Intrathecal morphine reduces cost and lowers opioid requirement in scoliosis surgery

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Vishal Sarwahi presenting at IMAST 2018

Using intrathecal morphine following surgical treatment of adolescent idiopathic scoliosis patients reduces hospital costs, yields better postoperative pain control and results in a significantly lower opioid requirement than patient-controlled analgesia, according to a study presented as part of the 27th Annual Meeting on Advanced Spine Techniques (IMAST 2020). The conclusions were presented online this week by Vishal Sarwahi (Cohen Children’s Medical Center, New York, USA) due to the cancellation of the IMAST meeting in April due to the COVID-19 pandemic. Sarwahi commented that the findings amount to a “compelling argument” for the routine use of intrathecal morphine for adolescent idiopathic scoliosis patients. Sarwahi and colleagues were nominees for the Whitecloud Award for Best Clinical Paper at IMAST.

Opening his presentation, Sarwahi said that surgeons taking care of adolescent idiopathic scoliosis patients face “two major healthcare issues”:the cost of care and the use of opioids to manage pain. Sarwahi claimed that around 22% of costs involved in the treatment of adolescent idiopathic scoliosis patients relates to intensive care unit (ICU) and hospital stay. Turning to opioid usage, he noted that patients undergoing posterior spinal fusion utilise more opioids than in any other surgery.

Although rapid recovery protocols have decreased hospital stay, he said, they still require up to two days of patient-controlled analgesia, as well a high dosage of Gabapentin. Additionally, Sarwahi noted that the US Food and Drug Administration (FDA) has warned that a high dose of Gabapentin, especially with opioids, carries a higher risk of respiratory depression and can prolong wake up tests, which he described as an important issue for adolescent idiopathic scoliosis. He added that patient-controlled analgesia, especially for up to two days, can lead to over 50mg of morphine consumption, on top of the additional opioids that are being administered.

Sarwahi also noted that intrathecal morphine has been utilised in adolescent idiopathic scoliosis patients in the past, but commented that pruritus, respiratory depression and emesis had led to its abandonment. Literature has shown that respiratory depression with intrathecal morphine increases only with a high dose, he added, commenting that a microdose of intrathecal morphine has been found to be effective in paediatric surgery, as well as caesarian section, providing adequate pain control and avoiding puritus and respiratory depression.

“The question is: can [a] microdose intrathecal morphine based rapid recovery programme lower morphine consumption and hospital cost, while maintaining outcomes in AIS?” Sarwahi posed to the viewers.He told the virtual IMAST audience of his experience implementing an intrathecal morphine approach within his centre. This included a total of 363 adolescent idiopathic scoliosis patients subdivided into two groups, one comprising 255 subjects using patient-controlled analgesia involving hydromorphone for an average of two days, and the second comprising 108 patients in the intrathecal morphine group. The two groups were largely consistent in terms of BMI, preoperative cobb angle and gender, Sarwahi said. However, those in the intrathecal morphine group were found to start or drinking or taking by mouth sooner, were out of bed earlier, had lower maximum pain and activity and had a full catheter removal sooner compared to PCA [patient-controlled analgesia], he commented. “In addition, there were fewer patients in the intrathecal morphine group who were constipated and their length of stay was shorter, three days compared to five days. All these things were significant,” he said.

Looking at morphine equivalence, patients in the intrathecal morphine group had significantly lower morphine consumption compared to the patient-controlled analgesia group at 24 hours and 48 hours, Sarwahi added. In terms of cost, he reported no significant difference between the two groups in terms of intra-operative, postoperative or ICU cost. However, the intrathecal morphine group had on average US$8,000 less in hospital stay cost compared to the patient-controlled analgesia group.

Discussing the findings, Sarwahi commented: “We found that intrathecal morphine patients had adequate pain control and used significantly less morphine during the treatment course. This is important because addiction is known to increase with not only the amount, but also the duration of morphine used. We also found a 33% cost reduction, and this was largely from a decreased hospital stay.”

In conclusion, he said: “[A] Microdose intrathecal morphine-based rapid recovery programme has adequate recovery, significantly better postoperative pain control and lower costs compared to traditional protocols using patient-controlled analgesia in adolescent idiopathic scoliosis patients. In addition, opioid requirement is significantly lower making for a compelling argument for its routine use.”


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