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Retrospective review.The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA).Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication.AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared.There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly11.6% of PCA patients (P 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation.This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Studies have shown that narcotic substance addiction has been on a rise across all patient populations, including pediatrics. Narcotics have long been used in complex spine surgeries as a pain control method and are often given in the form of patient controlled analgesia (PCA) during postoperative recovery and take home medication. The objective of this study was to report on one institution’s use of single bolus micro-dose intrathecal morphine (ITM) during Posterior Spinal Fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) and its comparison to patients whose pain was controlled with …

BACKGROUND CONTEXT Studies have shown that narcotic substance addiction has been on a rise across all patient populations, including pediatrics. Narcotics have long been used in complex spine surgeries as a measure of pain control, and are often given in the form of patient-controlled analgesia (PCA) during postoperative recovery as well as take-home medication. PURPOSE The objective of this study was to report on one institution's use of single bolus microdose intrathecal morphine (ITM) during PSF for AIS and its comparison to patients whose pain was controlled with PCA. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE AIS patients undergoing PSF from 2011–2019 were reviewed. PCA patients were included in Group 1 and ITM in Group 2. OUTCOME MEASURES Intraoperative clinical data (operative time, estimated blood loss), postoperative hospital stay course, request for prescription refill, morphine equivalence. METHODS In 2018, we instituted an RRP for scoliosis patients undergoing PSF utilizing intrathecal micro dose ITM. Previously, PCA was the mainstay for postop pain management. In the ITM protocol, patients receive 1.5 mcg/kg ITM diluted in 1 cc saline administered preoperatively by anesthesiologists or intraoperatively by the surgeon. Postoperatively, patients received IV ketorolac at 0.5mg/kg Q6h, PO Tylenol (15 mg/kg q6h), PO oxycodone (0.1 mg/kg q4), and IV hydromorphone (15 mcg/kg) for breakthrough pain. At discharge, PCA patients received 14-day prescriptions for 5mg oxycodone q6 compared to just 7-day prescriptions in the ITM group. Charts from 2011 – 2019 were reviewed. PCA patients were included in Group 1 and ITM in Group 2. Periop data and patient requests for prescription refills were analyzed and compared using Kruskal-Wallis and chi-squared tests. RESULTS A total of 340 patients (PCA: 215; ITM:125). Levels fused (p = 0.325) and BMI (p = 0.746) were similar. Patients in Group 1 had a significantly higher median length of stay (p CONCLUSIONS This is the first study showing that use of microdose ITM with oral analgesics have significantly better postoperative pain control and perioperative outcomes to PCA in the AIS population following PSF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is a complex procedure for which charges can exceed $150,000. Among the total costs, inpatient and intensive unit care contributed 22%. Many institutions have implemented rapid recovery pathways (RRP) to improve patient care following scoliosis surgery. This study aims to determine the effects of a multimodal RRP, utilizing intrathecal morphine (ITM) in combination with oral pain medication, on hospital costs and patient management. PURPOSE The purpose of this study was to determine whether a protocol that excludes postoperative patient care analgesia (PCA) with the utilization of preoperative/intraoperative ITM had similar or superior outcomes, including hospital costs. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE AIS patients undergoing PSF from 2013 – 2019. OUTCOME MEASURES Hospital stay data, requests for opioid refill and overall costs. METHODS AIS patients undergoing PSF from 2013 – 2019 were retrospectively reviewed. RRP patients received ITM as part of their multimodal analgesia. Fusion level-matched control patients received hydromorphone PCA for postoperative pain management. At discharge, PCA patients received 14-day prescriptions for oxycodone compared to 7-day prescriptions in the ITM group. Perioperative data, requests for opioid refill, and overall costs were analyzed. RESULTS A total of 363 patients were included (PCA: 255, RRP/ITM: 108). BMI (p=0.786) and preoperative Cobb (p=0.343) were similar. RRP patients had a significantly shorter length of stay (3 vs 5 days, p CONCLUSIONS With increasing concerns about opioid dependence and hospital costs, our RRP pathway, which incorporates microdose ITM injections, allows for optimum perioperative management, improved costs, with overall better outcomes than the traditional PCA. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations.