Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children

Abstract

Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side-effects. In a prospective study, 12 children (3-6 years of age) with six in each group, received either intermittent IT morphine (5 microg x kg(-1) four times a day) or continuous infusion of a mixture of bupivacaine (40 microg x kg(-1) x h(-1)) and morphine (0.6 microg x kg(-1) x h(-1)). Pain score was lower in the bupivacaine/morphine group (0.2 +/- 1.1) compared to intermittent morphine (2 +/- 2.4) on a scale from 0 to 6 (P less than or = 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations.

Validation of a Preclinical Spinal Safety Model

“…While it may be argued that administration via the more commonly used epidural/caudal route would diminish the exposure of the cord to high concentrations, we would note the following points. 1) Intrathecal morphine has been used in children following major surgery for many years, administered either as a single bolus55,93,94 or via continuous infusion;95,96 and intrathecal morphine has also been administered to neonates and infants following cardiac surgery17,18,97,98 and major craniofacial surgery99. 2) The use of spinal anesthesia in neonates and infants is increasing14 and the limited duration of action of local anesthesia may be improved by co-administration with spinal opioid19.…”

Prevention of brisk hyperactive response during selective dorsal rhizotomy in children with spasticity: Isoflurane versus sevoflurane maintenance anesthesia

“…The options range from continuous IV infusions of opiates or benzodiazepines to intrathecal or epidural placement of catheters for opiate administration. 19,20 Spasticity-related pain is usually gamma-aminobutyric acid (GABA)-mediated; hence, benzodiazepines (GABA receptor modulators) and GABA-a agonists (e.g. baclofen) are very helpful for this patient group.…”

Selective Dorsal Rhizotomy and Postoperative Pain Management

“…Our experience is that postoperative pain treatment in these children can be demanding, not only due to postincision pain from the lumbar laminotomy, but also due to dysesthesia of the lower extremities caused by manipulation of the nerve rootlets [8,24,25,26,27,28,29,30]. During the 1980s, it is most probable that these children were treated with conventional intravenous and/or oral regimes.…”

“…During the last two decades, various pain treatment strategies have been published for children undergoing SDR. Both ED [25, 29] and IT opioids [28, 30, 31] have been used as an effective and safe pain therapy. Continuous intravenous morphine infusion has been reported as an option [27].…”