SPINE Volume 36, Number 25, pp 2224–2231 ©2011, Lippincott Williams & Wilkins

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A Comparison of Three Types of Postoperative Pain Control After Posterior Lumbar Spinal Surgery Meng-Huang Wu, MD,* Chung-Hang Wong, MD,†§ Chi-Chien Niu, MD,‡§ Tsung-Ting Tsai, MD,‡§ Lih-Huei Chen, MD,‡§ and Wen-Jer Chen, MD‡§

Study Design. Retrospective, nonrandomized, comparative study. Objective. This study compared the early postoperative analgesic effects and the postoperative nausea and vomiting (PONV) associated with three methods of pain control after posterior lumbar spinal surgery. Summary of Background Data. The use of opioids for postoperative pain control is common after spinal surgery; however, PONV is the most frequently encountered side effect, and it is yet to be overcome. The effectiveness of the use of an absorbable low-dose morphine-soaked microfibrillar collagen hemostatic sponge placed on the surface of the dural sac (epidural MMCHS) was compared to patient-controlled analgesia (PCA) and intermittent intramuscular bolus injection of meperidine for postoperative pain control after spine surgery. Methods. One hundred sixty-five patients who underwent shortsegment posterior lumbar spinal decompression and fusion surgery between January 2007 and July 2007 in the orthopedic department of a medical center were enrolled. For postoperative pain control, 40 patients received epidural MMCHS, 48 patients received PCA, and 77 patients received meperidine injection. Patient ratings of pain intensity (visual analog scale score from 0 [no pain] to 10 [most severe pain]), nausea (from 0 [no nausea] to 5 [severe nausea]), and vomiting (from 0 [no vomiting] to 5 [severe vomiting]) were recorded at 4 hours postoperation and on postoperative days 1, 2, and 3. Results. The analgesic effect was enhanced significantly in both epidural MMCHS group and the PCA group as compared with the meperidine group on postoperative days 1 and 2 (P < 0.05). On postoperative days 1, 2, and 3, PONV was more severe in the PCA group than in the other two groups (P < 0.05). The side effects of From the *Departments of Orthopedic Surgery; †Anesthesiology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan; ‡Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; and §College of Medicine, Chang Gung University, Taoyuan, Taiwan. Acknowledgment date: February 18, 2010. Revision date: October 14, 2010. Acceptance date: November 8, 2010. 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. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Chi-Chien Niu, MD, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou 5th, Fu-Hsin St, Kweishan, Taoyuan 333, Taiwan, Republic of China; E-mail: [email protected] DOI: 10.1097/BRS.0b013e318205e3d7 Spine

epidural MMCHS were nausea (25%), pruritus (12.5%), vomiting (5%), and hypotension (2.5%). Conclusion. A single low-dose epidural MMCHS is effective for postoperative pain control and minimizes the occurrence of PONV after posterior lumbar spinal surgery. Key words: epidural morphine, PONV, spine surgical pain, postoperative pain, microfibrillar collagen hemostatic sponge. Spine 2011;36:2224–2231

M

ajor spinal surgeries cause severe postoperative pain, which typically lasts for at least 3 days.1 Therefore, effective pain control is an important aspect of patient care after spine surgery. The use of parenteral opioids has been the mainstay of analgesia for patients undergoing posterior lumbar spinal surgery.2 The route of opioid administration can be epidural, intrathecal, intramuscular (IM), or intravascular (IV), or opioid administration can be in the form of a continuous infusion or as patient-controlled analgesia (PCA) with or without background infusions. Intravenous or IM administration of opioids is associated with dose-dependent side effects such as respiratory depression, nausea and vomiting, sedation, and gastrointestinal ileus.2 Adequate use of PCA can lessen these side effects, but the incidence rate can still be as high as 71%, with mild to moderate symptoms.3 In an effort to resolve the problem of these systemic side effects, in 1982, Grabow et al4 described the epidural administration of opioids after spinal surgery. The analgesic onset of epidural opioids is usually noted within 15 to 60 minutes, and the effect of a single injection lasts for 16 to 24 hours.5–7 However, the pain reappears on the second day. Schmidek and Cutler8 suggested intraoperative insertion of an epidural catheter to prolong the analgesic effect. The safety and effectiveness were subsequently supported by several studies, and this method is now used extensively in obstetric and orthopedic surgery.9–12 Nevertheless, concerns over rare but serious complications such as epidural hematomas and infections associated with indwelling catheters have prevented some doctors from advocating this method.13,14 In this study, a microfibrillar collagen hemostatic sponge (Avitene, Davol Inc, Cranston, RI) was used as a novel carrier for morphine to prolong the duration of pain control. The use of a hemostatic sponge is very common in all surgical applications, including spine surgery, neurosurgery, and vascular surgery.15–17 The fibrin clot that forms is slowly absorbed for www.spinejournal.com

