Departments of1Neurosurgery and.
2Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
J Neurosurg Pediatr. 2021 Mar 12;27(5):594-599. doi: 10.3171/2020.9.PEDS20501. Print 2021 May 1.
Selective dorsal rhizotomy (SDR) requires significant postoperative pain management, traditionally relying heavily on systemic opioids. Concern for short- and long-term effects of these agents has generated interest in reducing systemic opioid administration without sacrificing analgesia. Epidural analgesia has been applied in pediatric patients undergoing SDR; however, whether this reduces systemic opioid use has not been established. In this retrospective cohort study, the authors compared postoperative opioid use and clinical measures between patients treated with SDR who received postoperative epidural analgesia and those who received systemic analgesia only.
All patients who underwent SDR at Boston Children's Hospital between June 2013 and November 2019 were reviewed. Treatment used the same surgical technique. Postoperative systemic opioid dosage (in morphine milligram equivalents per kilogram [MME/kg]), pain scores, need for respiratory support, vomiting, bowel movements, and length of hospital and ICU stay were compared between patients who received postoperative epidural analgesia and those who did not, by using the Wilcoxon rank-sum test or Fisher's exact test.
A total of 35 patients were identified, including 18 females (51.4%), with a median age at surgery of 6.1 years. Thirteen patients received postoperative epidural and systemic analgesia and 22 patients received systemic analgesia only. Groups were otherwise similar, with treatment selection based solely on surgeon routine. Patients who received epidural analgesia required less systemic morphine milligram equivalents/kg on postoperative days (PODs) 0-4 (p ≤ 0.042). Patients who did not receive epidural analgesia were more likely to require respiratory support on POD 1 (45% vs 8%; p = 0.027). Reported pain scores did not differ between groups, although patients receiving epidural analgesia trended toward less severe pain on PODs 1 and 2. Groups did not differ with respect to postoperative vomiting or time to first bowel movement, although epidural analgesia use was associated with a longer hospital stay (median 7 vs 5 days; p < 0.001).
Patients who received postoperative epidural analgesia required less systemic opioid use and had at least equivalent reported pain scores on PODs 1-4, and they required less respiratory support on POD 1, although they remained in the hospital longer when compared to patients who received systemic analgesia only. A larger prospective study is needed to confirm whether epidural analgesia lowers systemic opioid use in children, contributes to a safer postoperative hospital stay, and results in better pain control following SDR.
选择性脊神经后根切断术（SDR）需要进行大量的术后疼痛管理，传统上严重依赖全身阿片类药物。由于担心这些药物的短期和长期影响，人们对减少全身阿片类药物的使用而不影响镇痛效果产生了兴趣。硬膜外镇痛已应用于接受 SDR 的儿科患者；然而，其是否能减少全身阿片类药物的使用尚未得到证实。在这项回顾性队列研究中，作者比较了接受 SDR 治疗的患者中，接受术后硬膜外镇痛和仅接受全身镇痛的患者的术后阿片类药物使用情况和临床指标。
回顾了 2013 年 6 月至 2019 年 11 月在波士顿儿童医院接受 SDR 的所有患者。治疗采用相同的手术技术。通过使用 Wilcoxon 秩和检验或 Fisher 确切检验，比较接受术后硬膜外镇痛和未接受术后硬膜外镇痛的患者的术后全身阿片类药物剂量（以吗啡毫克当量/千克[MME/kg]计）、疼痛评分、呼吸支持需求、呕吐、排便以及住院和 ICU 住院时间。
共确定了 35 例患者，其中女性 18 例（51.4%），手术时中位年龄为 6.1 岁。13 例患者接受了术后硬膜外和全身镇痛，22 例患者仅接受了全身镇痛。两组患者在其他方面相似，治疗选择仅基于外科医生的常规。接受硬膜外镇痛的患者在术后第 0-4 天（POD）需要的全身吗啡毫克当量/kg 较少（p≤0.042）。未接受硬膜外镇痛的患者在 POD1 时更需要呼吸支持（45%对 8%；p=0.027）。两组患者的报告疼痛评分无差异，但接受硬膜外镇痛的患者在 POD1 和 2 时疼痛程度较轻。两组患者在术后呕吐或首次排便时间方面没有差异，尽管硬膜外镇痛的使用与住院时间延长有关（中位数 7 天对 5 天；p<0.001）。
接受术后硬膜外镇痛的患者需要较少的全身阿片类药物，并且在 POD1-4 时报告的疼痛评分至少相同，在 POD1 时需要较少的呼吸支持，尽管与仅接受全身镇痛的患者相比，他们在医院的时间更长。需要更大的前瞻性研究来证实硬膜外镇痛是否能减少儿童的全身阿片类药物使用，是否有助于更安全的术后住院治疗，以及是否能在 SDR 后更好地控制疼痛。
