Good afternoon. My name is Madeline Karsten, and I'm a clinical research assistant in the Department of Neurosurgery at Boston Children's Hospital. The title of my presentation today is Epidural Analgesia Reduces Postoperative Systemic Opioid Use Following Selective Dorsal Rhizotomy in Children. Selective dorsal rhizotomy is a surgical treatment for children with cerebral palsy. The nerve root manipulation that occurs during surgery can lead to severe acute postoperative pain, which traditionally has been managed with large quantities of systemic opioid use. Epidural analgesia has been used in pediatric patients undergoing SDR. However, whether this reduces systemic opioid use has not yet been established. In this study, we compared postoperative opioid use and clinical measures between SDR patients who received epidural analgesia with those that did not. We hypothesized that patients who received epidural analgesia would require less systemic opioids and would experience lower rates of opioid-induced side effects. A single center review identified 35 patients who underwent SDR at our institution between 2013 and 2019. Twenty-two of these patients received systemic analgesics only, and 13 patients received both postoperative systemic and epidural analgesia. All opioid dosages were converted to morphine milligram equivalents. Pain was measured using three pain scales, which were dichotomized into categories of no or mild and moderate or severe pain. Postoperative respiratory support was defined as the need for any supplemental oxygen or any ventilator support. Both groups shared similar demographic characteristics and disease burdens, as measured by the gross motor functional classification system level. Treatment groups differed in specific postoperative characteristics. The median length of stay was seven days for the epidural plus systemic analgesia group and five days for the systemic analgesia only group. Forty-five percent of patients in the systemic analgesia only group received respiratory support on postoperative day one, compared to 8% in the epidural plus systemic analgesia group. A similar but non-significant trend was observed on postoperative day two. A non-significant trend to a shorter median time to first postoperative bowel movement was noted for the epidural plus systemic analgesia group. Reported pain scores did not differ between groups on postoperative days one through four, though patients receiving epidural analgesia trended towards less severe reported pain on postoperative days one and two. Notably, 100% of the patients in the epidural plus systemic analgesia group with reported pain scores on postoperative days one and two reported no or mild pain, compared to 60% and 68% respectively in the systemic analgesia only group. Patients receiving epidural analgesia required significantly less morphine milligram equivalents per kilogram on postoperative days zero through four. The median total morphine milligram equivalents per kilogram administered to patients receiving epidural analgesia during their inpatient stay was 0.45 milligrams per kilogram, significantly less than the 8.3 milligrams per kilogram administered to patients receiving systemic analgesia only. This study has several limitations. Our sample size is small, which limited the statistical power to identify other potentially significant differences between groups. Furthermore, we did not have a standardized pain assessment system, resulting in not all patients having reported pain scores for their inpatient stay, as well as the use of three different scales. In this study, we found that SDR patients that received postoperative epidural analgesia with supplemental systemic opioids in comparison with those that received systemic opioid analgesia alone required significantly less morphine milligram equivalents per kilogram on postoperative days zero through four, required less respiratory support on postoperative day one, had at least equivalent pain scores on postoperative days one through four, though stayed in hospital slightly longer. We concluded that epidural analgesia can be considered as a beneficial additional pain management tool for patients undergoing SDR.

epidural analgesia

selective dorsal rhizotomy

SDR

opioid use

pain management