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Figure 1. Participants’ flow chart (according to the CONSORT statement).

up to 10 weeks, and this delays the dilution of medication by keeping morphine within the clot.15 The purpose of the study is to compare early postoperative pain control, as well as nausea and vomiting after posterior lumbar decompression surgery using three pain control methods: an absorbable low-dose morphine-soaked microfibrillar collagen hemostatic sponge placed on the surface of dural sac (epidural MMCHS), PCA with IV morphine, and intermittent IM bolus injection of meperidine.

MATERIALS AND METHODS Materials This retrospective study was approved by the institutional review board of Chang Gung Memorial Hospital. Five hundred eighty patients who had undergone posterior lumbar surgery at the spine division of the orthopedic department at Chang Gung Memorial Hospital in Linkou, Taiwan, between January and July 2007 were reviewed (Figure 1). Exclusion criteria included a history of hypersensitivity or idiosyncratic reaction to opioids and any contraindication to parenteral or epidural administration of morphine or meperidine. A total of 2225

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165 American Society of Anesthesiologists’ physical status I to III, opioid-naive adult patients who underwent elective shortsegment (one or two motion segments) posterior lumbar laminectomy and fusion surgery under general anesthesia were recruited for this study. These patients were diagnosed with either degenerative or spondylolytic spondylolisthesis with spinal stenosis syndrome, or degenerative disc disease with a herniated disc, the symptoms of which were not alleviated by treatment with oral analgesics for six consecutive weeks. No preoperative narcotics were used in the patients. The patient chose the pain control method without randomization at a preoperative anesthesia visit. Patients were divided into three groups on the basis of the method chosen for postoperative pain control. In the first group, 40 patients received the epidural morphine sponge (epidural MMCHS group). In the second group, 48 patients received PCA (PCA group), and in the third group, 77 patients received intermittent IM bolus injection of meperidine (Meperidine group).

SURGICAL METHODS All operations were performed using the standard posterior approach (Figure 2B). Depending on the extent of the disease, December 2011

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Figure 2. (A) The microfibrillar collagen hemostatic sponge with 1-mg morphine became a paste-like form. (B) Complete decompression, instrumentation, and posterolateral fusion of target motion segment. (C) The microfibrillar collagen hemostatic sponge was placed lightly covering the dura without pressing the nerve root.

laminectomy and instrumentation were performed until adequate decompression of the spinal canal and the neuroforamen was achieved. In all patients, posterior iliac bone grafts were routinely harvested for bilateral posterolateral fusion. The wound was irrigated with normal saline solution and hemostasis was ensured.

Pain Control Methods In the epidural MMCHS group, 1 mL of 0.1% preservativefree morphine (1 mg) was evenly applied to the microfibrillar collagen hemostatic sponge (2.5 × 2.5 cm in size; Figure 2A) and the entire sponge was placed on the surface of the dural sac (Figure 2C). The integrity of the dural sac was checked meticulously in every patient, and no patient was found to have a dural tear intraoperatively. A patch of Gelfoam (Johnson & Johnson Medical Ltd., Livingston, United Kingdom), a sterile compressed sponge equivalent in size to the area of the laminectomy, was then placed over the sponge to prevent the MMCHS from mixing with blood or being lost because of drainage. The wound was closed within 30 minutes and a Hemovac (Pahsco Co, Taipei, Taiwan) was inserted. In all patients, no local anesthetic was injected into the edge of the surgical incision. The PCA group and the Meperidine group underwent the same operation without the placement of the MMCHS. The PCA group received PCA with IV opioids in the operating room, which was prescribed by an anesthesiologist according to the patient’s body weight, with a baseline infusion. The PCA prescription was adjusted according to the patient’s Spine

