Fons Roger A, Hainsworth Keri R, Michlig Johanna, Jablonski Megan, Czarnecki Michelle L, Weisman Steven J
Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA.
Children's Wisconsin, Wauwatosa, Wisconsin, USA.
Paediatr Anaesth. 2024 May;34(5):438-447. doi: 10.1111/pan.14843. Epub 2024 Jan 30.
Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature.
We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion.
A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain.
Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects.
A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion.
在美国，后路脊柱融合术是矫正青少年特发性脊柱侧凸最常见的外科手术。术中使用美沙酮已被证明可改善接受复杂脊柱手术的成年患者的疼痛控制，目前的儿科研究也显示出令人鼓舞的结果；然而，儿科文献中缺乏前瞻性随机对照试验。
我们进行了一项单中心双盲随机对照试验，比较在接受后路脊柱融合术的儿科患者中术中使用美沙酮与吗啡的效果。
共有47名接受后路脊柱融合术的青少年（按性别分层）被随机分为美沙酮组（n = 25）或吗啡组（n = 22）。主要结局是术后阿片类药物的消耗量。次要结局包括术后疼痛严重程度、阿片类药物相关副作用以及患者自控镇痛注射次数与尝试次数的比率，以此作为疼痛未得到控制的行为指标。
美沙酮组患者术后总的阿片类药物消耗量（中位数[四分位间距]，0.3mg/kg[0.1, 0.5]）低于吗啡组（0.3mg/kg[0.2, 0.6]），中位数差异[95%置信区间]为-0.07[-0.2至0.02]；（p = 0.026）。尽管术后使用的阿片类药物量较少，但美沙酮组的疼痛评分（3.5[3.0, 4,3]）与吗啡组（4.0[3.2, 5.0]）相比无显著差异；（p = 0.250）。两组在阿片类药物相关副作用方面无差异。
与吗啡相比，术中使用两剂美沙酮方案可减少阿片类药物的消耗量。尽管这些结果的临床意义可能有限，但在不增加阿片类药物相关副作用且慢性疼痛发生率可能较低的情况下，镇痛效果相当可能使天平倾向于对接受后路脊柱融合术的青少年常规使用美沙酮有利。
