Reducing opioid usage: a pilot study comparing postoperative selective dorsal rhizotomy protocols

OBJECTIVESelective dorsal rhizotomy (SDR) is a surgical procedure used to treat spasticity in children with spastic cerebral palsy. Currently, there is a lack of work examining the efficacy of optimizing pain management protocols after single-level laminectomy for SDR. This pilot study aimed to compare the clinical outcomes of SDR completed with a traditional pain management protocol versus one designed for opioid dosage reduction.METHODSThe Texas Comprehensive Spasticity Center prospective database was queried for all patients who underwent SDR between 2015 and 2018. Demographic, surgical, and postoperative data for all patients who underwent SDR were collected from medical records. The study was designed as a retrospective study between the patient-controlled analgesia (PCA) and dexmedetomidine infusion (INF) groups with 80% power to detect a 50% difference at a significance level of 0.05. Patients in the INF group received perioperative gabapentin, intraoperative dexmedetomidine infusion, and scheduled acetaminophen and NSAIDs postoperatively.RESULTSMedication administration records, pain scores, and therapy notes were collected for 30 patients. Patients who underwent SDR between June 2015 and the end of December 2017 received traditional pain management (PCA group, n = 14). Patients who underwent SDR between January 2018 and the end of December 2018 received modified pain management (INF group, n = 16). No patients were lost to follow-up. Differences in age, weight, height, preoperative Gross Motor Function Classification System scores, operative duration, hospital length of stay, and sex distribution were not statistically different between the 2 groups (p > 0.05). Analysis of analgesic medication doses demonstrated that the INF group required fewer doses and lower amounts of opioids overall, and also fewer NSAIDs than the PCA group. When converted to the morphine milligram equivalent, the patients in the INF group used fewer doses and lower amounts of opioids overall than the PCA group. These differences were either statistically significant (p < 0.05) or trending toward significance (p < 0.10). Both groups participated in physical and occupational therapy similarly postoperatively (p > 0.05). Pain scores were comparable between the groups (p > 0.05) despite patients in the INF group requiring fewer opioids.CONCLUSIONSInfusion with dexmedetomidine during SDR surgery combined with perioperative gabapentin and scheduled acetaminophen and NSAIDs postoperatively resulted in similar pain scores to traditional pain management with opioids. In addition, this pilot study demonstrated that patients who received the INF pain management protocol required reduced opioid dosages and were able to participate in therapy similarly to the control PCA group.

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Postoperative Pain Protocol in Children after Selective Dorsal Rhizotomy

Pediatric Neurosurgery ◽

10.1159/000509333 ◽

2020 ◽

Vol 55 (4) ◽

pp. 181-187

Author(s):

Jeffrey Hatef ◽

Luke G.F. Smith ◽

Giorgio C. Veneziano ◽

David P. Martin ◽

Tarun Bhalla ◽

...

Keyword(s):

Intensive Care ◽

Postoperative Pain ◽

Pain Control ◽

Selective Dorsal Rhizotomy ◽

Icu Admission ◽

Dorsal Rhizotomy ◽

Pain Scores ◽

Protocol Group ◽

Management Protocol ◽

Opioid Administration

Introduction: 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. Objectives: We developed a multimodal pain management protocol that included intraoperative placement of an epidural catheter with continuous opioid administration. We present the 3-year results of protocol implementation. Methods: With institutional review board approval, all patients who were subjected to SDR at our institution were identified for review. Hourly pain scores were recorded. Adverse effects of medication, including desaturation, nausea/vomiting, and pruritus, were also noted. Comparisons were made between patients treated with PCA and those treated with multimodal pain control using t and χ2 tests as appropriate. Results: Thirty-nine patients undergoing the procedure with protocolized pain control (average age 6.8 years, 57% male) were compared to 7 PCA-treated controls (average age 6.6 years, 54% male). Pain control was satisfactory in both groups, with average pain scores of 1.5 in both groups on postoperative day 0, decreasing by postoperative day 3 to 1.1 in the PCA group and 0.5 in the protocol group. No patients under the protocol required ICU admission; all patients with PCA spent at least 1 day in the ICU. Desaturations were seen in 16 patients in the protocol group (41%), but none required ICU transfer. Treatment for pruritis was given to 57% of PCA patients and 15% of protocol patients. Treatment for nausea and vomiting was given to 100% of PCA patients and 51% of protocol patients. Medication requirements for the hospitalization were decreased from 1.1 to 0.28 doses per patient for pruritis, and from 3 to 1.1 doses per patient for nausea. Conclusions: Multimodal analgesia is an excellent alternative to PCA for postoperative pain after SDR. Actual analgesia is comparative to that of 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 outside the ICU.