Postoperative Pain Control After Spinal Surgery • Wu et al

condition, especially in response to the presence of side effects on subsequent days. The Meperidine group was given 40- to 50-mg IM meperidine at the patient’s request, with a 4-hour minimum wait between consecutive injections. Patients in all three groups received postoperative oral analgesics as a combined pain control method. These oral analgesics included acetaminophen (Fucole Paran, Yungshin Pharm Ind. Co, Ltd, Dajia, Taiwan), nonselective nonsteroidal anti-inflammatory drugs (Diclofenac, Novartis Pharmaceuticals Co, Ltd, East Hanover, NJ; Mefenamic acid, Sinphar Pharmaceutical Co, Ltd, Taipei, Taiwan; and Indomethacin, Veterans Pharmaceutical Plant, Taoyuan, Taiwan; Ibuprofen, Synmosa Biopharma Co, Ltd, Taipei, Taiwan), and a selective COX-2 inhibitor (Celecoxib, Pfizer Inc, New York,), and were administered according to patients’ history of peptic ulcer disease or any previous epigastric discomfort. The investigators and the orthopedic ward nurses were familiar with the pain scale, nausea sensation score, and vomiting score and recorded the scores and side effects on nursing records. No prophylaxis was used to preemptively treat postoperative nausea and vomiting (PONV) in any patient. Nausea and vomiting symptoms were controlled using prochlorperazine (5 mg, IM) as needed with an interval of at least 8 hours between consecutive injections. The use of benzodiazepines and other anxiolytics, sedating antihistamines, antidepressants, and other sedating medications was discouraged but permitted. If intolerable pain or side effects occurred, the pain control method was changed, and the patient was excluded from the study. No patient in the epidural MMCHS group was excluded, two patients in the PCA group were excluded, one because of hypotension and one because of respiratory distress, and one patient in the Meperidine group was excluded because of pain and received PCA instead.

Efficacy Assessments A time-weighted pain intensity recall score for up to 72 hours was calculated from pain assessments at the preoperation visit, 4 hours postoperation, and on postoperative days 1, 2, and 3. Postoperative pain intensity was assessed, while at rest at the first request for supplemental pain medication using a visual analog scale, which is a 10-cm scale with 0 indicating no pain and 10 indicating the most severe pain possible. Nausea sensation, ranging from 0 to 5 points was scored by the patient, with 0 being no nausea, and 5 being severe nausea. Vomiting, ranging from 0 to 5 points, was also scored by the patient, with 0 being no vomiting and 5 being severe vomiting. Both were recorded at the same time as pain assessment and at any time a patient complained of nausea or vomiting. Occurrences of other adverse events, such as hypotension, respiratory depression, skin itchiness, and urine retention, were also recorded.

Statistical Methods Analyses were performed using Statistical Package for the Social Sciences software (SPSS, version 12.0, SPSS Inc, www.spinejournal.com

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TABLE 1. Demographic and Perioperative Data Epidural MMCHS (N = 40)

PCA (N = 46)

Meperidine (N = 76)

P

66.50 (7.672)

65.80 (7.730)

64.12 (8.194)

0.256

28/12

33/15

49/28

0.670

Height (cm)

152.3 (3.949)

153.6 (5.595)

153.8 (5.328)

0.316

Weight (kg)

55.33 (8.513)

56.37 (6.346)

58.18 (4.389)

0.798

24/12/4

27/14/5

40/27/9

0.944

28/12

32/14

47/29

0.568

8/12/17/3

9/11/23/3

12/14/38/12

0.529

Age (yr) Sex (M/F)

ASA physical status (I/II/III) Decompression and fusion level (I/II) Postoperative NSAID Diclofenac/Mefenamic acid/ Celecoxib/Acetaminophen

Data are shown as the mean (standard deviation). There were no significant differences between groups (P > 0.05). ASA indicates American Society of Anesthesiologists; MMCHS, morphine-soaked microfibrillar collagen hemostatic sponge; PCA, patient-controlled analgesia; NSAID, nonsteroidal anti-inflammatory drug.

Chicago, IL). Demographic data were assessed using analysis of variance for continuous variables and Pearson chi-square test for nominal variables. Patient ratings were assessed using analysis of variance. All test details are described in Table 1 and Table 2 and Figure 3. A P value of less than 0.05 was considered statistically significant.

RESULTS

than that in the Meperidine group at 4 hours postoperation, and on postoperative days 1 and 2 (P < 0.01). The analgesic effect in the epidural MMCHS group and the PCA group was identical at 4 hours postoperation and on postoperative day 2, but the epidural MMCHS group had better pain control on postoperative day 1 (P < 0.01). There was also a statistically insignificant difference on postoperative day 3 (P = 0.310) (Table 2, Figure 3A).

