Multi-Institutional Study of Multimodal Analgesia Practice, Pain Trajectories, and Recovery Trends After Spine Fusion for Idiopathic Scoliosis
Authors: Einhorn Lisa M. , Monitto Constance L. , Ganesh Arjunan , Duan Qing , Lee Jiwon , Ramamurthi Radhamangalam J. , Barnett Kristi , Ding Lili , Chidambaran Vidya 
Published: January 2025

BACKGROUND:
Posterior spinal fusion (PSF) surgery for correction of idiopathic scoliosis is associated with chronic postsurgical pain (CPSP). In this multicenter study, we describe perioperative multimodal analgesic (MMA) management and characterize postoperative pain, disability, and quality of life over 12 months after PSF in adolescents and young adults.

METHODS:
Subjects (8–25 years) undergoing PSF were recruited at 6 sites in the United States between 2016 and 2023. Data were collected on pain, opioid consumption (intravenous morphine milligram equivalents (MME)/kg), and use of nonopioid analgesics through postoperative days (POD) 0 and 1. Pain descriptors, functional disability, and quality of life were assessed preoperatively, 2 to 6 and 10 to 12 months after surgery using questionnaires (PainDETECT, Functional Disability Inventory [FDI], and Pediatric Quality of Life Inventory [PedsQL]). Descriptive analyses of analgesic use across and within sites (by preoperative pain and psychological diagnoses), acute postoperative pain and yearly in-hospital analgesic trends are reported. Pain trajectories over 12 months were analyzed using group-based discrete mixture. CPSP (defined as pain score >3/10 beyond 2 months postsurgery), and associated FDI and PedsQL were analyzed.

RESULTS:
In this cohort (343 patients, median [interquartile range {IQR}] 15.2 (13.7–16.6) years, 71.1% female), perioperative use of opioids and nonopioid analgesics significantly varied across sites (P < .001). Preoperatively, gabapentinoids were administered to 48.2% (157/343). Intraoperatively, opioid use included remifentanil (264/337 [78.3%]) and fentanyl (73/337 [21.7%]) infusions, and methadone boluses (159/338 [47%]). Postoperatively, patient-controlled analgesia was commonly used (342/343 [99.9%]). Within sites MMA use did not appear to differ by preoperative pain or psychological comorbidities. Median in-hospital opioid use declined over time (−0.08 [standard error {SE} 0.02] MME/kg/POD 0 to 1 per year, P < .001) while increased use of ketamine (P < .001), methadone (P < .001), dexmedetomidine (P < .001), and regional analgesia (P = .015) was observed. Time spent in moderate-to-severe pain on POD 0 to 1 was ≈33%. CPSP was reported by 24.2% (64/264) with ~17% reporting ongoing neuropathic/likely neuropathic pain. Four postsurgical pain trajectories were identified; 2 (71%) showed resolving pain and 2 (29%) showed persistent mild and moderate-to-severe pain. Although FDI and PedsQL improved over time in both CPSP and non-CPSP groups (P < .001), FDI was higher (P < .001) and PedsQL lower (P = .001) at each time point in the CPSP versus the non-CPSP group.

CONCLUSIONS:
MMA strategies showed site-specific variability and decreasing yearly trends of in-hospital opioid use without changes in acute or chronic pain after PSF. There was a high incidence of persistent pain associated with disability and poor quality of life warrants postoperative surveillance to enable functional recovery.