Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.
AimHochuekkito formula includes four kinds of prescriptions in Japan. It is not known whether all the formulas express the same stimulating effect on the mucosal immune systems of the upper and lower respiratory tracts.MethodsBy using influenza virus‐sensitized BALB/c mice, which are immuno‐compromised with cyclophosphamide, effects of administration of decocted extracts of four kinds of hochuekkito formulas were compared on anti‐influenza antibody titers in nasal cavity and bronchoalveolar fluids. The contribution of inulooligosaccharides to immuno‐modualting effects on T lymphocyes in Peyer's patches and pulmonary immune responses in poly(I:C)‐induced pneumonia mice was also analyzed.ResultsHochuekkito formulas with either Atractylodis lanceae rhizoma (ALR‐hochuekkito) or Atractylodis rhizoma (AtR‐hochuekkito) stimulated anti‐influenza virus‐specific antibody titers in the nasal cavity; however, ALR‐hochuekkito stimulated the production of the antibody titer in lung but AtR‐hochuekkito did not. Longer‐size inulooligosaccharides in ALR‐hochuekkito induced more IFN‐γ‐producing T lymphocytes in Peyer's patches whereas the intermediate‐size inulooligosaccharides in AtR‐hochuekkito induced more IL‐10‐producing T lymphocytes. Oral administration of the intermediate‐size inulooligosaccharides reduced pulmonary inflammation in poly(I:C)‐inoculated mice but not the longer‐size inulooligosaccharides.ConclusionsAll the hochuekkito formulas stimulate the mucosal immune system in upper respiratory tracts whereas the formula with Atractylodis lanceae rhizoma up‐regulates the pulmonary immune system, and inulooligosaccharides from Atractylodis lanceae rhizoma and Atractylodis rhizoma play a crucial role in regulating the pulmonary immune system with the hochuekkito formula.
Dexamethasone is widely used for postoperative nausea and vomiting (PONV) prophylaxis, but its effect on PONV prevention in paediatric patients is validated only in short minor surgical procedures. In this study, we aimed to determine whether a single dose of dexamethasone reduces PONV in highly invasive surgeries that require opioid-based postoperative analgesia. One hundred adolescents undergoing scoliosis correction surgery were randomized to receive intravenous dexamethasone 0.15 mg/kg (dexamethasone group) or saline (control group) at induction of anaesthesia. The primary outcome was the incidence of PONV in the 72 h postoperatively. Data for 98 patients were available for analysis. The 72-h incidence of PONV was significantly lower in the dexamethasone group than in the control group (62.5% vs 84.0%; RR 0.74, 95% CI 0.58–0.96, P = 0.02). During the first and second 24-h postoperative intervals, fewer patients in the dexamethasone group received rescue antiemetics. Visual analogue scale scores for nausea and pain were lower in the dexamethasone group than in the control group during the first 24 h postoperatively. Dexamethasone did not increase the number of adverse events. The results of this study showed that a single dose of dexamethasone was effective for reducing PONV after paediatric scoliosis correction surgery.
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