Analgesic Effect

Postoperative Nausea and Vomiting

There was no difference in demographic and baseline characteristics among the treatment groups (Table 1). There was no difference in preoperative pain scale between each of the groups. There was no statistical difference in postoperative nonsteroidal anti-inflammatory drug use among the groups. Postoperative pain intensity was significantly lower (P < 0.01) in both the epidural MMCHS group and the PCA group compared with the Meperidine group. Pain control in the epidural MMCHS group and the PCA group was significantly better

Nausea scores of more than 1 point at 4 hours after surgery occurred in 20% (8 of 40) of patients in the epidural MMCHS group, in 91.3% (42 of 46) in the PCA group, and 22.4% (17 of 76) in the Meperidine group (Table 3). Vomiting scores of more than 1 point at 4 hours after surgery occurred in 5% (2 of 40) of patients in the epidural MMCHS group, and 91.3% (42 of 46) of patients in PCA group, and 11.8% (9 of 76) of patients in the Meperidine group (Table 4). Both nausea and vomiting were more severe in the PCA group than in the

TABLE 2. Preoperative and Postoperative Pain Rating (Visual Analog Scale) Epidural MMCHS (N = 40)

PCA (N = 46)

Meperidine (N = 76)

P

Scheffe

Preoperation

7.03 (1.143)

7.15 (1.154)

7.38 (1.177)

0.257

(1) = (2) = (3)

4 h postoperation

5.25 (1.020)

6.08 (1.671)

6.82 (1.411)

0.008*

(3) > (1) = (2)

1 day postoperation

4.35 (0.875)

5.19 (1.132)

6.05 (1.165)

0.005*

(3) > (2) > (1)

2 days postoperation

4.30 (0.820)

4.38 (0.983)

5.46 (1.371)

0.037*

(3) > (1) = (2)

3 days postoperation

3.75 (1.259)

3.80 (1.296)

4.00 (1.200)

0.310

(1) = (2) = (3)

Graded from 0 to 10 points (0 is no pain, 10 is the most severe pain possible). Data are presented as the mean (standard deviation). The rank of pain rating is listed in the Scheffe. *P < 0.01. †P < 0.05. MMCHS indicates morphine-soaked microfibrillar collagen hemostatic sponge; PCA, patient controlled analgesia.

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Other Side Effects One patient in the PCA group exhibited persistent hypotension and one patient exhibited respiratory depression. Both patients recovered after PCA was discontinued, and the side effects were treated symptomatically. In the epidural MMCHS group, one patient had transient hypotension, which resolved after fluid challenge and blood transfusion; another five patients in this group had prominent skin itching, which was relieved by treatment with oral antihistamines. No major side effects were noted in the Meperidine group. Furthermore, no epidural hematoma or infection was observed in the epidural MMCHS group.

DISCUSSION

Figure 3. (A) The scoring of pain intensity showed better postoperative pain control in the epidural MMCHS group and in the PCA group at 4 hours postoperation, and on postoperative days 1 and 2. (B) Nausea was significantly higher in the PCA group, peaking on day 1 postoperation. (C) Vomiting showed a similar pattern to nausea.

other two groups at 4 hours postoperation (P < 0.01), and on postoperative day 1 (P < 0.01), day 2 (P < 0.05), and day 3 (P < 0.05). The PCA group showed the most severe nausea and vomiting on postoperative day 1. No patients in the epidural MMCHS group or the Meperidine group had vomiting after postoperative day 2 (Figure 3B, C).

Because of the well-documented dose-dependent side effects of opioid therapy, the authors attempted to lower the dose of morphine to 1 mg, using a microfibrillar collagen hemostatic sponge applied to the epidural space, to decrease the side effects of morphine and prolong the analgesic effect. In this comparison study, the pain control effect of epidural MMCHS was still seen on postoperative days 1 and 2, which is an acceptable pain management duration for most spinal surgery patients. The analgesic effect of epidural MMCHS was similar to IV PCA and greater than IM bolus injection of meperidine. The incidence of PONV was significantly lower in the epidural MMCHS group than the IV PCA. Epidural MMCHS seems to be an effective analgesic method with less PONV after posterior lumbar spinal surgery. Local analgesics are thought to act directly on the pain producer. The effective dose of epidural morphine is lower than that of intravenous morphine because the drug acts directly on the neurotransmission pathway.4 It also prevents the systemic side effects caused by unwanted distribution of morphine to the central nervous system, which induces respiratory depression and PONV. The effective epidural morphine dose suggested by Martin et al18 was 2 mg and the effective dose suggested by Yamaguchi et al19 was 2 to 4 mg. These doses were found to be equipotent to an intrathecal morphine dose of 0.06 to 0.12 mg without combination with other analgesic methods.19,20 A more recent study demonstrated similar pain relief with even lower doses of

