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A Randomized Prospective Evaluation of 3 Techniques of Postoperative Pain Management After Posterior Spinal Instrumentation and Fusion

Klatt, Joshua W. B., MD*; Mickelson, Jennie, BS*; Hung, Man, PhD; Durcan, Simon, MD; Miller, Chris, MD; Smith, John T., MD*

doi: 10.1097/BRS.0b013e31829cab0b
Randomized Trial

Study Design. Randomized prospective trial.

Objective. To compare the efficacy of intravenous analgesia with single and dual continuous epidural analgesia (CEA) in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion and instrumentation (PSIF).

Summary of Background Data. Pain management after posterior spinal fusion (PSF) for patients with AIS is challenging. Although intravenous patient-controlled analgesia (PCA) is used most commonly, CEA has been found to be safe and effective. Recently, the use of 2 epidural catheters has been thought to be more effective than a single catheter, although the efficacy of using 2 catheters has not been directly compared with a single catheter.

Methods. Sixty-six patients with AIS were randomized into 3 groups prior to PSF; PCA, single CEA, and double CEA. Postoperative pain scores as well as side effects, complications, and use of breakthrough medication were collected. Recovery times were also recorded, including hospitalization, times to first bowel movement, and days to walk and climb stairs. Four patients were withdrawn due to the inability to maintain the pain management protocol.

Results. Pain intensity was most effectively controlled with a double CEA when compared with PCA (P < 0.05) and a single CEA (P < 0.05). Pain control was equivalent in both the PCA and single CEA groups (P = 0.21). The pain control method with the fewest side effects trended toward the single CEA, with an average of 2.55 side effects per patient. The majority of the side effects included pruritis, constipation, and nausea. Late onset neurological events were absent in all patients.

Conclusion. These data document that the double CEA most effectively controls postoperative pain after surgery for AIS. The single CEA trended toward having the fewest side effects when compared with the other techniques. On the basis these findings, we now routinely use the double CEA technique for all patients having surgery for AIS.

Level of Evidence: 1

A prospective study of 60 patients randomized to postoperative pain management using intravenous analgesia, single or double continuous epidural analgesia. Pain intensity was most effectively controlled with a double continuous epidural analgesia (CEA) when compared with intravenous analgesia (P < 0.05) and a single CEA (P < 0.05) with no increase in side effects or complications.

*Department of Orthopaedic Surgery, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT

Department of Orthopaedic Surgery, University of Utah School of Medicine, University Orthopaedic Center, Salt Lake City, UT; and

Department of Anesthesia, Primary Children's Medical Center, Salt Lake City, UT.

Address correspondence and reprint requests to Joshua W. B. Klatt, MD, Department of Orthopaedic Surgery, University of Utah School of Medicine, Primary Children's Medical Center, 100 N. Mario Capecchi Dr., Ste 4550, Salt Lake City, UT 84113; E-mail:

Acknowledgment date: June 26, 2012. Revision date: January 8, 2013. Acceptance date: February 28, 2013.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, royalties.

© 2013 by Lippincott Williams & Wilkins