The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

Abstract

Study Design. Retrospective controlled cohort. Objective. To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). Summary of Background Data. Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. Methods. 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed.Results. Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. Conclusions. LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period.

Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

“…In pediatrics, published protocols for idiopathic spinal fusion surgery, a procedure with high incidence of CPSP, are highly variable in their use of opioids, regional anesthesia, and adjuvant analgesic medications including gabapentinoids, muscle relaxants, ketamine, subcutaneous local anesthetic infusions, and dexmedetomidine. [89][90][91][92][93][94][95][96] At this time, there is little evidence to support the use of one perioperative analgesic protocol over another for acute pain in pediatric patients undergoing major musculoskeletal surgery, and no evidence to support any specific pharmacologic approach to prevent the transition to CPSP. Thus, we propose that operative protocols and institutional "best practice" should incorporate universal screening of each child or adolescent undergoing surgery to determine their risk level for developing CPSP.…”

Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion

“…The literature on MMA strategies for spine surgery is expanding, [7][8][9][10][11] but these protocols do not always include intravenous ketorolac (IV-K) or intravenous acetaminophen (IV-A). IV-K is often contraindicated due to the potential controversial risk of postoperative hematoma and pseudarthrosis after spinal fusion based on in vitro, [12][13][14][15][16][17] animal, [18][19][20][21] and clinical studies.…”