TABLE 3. Postoperative Nausea Rating Epidural MMCHS (N = 40)

PCA (N = 46)

Meperidine (N = 76)

P

Scheffe

8/0.30 (0.657)

42/0.92 (0.891)

17/0.29 (0.607)

0.007*

(2) > (1) = (3)

1 day postoperation

12/0.35 (0.587)

46/3.69 (0.884)

16/0.26 (0.597)

0.009*

(2) > (1) = (3)

2 days postoperation

0/0.10 (0.236)

44/2.27 (0.919)

0/0.04 (0.196)

0.012†

(2) > (1) = (3)

3 days postoperation

0/0.04 (0.221)

35/1.23 (1.142)

0/0.01 (0.115)

0.025†

(2) > (1) = (3)

4 h postoperation

Graded from 0 to 5 points (0 is no nausea, 5 is severe nausea). Data are presented as the number of patients who had more than 1 point/mean (standard deviation). The rank of nausea rating is listed in the Scheffe. *P < 0.01. †P < 0.05. MMCHS indicates morphine-soaked microfibrillar collagen hemostatic sponge; PCA, patient controlled analgesia.

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TABLE 4. Postoperative Vomiting Rating Epidural MMCHS (N = 40)

PCA (N = 46)

Meperidine (N = 76)

P

Scheffe

4 h postoperation

2/0.05 (0.224)

42/1.92 (1.055)

9/0.13 (0.377)

0.008*

(2) > (1) = (3)

1 day postoperation

4/0.10 (0.308)

44/3.85 (1.084)

8/0.17 (0.500)

0.007*

(2) > (1) = (3)

2 days postoperation

0/0.00 (0.000)

44/1.88 (1.033)

0/0.00 (0.000)

0.011*

(2) > (1) = (3)

3 days postoperation

0/0.00 (0.000)

30/1.15 (1.142)

0/0.00 (0.000)

0.021†

(2) > (1) = (3)

Graded from 0 to 5 points (0 is no vomiting, 5 is severe vomiting). Data are presented as the number of patients who had more than 1 point/mean (standard deviation). The rank of vomiting rating is listed in the Scheffe. *P < 0.01. †P < 0.05. MMCHS indicates morphine-soaked microfibrillar collagen hemostatic sponge; PCA, patient controlled analgesia.

epidural morphine (10–20 μg/kg).21 With a lower effective dose, epidural morphine administration produces fewer side effects than intravenous morphine; however, at doses of 2 to 10 mg, side effects still occur, such as pruritus, nausea, vomiting, respiratory depression, hypotension, and sphincter dysfunction.19,22,23 This study lowered the dose to 1 mg and allowed every patient to receive oral analgesics, which is more in line with a multimodal approach and can theoretically lower the effective morphine dose as Bonhomme et al24 and Sun et al25 previously proposed. The side effects observed in this study with epidural MMCHS are lower than those seen in previous studies: nausea (25%), pruritus (12.5%), vomiting (5%), and hypotension (2.5%). No patient in the epidural MMCHS group suffered from urinary retention or respiratory depression, which may be a result of the lower morphine dose. Another issue is that although a single dose of epidural morphine in posterior lumbar spine surgery has been widely used, the analgesic effect lasts only for less than 24 hours, which is not sufficient to provide adequate pain control.7 A solution for this inadequacy was the placement of an epidural catheter for continuous or patient-controlled analgesia.9,26 Two followup studies have compared continuous epidural analgesia with IV morphine administered via PCA devices after major spinal surgery.27,28 In one retrospective study, a reduced hospital stay time was observed in the epidural group, although the cost of care was higher.27 Conversely, another randomized study was unable to find any significant difference in pain scores or side effects between the epidural group and the PCA group.28 The incidence of local superficial infection after routine epidural catheter placement is as high as 12%,13 and epidural abscesses still occur, although the incidence is rare. A recent review of the literature from 1974 to 1996 revealed 42 catheter-related epidural abscesses.14 This devastating complication of spinal surgery is more likely to occur with catheter insertion close to larger skin incisions. There is an extended-release epidural morphine formulation (DepoDur, Endo Pharmaceuticals, Chadds Ford, PA) that is administered through a single perioperative epidural injection to provide extended, 48-hour analgesia.29 This may eliminate the need for an indwelling epidural catheter; 2229

