Efficacy of postoperative epidural analgesia in adolescent scoliosis surgery: a meta-analysis

Background: Scoliosis surgery is one of the most painful operations performed. Postoperative pain management has been historically based on the use of intravenous opioids. Many of the adolescents who undergo these procedures are at increased risk for opioid-related side effects because of underlying medical problems. Epidural analgesia has been demonstrated to provide superior pain control with fewer side effects for chest and abdominal surgery in children as well as adults. We aim to analyze the available literature for sufficient evidence to allow recommendations regarding the use of epidural analgesia with parenteral opioids vs. intravenous opioids only. Search strategy: Public Medline and the Cochrane database were searched (1966-10/2008) using scoliosis-related and epidural analgesia-related terms. In Medline, the intersection of these results was combined with Phases 1 and 2 of a highly sensitive search strategy recommended for identifying randomized trials. No limits were used in any search. Additionally, professional journals and proceedings of meetings were screened, and nationally recognized experts in the field of pediatric pain management were asked for further sources of data. Selection criteria: Randomized, controlled trials comparing the use of a continuous infusion of epidural local anesthetics plus intravenous opioids vs. intravenous opioids only for postoperative pain management in adolescent scoliosis repair were eligible for inclusion in the meta-analysis. All studies had to include at least the primary outcome of interest, postoperative pain scores. Data collection and analysis: After the development of a data collection and extraction form, two independent reviewers extracted all. No data conflicts were encountered. Data were analyzed with Review Manager when possible, significance for difference between relative rates between groups was analyzed by chi-square tests. Main results: Average pain scores were lower in the epidural group than no epidural group at 24, 48 and 72 h after surgery. Pain scores (0-100) were lower on all first three postoperative days (POD) in the epidural group: -15.2 on POD1, -10.1 on POD2 and -11.5 on POD3. Differences were significant in the summary analysis for all 3 days (P < 0.05). Authors' Conclusion: Epidural analgesia is beneficial to patients in terms of improving pain control and reducing side effects. The influence on respiratory depression, length of stay in the intensive care unit, or mortality is not available in the literature at this time.