Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children

Abstract

Study Design: Retrospective comparative cohort study. Objective: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. Summary of Background Data: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. Materials and Methods: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)—median=2, interquartile range (IQR)=(0–5) vs. 5 (2.5–7); POD 2—3 (0–5) vs. 4 (3–6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3–4 vs. 4 d, IQR=4–6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64–0.93; P=0.009 and 0.67; 95% CI, 0.50–0.90; P=0.008). Conclusions: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. Level of Evidence: Level III.

Clinical and Economic Outcomes Associated With Use of Liposomal Bupivacaine Versus Standard of Care for Management of Postsurgical Pain in Pediatric Patients Undergoing Spine Surgery

“…In the current study, patients who received LB experienced shorter in-hospital LOS than those who received non-LB analgesia. This finding is consistent with previous reports in adult 22,23 and pediatric 17 patients undergoing spine surgery, as well as studies in adult patients in other surgical areas. 24,25 Use of opioids in the postanesthesia care unit may contribute to ORAEs, possibly resulting in an increase in LOS and total costs.…”

“…These clinical and economic benefits are in accordance with and expand upon results from other retrospective studies examining the use of opioid consumption and LOS for pediatric patients receiving LB or non-LB analgesia for postsurgical pain after spine deformity surgery and LOS for adult Medicare patients undergoing total knee arthroplasty. 17,18 Adolescents (defined by the World Health Organization as those aged 10-19 years) 19 may be at increased risk of opioid misuse compared with adults. This may be explained by changes in brain reward and habit formation centers during this developmental period.…”

“…The Premier Healthcare Database also does not provide information about perisurgical pathways, which may be heterogenous across institutions; as such, use of LB in spine surgery may reflect implementation of comprehensive enhanced recovery pathways in pediatric and adult patients that may have contributed to the reduction in opioid consumption and shorter hospital stays observed in the present study. 17,30 Further, as the Premier Healthcare Database is an administrative database lacking clinical details, surgical information related to management protocols and practices was not available. We also did not have data on baseline MME intake, and thus, we were unable to control for this confounding factor in our model.…”

Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery?

“…Both retrospective studies investigated the use of LB as an adjunct to existing multimodal pain regimens in patients undergoing pediatric spinal deformity correction. 33,34 Cloyd et al found no difference in postoperative opioid use or postoperative pain scores with use of LB in their study. On the other hand, Chughtai et al found that the addition of periincisional LB at closure of surgery improved these aforementioned metrics.…”

Subcutaneous Bupivacaine Infiltration Is Not Effective to Support Control of Postoperative Pain in Paediatric Patients Undergoing Spinal Surgery

“…They also failed to reduce the total dose of opiate medications, shortening only the duration of the required administration [25]. In contrast, liposomal bupivacaine, injected into paraspinal musculature, demonstrated a reduced pain score in paediatric patients subjected to spinal surgery [26].…”