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however, nausea, vomiting, and other side effects were observed, even at the suggested dose (15 mg).30–32 The carrier used in this study is the microfibrillar collagen hemostatic sponge, which has been in use since 1970.33 It is bioabsorbable and is absorbed in 8 to 10 weeks.15 The helical collagen molecules induce platelet aggregation, and platelet contact activation helps to stimulate the clotting cascade.33 We used the mechanical characteristics of an absorbable sponge, namely the absorbency and slow release, to carry morphine for a longer pain control effect. Currently, there is only limited evidence to support its use as a carrier. However, the hemostatic effect of the microfibrillar collagen hemostatic sponge is well-established; therefore, it can reduce local hemorrhaging and therefore decelerate morphine diffusion.34,35 One preliminary report showed a strong analgesic effect in laminectomy with the use of steroid and morphine-infused topical microfibrillar collagen gel.36 Seventy-eight of 80 patients (97.5%) were able to walk without support on the first postoperative day. Moreover, only 15 patients had nausea or vomiting on the first postoperative day. This supports the use of microfibrillar collagen hemostatic sponge as a carrier for epidural morphine to prevent PONV. Although some case reports have shown that immune responses such as hypersensitivity and granuloma formation can occur with the use of a microfibrillar collagen hemostatic sponge,37–42 none of the patients in this study experienced such complications. However, it is still an issue, and the potential risks of using a microfibrillar collagen hemostatic sponge as a biocarrier should be carefully addressed during follow-up. On the contrary, the mass effect caused by the hemostatic collagen sponge during disc surgery has been published.43 To prevent this possible complication, the hemostat collagen sponge only covered the thecal sac, and not the nerve root. No patient in this study mentioned any new onset of radiculopathy. Iliac crest harvest was performed in all patients; however, harvest site pain was not specifically evaluated in this study. Therefore, whether the epidural morphine sponge has an effect on pain that originated from the iliac crest graft harvest was not definitively answered by this study. However, overall pain control by the morphine sponge was effective in this December 2011

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SURGERY study. Further studies are needed to determine the effect of the epidural morphine sponge on the donor site pain and direct placement of morphine sponge in the iliac crest bone graft site. While the use of single low-dose morphine on a microfibrillar collagen hemostatic sponge for slower release is supported by the analgesic effect persisting for more than 24 hours, no actual data on the release rate in the surgical area were available. In addition, all patients had a suction drain and drug loss from the drain may reduce the effect of epidural MMCHS. However, these patients still had less pain intensity than the Meperidine group in the first 48 hours postoperative. This may be because the hemostat sponge retained some of the morphine inside the clot and less was lost from the drain. This was a nonrandomized retrospective study. Many uncontrolled factors and bias may be unavoidably present and may have influenced postoperative pain recording. This was the major limitation of this study and further prospective, randomized, and controlled studies are necessary to confirm these results.

CONCLUSION This retrospective, multiple-group comparison study demonstrated that low-dose (1-mg) epidural MMCHS was a useful alternative for postoperative pain control after short segment posterior lumbar spine decompression and fusion surgery with the benefit of lesser side effects than IV PCA or IM meperidine administration.

➢ Key Points ‰ A low-dose epidural MMCHS provides an effective analgesic effect within 2 days after posterior lumbar spinal surgery. ‰ A lower dose of morphine reduces postoperative nausea, vomiting, and other opioid-related side effects. ‰ The incidence of PONV in patient-controlled analgesia is high and should be properly managed.

Acknowledgment This study was performed with the approval of the institutional review board of Chang Gung Memorial Hospital, Taiwan.

References

1. Bianconi M, Ferraro L, Ricci R, et al. The pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg 2004;98:166–72. 2. Raw DA, Beattie JK, Hunter JM. Anaesthesia for spinal surgery in adults. Br J Anaesth 2003;91:886–904. 3. Cohen BE, Hartman MB, Wade JT, et al. Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. Spine 1997;22:1892–6. 4. Grabow L, Kremer G, Stannigel H, et al. [Intraoperative epidural opiate analgesia for pain treatment after spine surgery (author’s transl.)]. Anasth Intensivther Notfallmed 1982;17:96–7. 5. Behar M, Magora F, Olshwang D, et al. Epidural morphine in treatment of pain. Lancet 1979;1:527–9. 6. Ionescu TI, Taverne RH, Houweling P, et al. A study of epidural morphine and sufentanil anesthesia for abdominal aortic surgery. Acta Anaesthesiol Belg 1989; 40:65–77.

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