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Standardizing postoperative pain control for decompression of pediatric Chiari type I malformation by limiting
Rebecca A Reynolds1, Amanda V Jenson2, Kentlee Battick2
11Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and.
Insights
A new multimodal pain control protocol for children undergoing Chiari type I malformation (CM-I) decompression resulted in similar pain scores and reduced antiemetic use. This approach offers effective pain management for CM-I patients without narcotic patient-controlled analgesia.
Area of Science:
- Pediatric Neurosurgery
- Pain Management
- Surgical Outcomes
Background:
- Chiari type I malformation (CM-I) often requires surgical decompression.
- Effective postoperative pain control is crucial for pediatric patients.
- Traditional pain management may involve significant narcotic use.
Purpose of the Study:
- To evaluate a novel multimodal pain control protocol for pediatric CM-I decompression.
- To compare perioperative pain scores and resource utilization before and after protocol implementation.
Main Methods:
- Retrospective matched cohort study of patients under 21 undergoing CM-I decompression.
- Comparison of pre- and post-implementation cohorts of a standardized multimodal pain protocol.
- Primary outcome: average perioperative pain score; secondary outcomes: length of stay, narcotic and antiemetic usage.
Main Results:
- The new protocol demonstrated noninferior average pain scores (p=0.08) and significantly reduced antiemetic administration (p=0.048).
- No significant differences were observed in length of stay, discharge narcotic prescriptions, or morphine equivalent usage.
- Duraplasty was associated with longer LOS, increased narcotic use, and lower pain scores compared to bone-only decompression.
Conclusions:
- A postoperative multimodal pain regimen provides effective, noninferior pain control for pediatric CM-I decompression.
- This protocol successfully reduced antiemetic requirements.
- Neurosurgeons should consider this multimodal approach for CM-I decompression patients.
Objective:
The aim of this study was to assess the effectiveness of a postoperative multimodal pain control protocol on perioperative pain scores in children undergoing decompression for Chiari type I malformation (CM-I).
Methods:
This retrospective matched cohort study included patients < 21 years of age who underwent elective suboccipital craniectomy and C1 laminectomy for CM-I with or without duraplasty at a single center from January 2020 to July 2023. A standardized, multimodal postoperative pain protocol was implemented in August 2021 that did not use narcotic patient-controlled analgesia. Pre- and postprotocol cohorts were compared. The primary outcome was average perioperative pain score. Secondary outcomes included postoperative length of stay (LOS), narcotic usage, and antiemetic usage.
Results:
Thirty-four children met the inclusion criteria (17 preprotocol, 17 postprotocol). Fifty-three percent were female (18/34). The mean patient age was 7.0 ± 5.0 years. After implementation of the pain protocol, noninferior average pain scores (p = 0.08) and less antiemetic administration (p = 0.048) were found across both surgery types. Equivalent inpatient LOS (p = 0.78), narcotic prescriptions at discharge (p = 0.73), and milliequivalents of morphine used (p = 0.55) were also found. Bone-only decompression was completed in 65% of patients (n = 22/34, 11 in each pre- and postprotocol group) with 12 of 34 undergoing duraplasty (6 in each pre- and postprotocol group). Patients who underwent posterior fossa decompression with duraplasty had a significantly longer LOS (p = 0.003), more overall narcotic usage (p = 0.015), and lower pain scores (p = 0.047) compared with those who underwent decompression without duraplasty.
Conclusions:
Patients undergoing a CM-I decompression had noninferior postoperative pain control and required less antiemetic dosing after implementation of a multimodal pain protocol. Neurosurgeons should consider a postoperative multimodal pain regimen for their patients with CM-I who undergo decompression with or without duraplasty.
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