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The influence of continuous local wound infusion on postoperative pain in patients undergoing transfemoral amputation

VASA ◽

10.1024/0301-1526/a000457 ◽

2015 ◽

Vol 44 (5) ◽

pp. 381-386 ◽

Cited By ~ 1

Author(s):

Christian Uhl ◽

Thomas Betz ◽

Andrea Rupp ◽

Markus Steinbauer ◽

Ingolf Töpel

Keyword(s):

Pain Management ◽

Pilot Study ◽

Local Anaesthetic ◽

Phantom Pain ◽

Transfemoral Amputation ◽

Postoperative Wound ◽

Stump Pain ◽

Management Protocol ◽

Group 2 ◽

Group 1

Abstract. Summary: Background: This pilot study was set up to examine the effects of a continuous postoperative wound infusion system with a local anaesthetic on perioperative pain and the consumption of analgesics. Patients and methods: We included 42 patients in this prospective observational pilot study. Patients were divided into two groups. One group was treated in accordance with the WHO standard pain management protocol and in addition to that received a continuous local wound infusion treatment (Group 1). Group 2 was treated with analgesics in accordance with the WHO standard pain management protocol, exclusively. Results: The study demonstrated a significantly reduced postoperative VAS score for stump pain in Group 1 for the first 5 days. Furthermore, the intake of opiates was significantly reduced in Group 1 (day 1, Group 1: 42.1 vs. Group 2: 73.5, p = 0.010; day 2, Group 1: 27.7 vs. Group 2: 52.5, p = 0.012; day 3, Group 1: 23.9 vs. Group 2: 53.5, p = 0.002; day 4, Group 1: 15.7 vs. Group 2: 48.3, p = 0.003; day 5, Group 1 13.3 vs. Group 2: 49.9, p = 0.001). There were no significant differences between the two groups, neither in phantom pain intensity at discharge nor postoperative complications and death. Conclusions: Continuous postoperative wound infusion with a local anaesthetic in combination with a standard pain management protocol can reduce both stump pain and opiate intake in patients who have undergone transfemoral amputation. Phantom pain was not significantly affected.

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Short-term Gait Parameters Change in Mild Spastic Cerebral Palsy after Selective Dorsal Rhizotomy Guided by Our Newly-Modified Protocol

10.21203/rs.3.rs-278334/v1 ◽

2021 ◽

Author(s):

wenbin jiang ◽

Shuyun Jiang ◽

Yan Yu ◽

Qijia Zhan ◽

Min Wei ◽

...

Keyword(s):

Cerebral Palsy ◽

Lower Limbs ◽

Spastic Cerebral Palsy ◽

Selective Dorsal Rhizotomy ◽

Short Term ◽

Term Outcome ◽

Long Term Outcome ◽

Dorsal Rhizotomy ◽

Gait Parameters

Abstract Background Selective Dorsal Rhizotomy (SDR) guided by our modified protocol can decrease spasticity in certain muscles. This study aimed to investigate gait parameters changes in cerebral palsy (CP) with focal spasticity after SDR in short-term follow-up. Methods CP classified as Gross Motor Function Classification System (GMFCS) level Ⅰ and Ⅱ who underwent SDR were included. Changes of spasticity, gait parameters and gait deviation index (GDI) were retrospectively reviewed. Results This study contained 26 individuals with 44 affected and 8 intact lower limbs (4 monoplegia, 4 hemiplegia and 18 diplegia). Mean age was 5.7 ± 1.9 years-old and follow-up duration was 9.9 ± 6.6 months. After SDR, average spasticity of 108 target muscles decreased from 2.9 ± 0.8 to 1.8 ± 0.6 in Modified Ashworth Scale (MAS). Kinematic curves changed after the surgery in sagittal and transverse plane in affected sides, further investigation showed improvements in ankle and knee. No changes were found in temporal-spatial parameters except decrease in cadence in affected sides. GDI improved significantly in affected limbs. Conclusion In short-term follow up, the new-protocol-guiding SDR can lower focal spasticity, GA showed improvements in kinematic parameters and GDI. Longer follow-up duration is needed to clarify the long-term outcome.

