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YOUR PATIENT

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A 14-year-old female with idiopathic scoliosis (IS) is seen on postoperative day 0 following a posterior spinal fusion and instrumentation.

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PREOPERATIVE CONSIDERATIONS

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Idiopathic scoliosis is a chronic spinal condition; between 1% and 3% of older children and adolescents in the United States are diagnosed with it every year, with a greater prevalence among females. This condition is commonly conservatively managed with bracing therapy and physiotherapy; alternatively, as in the patient described here, a surgical approach using pedicle screws and spinal fusion techniques can be used for more severe cases of curve distortion.

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POSTOPERATIVE CONSIDERATIONS

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Patients require intensive care unit or stepdown monitoring for medical and surgical management immediately following surgery. In addition, most patients require a large amount of opioid to maintain adequate analgesia in the first 24 hours.

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  • Use an opioid prescription via patient-controlled analgesia (PCA) for the first 48 hours.

  • Make a transition to a regularly administered short-acting opioid such as oral morphine or oxycodone or a transition to an oral long-acting opioid such as methadone or oxycodone CR in addition to a short-acting opioid as needed for moderate to severe pain on postoperative days 2 and 3.

  • Prescribe a taper for the long-acting opioid, if utilized.

  • Prescribe oral acetaminophen as needed for mild pain or around the clock for 3 days as an adjuvant during the most severe postoperative pain before changing to as needed for mild pain.

  • Schedule inpatient physical therapy in accordance with the orthopedist’s recommendation.

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DOs and DON’Ts

  • ⊗ Do not prescribe a demand dose via PCA if the patient is not able to utilize it.

  • ✓ Do monitor for sedation and adequate analgesia after the transition to an oral regimen.

  • ⊗ Do not allow the parent to utilize the demand dose of a developmentally normal patient.

  • ✓ Do begin a bowel regimen on postoperative day 1.

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CONTROVERSIES

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Intravenous ketorolac for analgesia in the postoperative period. In animal models, nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to inhibit bone metabolism by disrupting prostaglandin synthesis, reducing immune and inflammatory responses, and inhibiting osteoblast cell production. In adults, a significant inhibitory effect on spinal fusion when using ketorolac has been shown. Retrospective studies in adolescents with IS have not shown that postoperative ketorolac within the first 48 hours of surgery significantly influences the development of pseudoarthrosis or other reasons for failed fusion. At the authors’ institution, IV ketorolac is started at 48 hours postop (if blood urea nitrogen and creatinine are normal and hemoglobin is stable) to minimize any effect that the NSAID may have on fusion.

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OUTPATIENT CONCERNS

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Various short- and long-acting opioid analgesics, as well as sedatives, are increasingly prescribed for relief of pain in the adolescent and young adult population, but carry a risk for misuse and diversion. Attention to ...

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