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Updated: Jun 17, 2025
An Experimental Paradigm for the Prediction of Post-Operative Pain PPOP
Published on: January 27, 2010
Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral
Danielle Greig1, Christina A Sun1, Daniel McBride2
1Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA.
Insights
A multimodal analgesic injection significantly reduced pain and narcotic use in children with cerebral palsy (CP) after hip reconstruction surgery. This safe and effective approach improves postoperative pain control for pediatric orthopedic procedures.
Area of Science:
- Orthopedic Surgery
- Pediatric Anesthesiology
- Pain Management
Background:
- Cerebral palsy (CP) affects 1 in 4 children, necessitating orthopedic surgery.
- Postoperative pain control in pediatric CP patients is understudied and linked to adverse outcomes.
- Multimodal analgesic injections, proven in adults, lack study in pediatric CP patients undergoing complex orthopedic procedures.
Purpose of the Study:
- To evaluate the efficacy of multimodal surgical site injections for postoperative pain control in pediatric CP patients undergoing hip reconstruction.
Main Methods:
- A multicenter, randomized, double-blind, placebo-controlled trial.
- Inclusion of pediatric patients (<18 years) with CP undergoing varus derotation osteotomy (VDRO).
- Comparison of a multimodal analgesic injection (ropivacaine, epinephrine, ketorolac) versus normal saline for surgical site infiltration.
Main Results:
- The experimental group showed significantly lower narcotic consumption (P=0.01) and pain scores (P<0.001) compared to controls.
- No significant differences in operative time, blood transfusion, or hospital length of stay.
- No adverse medication reactions or injection site complications were observed.
Conclusions:
- Multimodal analgesic injections are effective for improving pain control and reducing narcotic use in pediatric CP patients post-hip reconstruction.
- This approach offers a safe and beneficial addition to standard multimodal pain management for osseous surgeries in this population.
Background:
One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP.
Methods:
After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables.
Results:
Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group.
Conclusions:
In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects.
Significance:
Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries.
Level Of Evidence:
Level I-therapeutic.
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