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Selective Dorsal Rhizotomy for Spastic Cerebral Palsy

Pediatric Neurosurgery ◽

10.1055/b-0034-72758 ◽

2008 ◽

Keyword(s):

Cerebral Palsy ◽

Spastic Cerebral Palsy ◽

Selective Dorsal Rhizotomy ◽

Dorsal Rhizotomy

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Deformity of lumbar spine after selective dorsal rhizotomy for spastic cerebral palsy

Microsurgery ◽

10.1002/micr.20444 ◽

2007 ◽

Vol 28 (1) ◽

pp. 10-12 ◽

Cited By ~ 19

Author(s):

Zhiyong Li ◽

Jiakai Zhu ◽

Xiaolin Liu

Keyword(s):

Cerebral Palsy ◽

Lumbar Spine ◽

Spastic Cerebral Palsy ◽

Selective Dorsal Rhizotomy ◽

Dorsal Rhizotomy

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Variation between Centers in Electrophysiologic Techniques Used in Lumbosacral Selective Dorsal Rhizotomy for Spastic Cerebral Palsy

Pediatric Neurosurgery ◽

10.1159/000121131 ◽

1996 ◽

Vol 25 (5) ◽

pp. 233-239 ◽

Cited By ~ 24

Author(s):

Paul Steinbok ◽

John R. Kestle

Keyword(s):

Cerebral Palsy ◽

Spastic Cerebral Palsy ◽

Selective Dorsal Rhizotomy ◽

Dorsal Rhizotomy

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Changes in ankle spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy

Journal of Neurosurgery ◽

10.3171/jns.1999.91.5.0727 ◽

1999 ◽

Vol 91 (5) ◽

pp. 727-732 ◽

Cited By ~ 51

Author(s):

Jack R. Engsberg ◽

Sandy A. Ross ◽

Tae Sung Park

Keyword(s):

Cerebral Palsy ◽

Physical Therapy ◽

Spastic Cerebral Palsy ◽

Control Group ◽

Selective Dorsal Rhizotomy ◽

Content Type ◽

Dorsal Rhizotomy ◽

Angle Data ◽

Work Done ◽

Fine Print

Object. In this investigation the authors quantified changes in ankle plantarflexor spasticity and strength following selective dorsal rhizotomy (SDR) and intensive physical therapy in patients with cerebral palsy (CP).Methods. Twenty-five patients with cerebral palsy (CP group) and 12 able-bodied volunteers (AB controls) were tested with a dynamometer. For the spasticity measure, the dynamometer was used to measure the resistive torque of the plantarflexors during passive ankle dorsiflexion at five different speeds. Data were processed to yield a single value that simultaneously encompassed the three key elements associated with spasticity: velocity, resistance, and stretch. For the strength test, the dynamometer rotated the ankle from full dorsiflexion to full plantarflexion while a maximum concentric contraction of the plantarflexors was performed. Torque angle data were processed to include the work done by the patient or volunteer on the machine. Plantarflexor spasticity values for the CP group were significantly greater than similar values for the AB control group prior to surgery but not significantly different after surgery. Plantarflexor strength values of the CP group were significantly less than those of the AB control group pre- and postsurgery. Postsurgery strength values did not change relative to presurgery values.Conclusions. The spasticity results of the present investigation agreed with those of previous studies indicating a reduction in spasticity for the CP group. The strength results did not agree with the findings of most previous related literature, which indicated that a decrease in strength should have occurred. The strength results agreed with a previous investigation in which knee flexor strength was objectively examined, indicating that strength did not decrease as a consequence of an SDR. The methods of this investigation could be used to improve SDR patient selection.

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