SS, Ahmed I, Cook JA et al (2015) Single port/incision laparoscopic surgery compared with standard three-port laparoscopic surgery for appendicectomy: a randomized controlled trial. Surg Endosc 29:77–85
Hansen TB, Jakobsen IA (2008) Intra-articular bupivacaine as treatment for postoperative pain after arthroscopy of the wrist. Scand J Plast Reconstr Surg Hand Surg 42:313–315
Sidman JD, Lander TA, Finkelstein M (2008) Platelet-rich plasma for pediatric tonsillectomy patients. Laryngoscope 118:1765–1767
Heath LE, Heeney MM, Hoppe CC et al (2017) Successful utilization of an electronic pain diary in a multinational phase 3 interventional study of pediatric sickle cell anemia. Clin Trials 14:563–571
Bandarian-Balooch S, Martin PR, McNally B et al (2017) Electronic-diary for recording headaches, triggers, and medication use: development and evaluation. Headache 57:1551–1569
Funding
No funding was received for this study.
Author information
Authors and Affiliations
Contributions
Amelia M. Lindgren: Analysis and Interpretation of Data, Manuscript Preparation/Review and Final Manuscript Approval. Vidyadhar V. Upasani, Rebecca Bennett: Design, Data Acquisition, Analysis and Interpretation of Data, Manuscript Preparation/Review and Final Manuscript Approval. Burt Yaszay, Peter O. Newton: Design, Analysis and Interpretation of Data, Manuscript Preparation/Review and Final Manuscript Approval.
Corresponding author
Ethics declarations
Ethical approval
This study was reviewed by the participating hospital’s institutional review board and was determined to be exempt from review.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Study conducted at Rady Children’s Hospital.
Rights and permissions
About this article
Cite this article
Lindgren, A.M., Bennett, R., Yaszay, B. et al. Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion. Spine Deform 8, 441–445 (2020). https://doi.org/10.1007/s43390-019-00002-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43390-019-00002-6