The Northeastern Society of Plastic Surgeons

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Epidural Analgesia in Low Level Spina Bifida Patients - A Proof of Concept
Joshua D. Roth, MD, Rosalia Misseri, MD, Mark P. Cain, MD, Morton C. Green, MD.
Riley Hospital for Children, Indianapolis, IN, USA.

Background:
Treatment of post-operative pain has made significant advances due in part to the greater utilization of regional pain techniques. Thoracic epidural analgesia has been advantageous in the treatment of pain following abdominal procedures by promoting more prompt resolution of ileus, as fewer narcotics are required. Although the use of epidural analgesia in low level spina bifida (LLSB) patients during labor and delivery has been reported, its post-operative use has not been studied or reported. Concern of anatomical anomalies and worsening neurologic symptoms has prevented its utilization in these patients. Patients with LLSB can have normal sensation of the abdominal wall and experience abdominal discomfort. We hypothesize that thoracic epidural placement in the T9-T10 interspace would allow for safe analgesia in patients with LLSB following abdominal procedures.
Methods:
We retrospectively reviewed consecutive patients with LLSB who received T9-10 thoracic epidurals after induction of general anesthesia at our institution from 4/16 to 5/17. Though all epidurals, 0.2% ropivicaine was administered at a rate between 0.385 and 0.46 mg/kg/hr. Opioid consumption was calculated by conversion of opiates into IV morphine (mg/kg). Pain was assessed by nursing every 2 hours and was measured by mean and maximum FLACC scores on POD 0-3 while the epidural was in place. Use of antiemetic medications and changes in functional status were recorded as secondary metrics.
Results:
Eight patients with LLSB had thoracic epidural anesthesia at our institution. All patients had function levels at or below L3. Procedures included ileocystoplasty, creation of a catheterizable channel and Malone antegrade continence enema, and bladder neck slings. There were no complications associated with epidural placement including hypotension or wound issues. FLACC scores in all patients were low, averaging 1.77 (range 0-3.33) on POD0, 1.66 (0.92-2.92) on POD1, 1.09 (0.17-2.41) on POD2 and 0.91 (0.33-1.5) on POD3. All epidurals were removed on POD 3-5. We were unable to calculate total opioid consumption in three patients who had received patient controlled analgesic machines. The remaining patients received intermittent IV morphine. Depending on patient requirements, diazepam, acetaminophen, and hydrocodone elixir were prescribed. Average opioid consumption was 14.47 mg IV morphine (7.1-25.34) and 0.68 mg/kg IV morphine (0.31-1.08) while the epidural was in place. On average, patients required 2.88 doses of antiemetics while the epidural was in place (0-11). No changes in functional status level were noted.
Conclusions:
Thoracic epidural analgesia can be a safe and effective option to assist with post-operative pain management following complex lower urinary tract reconstruction in patients with LLSB.
Table 1: Patient Characteristics

Cohort (N=8)
Age in years, avg (range)7.1 (4-13)
Male patients, no. (%)6 (75%)
Weight in kg, avg (range)24.7 (16-46.7)
Functional Level
L3, no. (%)5 (62.5%)
L5, no. (%)1 (12.5%)
S1, no. (%)1 (12.5%)
S3, no. (%)1 (12.5%)
Date of Epidural Removal
POD3, no. (%)4 (50%)
POD4, no. (%)3 (37.5%)
POD5, no. (%)1 (12.5%)
Total IV Morphine Requirements with Epidural in Place (mg), avg (range)14.47 (7.1-25.34)
Total IV Morphine Requirements with Epidural in Place (mg/kg), avg (range)0.68 (0.31-1.08)
FLACC Scores
Mean POD #0, avg (range)1.77 (0-3.33)
Max POD #0, avg (range)4.13 (0-10
Mean POD #1, avg (range)1.66 (0.92-2.92)
Max POD #1, avg (range)5.38 (3-7)
Mean POD #2, avg (range)1.09 (0.17-2.41)
Max POD #2, avg (range)3.63 (1-6)
Mean POD #3, avg (range)0.91 (0.33-1.5)
Max POD #3, avg (range)4.25 (2-9)
Antiemetics Taken While Epidural in Place, avg (range)2.88 (0-11)
Change in Functional Status, no. (%)0 (0%)


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