Журнал «Здоровье ребенка» 2 (45) 2013

STUDY DESIGN: Prospective, nonrandomized, comparative study.

OBJECTIVES: This study compared the early postoperative analgesic effects and circulation parameters associated with two methods of pain control after scoliosis posterior spinal instrumentation and fusion.

SUMMARY OF BACKGROUND DATA: Posterior transpedicular screw instrumentation for scoliosis correction is associated with high degree of postoperative pain. Most patients require parenteral administration of analgesics especially during 3 days after operations or more. High degree of postoperative pain precludes them from early mobilization, which is known to lengthen hospital stay and might result in various complications The use of opioids for postoperative pain control is common after spinal surgery. No study was found in the literature in which intermittent intramuscular bolus injection of promedol was compared with prolonged epidural infusion.

METHODS: Patients who underwent posterior spinal fusion surgery between 2010 and 2011 in Sytenko Institute were enrolled. They were divided into two groups on the basis of the method chosen for postoperative pain control. A total of 100 American Society of Anesthesiologists' physical status II to IV, patients who underwent posterior fusion surgery under general anesthesia were recruited for this study. These patients were diagnosed with idiopathic scoliosis. No preoperative narcotics were used in the patients. In the I group for analgesia 50 patients received intermittent intramuscular bolus injection of promedol. Patients of II group (n=50) received prolonged epidural infusion of ropivacaine. Epidural catheter was inserted into the epidural space 5-7 cm above laminectomy level under direct visualization and was passed retrograde through the needle in the paraspinal muscles after removal of the stylet before wound closure. Pain intensity was determined using visual analog scale (VAS) from 0 (no pain) to 10 (most severe pain). VAS score, blood pressure, heart rate and oxygen saturation were recorded before surgery and on postoperative days 1, 3, and 7.

Inclusion criteria were: patients with idiopathic scoliosis at the age of 10 to 18 years, the value of scoliosis at 60-90 ° Cobb, female patients. The exclusion criteria were: allergy to local anesthetics, laboratory-confirmed anticoagulation, neurological disorders, long-lived pain syndrome is not associated with the proposed transaction.

After day 3 patients in both groups recieved nonsteroidal anti-inflammatory drugs for analgesia. Research data were processed by variation statistics. We use the "Statistic 6.0" for Windows. Differences were considered significant at p <0,05.

RESULTS: There was no difference in demographic and baseline characteristics among the treatment groups.

 There was no difference in preoperative pain scale between the groups (p>0,05). On the  postoperative day 1 average pain intensity was significantly higher in group I - 3,9 ± 0,2 cm, in II group - 2,1 ± 0,3 cm (p <0,001) . Pain control also was significantly better on day 3 after surgery in the II group. VAS score was 2,8 ± 0,2 cm in the I group and 1,8 ± 0,1 cm in II group (P < 0.01). On day 7 the level of pain intensity was  minimal in both groups - 1,5 ± 0,2 cm and 0,9 ± 0,2 cm, respectively, but remained slightly higher in group I (p <0,05).

There was no significant difference in heart rate among the groups before surgery (p>0,05). The most marked tachycardia on day 1 was in group I - 112,2 ± 1,5 /min compared to group II - 98,9 ± 0,8 /min, (p <0,001). On the third day there was also a significant difference between the groups - 94,3 ± 1,1 /min and 90,5 ± 0,6 /min, respectively (p <0,001). On day 7 average heart rate was 87,4 ± 0,9 /min in I group and 85,7 ± 0,5 /min in II group (p> 0,05).

Mean values ​​of oxygen saturation during the study were normal. There were no significant difference prior to surgery - 99,5 ± 0,1% in group I and 99,3 ± 0,1% in group II (p> 0,05). On day 1 there was a significant difference between the groups - 97,1 ± 0,3% and 98,4 ± 0,2%, respectively, (p <0,001). On the 3-d and 7-th day there was no statistically significant difference between the two groups of patients (p> 0,05).

 There was no statistically significant difference in blood pressure between the groups during the study (p>0,05).

No significant complications were reported in either group.

CONCLUSIONS:

1.  The most significant changes in hemodynamic parameters were observed in the day 1 after surgery in both groups.

2.  Prolonged EA promoted earlier recovery of hemodynamic parameters.

3. Prolonged EA provides high quality pain control after scoliosis posterior spinal fusion.

4. Continuous epidural anesthesia can be used as an alternative method of analgesia for patients with spinal deformity in the postoperative period.