Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses

Abstract

Summary Background: Children undergoing selective dorsal rhizotomy (SDR) experience severe pain postoperatively; a pain related to both the extensive surgical exposure with multilevel laminectomy and nerve root manipulation. We sought to define an optimal dose of continuous intrathecal (IT) morphine and bupivacaine to treat this severe pain. The aim of this study was to compare two different concentrations of morphine in a fixed dose of bupivacaine with regard to the analgesic effect and survey if they differed in side effects. Methods: Twenty‐six children, aged 2.7–7.4 years undergoing SDR were included in this study. Postoperatively 11 children received a continuous infusion of morphine 0.4 μg.kg−1.h−1 and bupivacaine 40 μg.kg−1.h−1 (low‐dose group) and 15, a continuous infusion of morphine 0.6 μg.kg−1.h−1 and bupivacaine 40 μg.kg−1.h−1 (high‐dose group). The Behavioral Observational Pain Scale (BOPS) was used to evaluate pain. Results: Better pain relief was obtained in the high‐dose group seen in lower BOPS score compared with the low‐dose group [P = 0.03, Fisher's permutation test and P = 0.06 Wilcoxon–Mann–Whitney (WMW) test]. The low‐dose group received seven times as much ketobemidone 0.43 ± 0.54 mg.kg−1 48 h−1 compared with 0.06 ± 0.09 mg.kg−1 48 h−1 in the high‐dose group (P = 0.0005 Fisher's permutation test, P = 0.0017 WMW test). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. Respiratory and hemodynamic depression was not found. Conclusion: This study shows that, compared with low‐dose, the higher dose of continuous IT morphine combined with bupivacaine, significantly reduce pain score and postoperative intravenous analgesic requirements without increasing adverse effects.

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.…”

Continuous Spinal Analgesia after Extensive Lumbar Spine Surgery

“…Continuous spinal anaesthesia/analgesia has been recently reviewed by Bevacqua 4 . Hesselgard 5,6 described up to 38 children (it is unclear whether some children are reported in both studies) undergoing multiple level selective dorsal rhizotomy receiving either intermittent or continuous spinal analgesia through surgically placed spinal catheters for five days postoperatively. To our knowledge these are the only case series of continuous intrathecal analgesia after spinal surgery.…”

“…In contrast, percutaneously placed CSA catheters using full sterile preparation are widely accepted to be safe to leave in situ for between 72 to 96 hours 18 . Hesselgard 5,6 reported no wound infections and made no mention of any case of meningitis. All children received perioperative cefuroxime, but the dose and duration were not reported.…”