An innovative method of intraoperative epidural catheter placement for postoperative pain relief in children undergoing spinal surgery

Objective. The purpose of this study is to describe an intraoperative technique for placement of an epidural catheter for post-operative pain relief in patients undergoing corrective spine surgery. Introduction. Corrective surgery for scoliosis is associated with significant pain and respiratory compromise. Relief of post-operative pain with epidural analgesia has been shown to extend the period of post-operative pain relief and may reduce the incidence of post-operative respiratory problems (1, 2). Placing the epidural catheter pre-operatively is often associated with anxiety and fear for the child with scoliosis, (3) as well as inherent difficulties due to their anatomic deformity (4). Post-operative epidural placement in a patient who has undergone spinal surgery is potentially dangerous since the catheter must cross the surgical site. We describe here an intraoperative technique for placement of the epidural catheter for pédiatrie corrective spinal surgery. Methods. After Institutional Review Board approval and patient informed consent, fifteen patients, ages 9-18, undergoing Harrington Rod instrumentation for scoliosis were studied. Patients were excluded from the study if their epidural space was previously surgically disrupted, they had a known coagulopathy, or they were hemodynamically unstable before or during the operation. After instrumentation of the spine and iliac bone graft were completed, an epidural catheter was placed in the lumbar (L3) epidural space under direct vision by the surgeon. A separate incision was made and the catheter was brought out through the skin. A 3 cc test dose of 1.5% xylocaine with 1:200 epinephrine was given via the epidural catheter to verify position before an infusion of Fentanyl 10 ug/cc in NS with 0.05% or 0.1% bupivacaine per protocol was started. The patients were closely monitored in the Pédiatrie Intensive Care Unit. A standardized pain scale was used to evaluate quality of pain control (5). The epidural infusions were used for no longer than 72 hours postoperatively, at which time the catheter was removed and alternative pain control was made available. The epidural infusion rate was discontinued and the catheter was removed if the patient experienced an infection at the catheter site, fever of unknown origin, sepsis, evidence of catheter migration into the subarachnoid space, or inability to obtain adequate pain relief. Results. A total of 15 epidural catheters were placed intraoperatively via this technique and remained in place for 72 hours post-operatively. There were no complications from either the catheter placement or during the use of the catheter post-operatively. Based upon pain scale means/averages, and follow-up phone interviews, patient satisfaction was 100% with this method of catheter placement. Discussion. Pre-operative placement of epidural catheters in this population is often difficult and arduous because of their scoliotic deformity as well as the emotional distress these children experience prior to surgery (4). Placement of the epidural catheter post-operatively is dangerous, as the catheter must traverse a surgically disrupted site and there is a significant chance that the catheter may be misplaced. Intraoperative placement of the catheter by the surgeon allows for direct visual recognition of the epidural space, uniform placement of the catheter in the study population, and decreases the likelihood of improper placement. Having the patients under general anesthesia at the time of placement reduces their anxiety regarding catheter placement and allows for an improved post-operative course. We find that this method when used in pédiatrie patients undergoing corrective spinal surgery is easy, reliable, and has a very high rate of patient satisfaction. References:.