Postoperative Intrathecal Pain Treatment in Children

University dissertation from Dep. of Clinical Neuroscience Division of Neurosurgery Lund University Hospital Sweden

Abstract: Selective dorsal rhizotomy (SDR) is an effective operations method that successfully decreased the degree of spasticity with long lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminotomy and the nerve root manipulation. To give an optimal pain relief, pain measurement is a necessity in pain treatment, but it can be difficult in pre-school children. A worldwide survey was made (study I) to estimate the extent of SDR surgery, evaluate operation techniques and to clarify different centres pain management after SDR. A questionnaire comprise 8 questions was sent to 59 centres. 44 (75%) centres responded to the questionnaire. 33 centres constitute the study material. In a prospective study (study II), two IT different regimes was evaluated, continuous infusion versus inter-mittent, concerning pain killing and possible side effects. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the pain treatment after selective dorsal rhizotomy operations. To define an optimal dose (study III) of the continuous IT morphine and bupivacaine for severe pain treatment after SDR with regard to the analgesic effect and survey if they differed in side effects, we compared two different concentrations of morphine 0.4 ug/kg/h and 0.6 ug/kg/h in a fixed dose of bupivacaine 40 ug/kg/h. The Behavioural Observational Pain Scale (BOPS) was used to evaluate pain. Continuoues IT pain treatment with 0.6 ug/kg/h morphine and 40 ug/kg/h bupivacaine provides safe and good analgesia after major spinal operations. This is furthered strengthened by the fact that the adverse effect did not differ between the groups and was therefore not a drawback of the high-dose group. Effective pain management in infants and children starts with routine evaluation of pain and a clear documentation. This requires measurement of pain intensity and pain relief with reliable, valid and clinically sensitive assessment tools. Observation of behaviour can be an acceptable alternative when valid self-report is not possible. We evaluate (study IV) the validity and reliability of BOPS, as a postoperative pain measurement scale for children aged 1 - 7 years. The scale assess three variables of pain behaviours; facial expression, verbalization and body position. With BOPS the nurses can evaluate and document pain with high reliability and validity and thereby improve the postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit.

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