Authors: Jeffrey Bejan Hatef, Jr., MD; Luke Smith, MD; Giorgio Veneziano; David Martin; Tarun Bhalla; Jeffrey Leonard, MD (Columbus, OH)
Selective dorsal rhizotomy (SDR) provides lasting relief of spasticity for children suffering from cerebral palsy, although controlling postoperative pain is challenging. Postoperatively, escalation of therapies to include a patient-controlled analgesia (PCA) pump and intensive care unit (ICU) admission is common. We developed a multi-modal pain management protocol that included intraoperative placement of an epidural catheter. We present the three year results of protocol implementation.
With IRB approval, all patients undergoing SDR at our institution were identified for review. Hourly pain scores were recorded. Adverse effects of medication, including desaturations, nausea and vomiting, and pruritus were also noted. Thirty nine patients undergoing the procedure with protocolized pain control were compared to seven controls treated with PCAs.
Pain control was satisfactory in both groups, with average pain scores of 1.5 in both groups on postoperative day (POD) zero, decreasing by POD three to 1.1 in the PCA group and 0.5 in the protocol group. No patients under the protocol required admission to ICU; all patients with PCA spent at least one day in the PICU. Desaturations were seen in 16 patients in the protocol group (41%), but none required transfer to the PICU. 42% of PCA patients and 15% of protocol patients required treatment for itch (p=0.08). 86% of PCA patients and 46% of protocol patients required treatment for nausea or vomiting (p=0.05). Medication requirements for the hospitalization were decreased from 1.1 to 0.28 doses per patient for itch, and from 3 to 1.1 doses per patient for nausea.
Multi-modal analgesia is an excellent alternative to PCA for postoperative pain after SDR. Actual analgesia is comparative to controls without the need for intensive care monitoring. Side effects of high dose opiates were less frequent and required less medication. With the protocol, patients were safely treated on the floor.