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Weekly UpdatesMobility was assessed by the physiotherapist or nurse on the morning of the first postoperative day. This was done using a mobility assessment chart based on a 20-meter walk with pre- and post-walk pain scores recorded. The assessment was done twice daily until discharge.
Instruments
The VNS was used as a standardized method of pain severity assessment (Murphy, McDonald, Power, Unwin, & MacSullivan, 1987; Scott, 1992). Participants were asked to rate their neck and hip pain on a scale of 0 (no pain) to 10 (severe pain). Nurses then recorded the participant's pain rating onto a modified special observations chart. This scale was used extensively by nurses at this hospital for patients using the PCA pump to self-administer opioids. In addition, demographic details such as age, gender, diagnosis, and operation type also were gathered.
Data were analyzed by using a combination of nonparametric tests and descriptive statistics. The Statistical Package for the Social Sciences (SPSS, 1999) for Windows software package was used.
Results
The sample consisted of 22 patients (study group = 14; placebo group = 8) who were undergoing a single-level anterior cervical fusion. Overall age ranged from 33 years to 74 years (M = 49 years). The mean age for participants in the study group was 48 years compared to 51 years in the placebo group. Despite the fact that the study group was slightly younger, no significant age-related differences were noted between the groups. The majority of participants in this study were males (68%).
Donor Site Hip and Neck Pain Scores
Hourly pain scores were collapsed to facilitate analysis; the 3-hr donor site pain scores are presented in Fig 1. Participants receiving the study drug bupivacaine consistently reported lower donor site pain scores than participants receiving the placebo. When the Mann-Whitney test statistic was used, a significant difference was noted between the groups for donor site pain scores only at 3 hours (p = .036) and 9 hours (p = .027), with participants receiving the study drug bupivacaine reporting less pain.
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Fig 2 shows the percentage of participants in the study group who reported a donor site pain score of 0 or 1. At 9 hours (i.e., 3 hours after the second dose of study treatment), 100% of participants receiving bupivacaine reported experiencing no donor site hip pain or gave a score of 1. Despite the use of IV and oral analgesic, both groups experienced neck pain for the first 24 hours (Fig 3).
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Analgesics
There was no significant difference in the total mean amounts of morphine used by the placebo or study groups; however, the study group's mean morphine intake (32 mg) was lower than that of the placebo group (44 mg) for the first 24 hours after surgery. The study group's morphine intake ranged from 0 mg to 75 mg, whereas that for the placebo group ranged between 10 and 88 mg. Two participants from the study group did not require any morphine, receiving only the standard paracetamol regimen of 1 g four times per day for break-through pain. In addition to this medication regimen, one study group participant and three placebo group participants also consumed four tablets each containing 500 mg paracetamol and 30 mg codeine phosphate in the first 24 hours as a pain relief measure. Participants in the placebo group age 49 years or younger required nearly twice as much morphine (34 mg) as their counterparts older than 50 years (18 mg); however, no significant difference was noted.
Mobility Assessment
Participants in both groups were able to complete the twice daily designated 20-meter walks on the first day after surgery. After the morning walk, 88% of participants in both groups complained that walking aggravated their donor site. At the afternoon assessment only 67% complained of donor site pain due to walking.
Pain scores before and after the walks were recorded, and as expected, donor site pain scores increased after walking regardless of grouping. Although participants receiving bupivacaine consistently reported lower pain scores than those receiving the placebo (Fig 4), there was no significant difference between the groups with regard to their pain scores for walking.
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Length of Stay and Complications
Mean length of stay (LOS) also was calculated for both groups and was found to be similar (study group LOS = 3.9 days; placebo group LOS = 4 days). However, no statistical difference was noted. The LOS ranged from 2 days to 8 days, with 82% of participants staying in hospital 4 days or less. Participants younger than 49 years who received bupivacaine stayed in hospital on average 1 day less (3.6 days) than placebo group participants of the same age (4.5 days). For patients older than 50 years, the placebo group (3.5 days) on average stayed in hospital less than the study group (4.3 days). The donor sites of all participants were assessed on a regular basis for the development of hematoma and signs of infection. No participants from either group developed any of these complications during their hospital stay.
