Preemptive Opioid Sparing Medication Protocol Decreases Pain and Length of Hospital Stay in Children Undergoing Posterior Spinal Instrumented Fusion for Scoliosis

By Selina Poon, MD1, De-An Zhang, MD1, Frederic Bushnell, MD1, Ronen Sever, MD1, Ji-Ming Yuen, MD2, Robert Cho, MD1
1Shriners for Children Medical Center, Pasadena, CA, USA,
2Huntington Hospital, Pasadena, CA, USA
(Summarized and submitted by De-An Zhang, MD)

Poorly controlled post-operative pain may be associated with delays in ambulation, longer inpatient hospital stays, decreased patient satisfaction, higher hospital cost, and higher opioid use [1].  In addition, post-operative pain in children can cause behavioral problems lasting beyond the duration of the pain itself [2].  Starting in August of 2016, the Department of Anesthesiology began the implementation of a multimodal analgesic protocol.  A combination of acetaminophen, celecoxib, and gabapentin are started 2 days pre-operatively in order to achieve a steady state of plasma concentration of the non-opioid medications prior to incision.

We retrospectively reviewed 116 posterior spinal instrumented fusion (PSIF) cases from March 2014 to November 2017.  Our goal was to compare the 64 patients who received the multimodal analgesic protocol with the 52 patients who, before 2016, did not receive multimodal non-opioid analgesia.  Both groups were prescribed the same inpatient opioid pain regimen of scheduled oxycodone and intravenous hydromorphone via patient controlled analgesia by the attending pediatricians.  We analyzed length of stay, total opioid consumption in oral morphine milligram equivalents, and maximum pain scores per day from surgical to discharge date.

After analysis, we found no difference in the total opioid consumption between the two groups.  However, length of stay was shorter (0.6 days, p<0.05) in the multimodal group.  Also, the multimodal group lower had lower maximal pain levels on post-operative days #1 (4.9 vs. 5.8, p=0.0196), #3 (4.4 vs. 6.1, p=0.0006), and #4 (4.2 vs. 5.4, p=0.0393).
In conclusion, we found a positive relationship between multimodal analgesia and length of stay.  While there was no difference in the amount of opioid consumed, the multimodal group had lower pain scores.  This invites further research into whether the amount of opioids consumed can be decreased while maintaining a shorter length of stay.


  1. Lachiewicz, P.F., The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics, 2013. 36(2 Suppl): p. 15-9.
  2. Kotiniemi, L.H., P.T. Ryhanen, and I.K. Moilanen, Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia, 1997. 52(10): p. 970-6.

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