Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

Abstract

Background: Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems. Methods: Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME). Results: Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013). Conclusions: A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of surgeon-directed postoperative local injection with an analgesic mixture in posterior fusion surgery for adolescent idiopathic scoliosis

“…Second, the best mixture, concentration of local analgesics, and administration site (subcutaneous or submyofascial) are unknown. The effect of dexamethasone on postsurgical pain after posterior spinal fusion has been reported recently [ 28 ].…”

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

“…No longer is LOS measured in weeks 16 but is now measured in days. 5 6 7 8 , 11 , 14 The introduction of ERAS protocols for AIS surgery, including multimodal pain management strategies, has been shown to produce substantial reductions in LOS but also improved pain control, faster postsurgical recovery, and lower opioid medication requirement. 4 , 5 , 17 As the adoption of ERAS protocols has shown growing implementation since their introduction, 17 we hypothesized that hospital LOS would significantly decrease between year cohorts and was supported with a mean 1.1 day decrease in hospital LOS in the post-ERAS cohort (4.3 ± 3.2 days versus 5.4 ± 4.0 days, P < 0.0001).…”

“…[5][6][7][8][9][10][11][12][13] There has been a significant increase in publications for ERAS application in patients with AIS since the initial report in 2014. 4 The healthcare utilization and economic benefits of ERAS protocols suggest the potential for a significant societal effect [5][6][7][8]14,15 ; however, no study to date has investigated the nationwide effect of ERAS pathway utilization on the US healthcare system. This study sought to investigate the effect of ERAS pathways after PSF in AIS on LOS and hospital charges in the US healthcare system.…”

Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS

“…No postoperative doses of dexamethasone were given. 7 Our standard postoperative posterior spinal fusion pathway for patients with AIS included intravenous opioid (hydromorphone) as needed (no basal rate) with transition to an oral opioid (oxycodone or hydrocodone) within the first 24 hours postoperatively. Intravenous ketorolac was given every 6 hours for 24 hours with transition to oral ibuprofen; intravenous acetaminophen was given every 6 hours for 24 hours with transition to oral acetaminophen.…”