Discussion
The results of this study suggest that the use of bupivacaine is beneficial in lowering iliac crest donor site pain for patients undergoing single-level anterior cervical fusion. This concurs with the findings of Brull et al. (1992) and of Todd and Reed (1991), who also reported lower donor pain scores for patients receiving bupivacaine.
Specifically, when asked to rate their donor site hip pain using a verbal numerical scale, participants who received bupivacaine consistently reported less donor site pain than their counterparts who only received normal saline. Statistical significance was found at 3 hours (p = .036) and 9 hours (p = .027), which is congruent with the pharmakinetics of bupivacaine.
Pain management for both groups included IV morphine and regular paracetamol. Although no statistical significance was found between the groups with regard to the amount of analgesic used, participants who received bupivacaine used less 1V morphine than the placebo group. Brull et al. (1992) reported similar findings, with the treatment group requiring significantly less morphine than the control group (p < .05). A contrasting finding between these two studies was the amount of morphine used. Participants in the Brull et al. study used a much higher amount of morphine in both the control (90.8 mg) and treatment groups (47.3 mg) in the first 24 hours after surgery. One explanation for this discrepancy in morphine intake between the two studies may be that participants in the Brull et al. study were not given bupivacaine on a regular basis but rather needed to request local anesthetic for their donor site pain. Given this scenario, these participants simply may have used their PCA pump more regularly to cover all their pain requirements.
Interestingly, participants in the placebo group age 49 years or younger required nearly twice (34 mg) as much morphine as their counterparts older than 50 years (18 mg). In general, older participants from both groups were found to use much less morphine than younger participants undergoing the same procedure. Unfortunately, other studies utilizing local anesthetic for the relief of donor site pain have not published data with regard to age differences and narcotic analgesic intake; therefore, comparisons are not possible.
Over the first 24 hours donor site pain scores were lower in those participants receiving the study drug bupivacaine. Unfortunately, a high incidence of missing pain score data prevented further analysis of donor site pain trends for the second postoperative day.
Results showed that both groups experienced higher neck pain scores for the first 24 hours despite the use of IV and oral analgesics. This result once again highlights the efficacy of bupivacaine in controlling donor site pain, because it was the main therapeutic difference between the groups.
A problem with bone harvesting is the pain associated with activities such as walking or movement (Goulet et al., 1997; Kalk et al., 1996; Summers & Eisenstein, 1989). On the first postoperative day all participants undertook a 20-meter walk. After completing their morning ambulation regimen, 88% of participants complained of donor site pain; this figure decreased to 67% after the afternoon walk. One explanation for why participants reported less pain after their afternoon walk may be that as a result of their morning walk, participants ensured they had better pain coverage prior to undertaking their afternoon exercise. Summers and Eisenstein also found that 69% of patients complained of pain after ambulation. Despite the majority of participants complaining of donor site pain, results from this study are promising, because they show that participants who received bupivacaine consistently reported less pain on ambulation compared to those receiving the placebo.
Length of stay also was reviewed, but no difference was found--both groups stayed in hospital on average 4 days. However, younger participants receiving bupivacaine stayed in hospital on average 1 day less than participants in the same age group who received the placebo. Although this result was found to be not statistically significant, this finding is encouraging because it suggests that effective pain management can have both clinical and economic implications.
The administration of both treatments was found to be simple and easy to undertake. No complications from either the local anesthetic or normal saline administered directly into the periosteum were observed in this sample of patients. This result supports previous study findings by Brull et al. (1992) and Kennedy and Hiranaka (1995), who also reported no adverse reactions or wound complications at the donor site.
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