Pain management in paediatric spinal surgery

Posterior spinal fusion is one of the most common major surgical procedures performed in children and adolescents. Pain control can be challenging owing to the extensive posterior exposure and major tissue trauma. Therefore, a multimodal pain management is often necessary. Pregabalin was originally developed for use as an anti-epileptic drug. It has been shown to have antinociceptive and neuroprotective effects, and the use in pre-emptive analgesia has increased worldwide. Pregabalin has been shown to reduce pain scores and opioid consumption after spine surgery in adult population. Thus, the study objective was to evaluate the effect of perioperative pregabalin on postoperative pain scores and oxycodone consumption in adolescents after posterior spinal fusion and to assess the effect of pregabalin on the intraoperative neurophysiological measurements. Multimodal pain management aims to reduce the need for opioids and reduce the adverse effects of high opioid use. One of these adverse effects is postoperative urinary retention. The fourth publication of this thesis evaluates the incidence of urinary retention in adolescents after spinal surgery. The results of previous studies on the causal relationship between spinal deformities in children and back pain have been controversial. The traditional view is that deformities do not result in back pain. However, more recent studies suggest that spinal asymmetry and scoliosis are risk factors for back pain. Evidence of chronic pain after spinal surgery in children is sparse. The main goal of our third study was to evaluate the preoperative pain and to assess the prevalence of persistent postsurgical pain in children after spinal surgery. In our study we showed that pregabalin did not affect the intraoperative neuromonitoring, postoperative opioid consumption or pain scores after spinal fusion. Children with scoliosis reported a moderate amount of pain prior to surgery and a reduction in pain after surgery. Compared to the healthy controls the back pain was similar in the surgically treated patients. Almost 50% of adolescents experience impaired bladder emptying after spinal surgery.Kivunhoito lasten ja nuorten selkäleikkauksissa Selän luudutusleikkaus on yksi tavallisimmista suurta kirurgiaa vaativista toimenpiteistä lapsilla ja nuorilla. Suuri kirurginen avaus ja laaja kudosvaurio voi tehdä leikkauksenjälkeisestä kivunhoidosta haastavan. Tämän takia, multimodaalinen kivunhoito on usein tarpeellista. Pregabaliini on lääke, jota alunperin kehitettiin epilepsian hoitoon. Mutta sillä on todettu myös kipua lievittäviä ja hermoja suojaavia ominaisuuksia, ja lääkkeen käyttö ennaltaehkäisevässä kivunhoidossa on lisääntynyt maailmalla. Aikuispotilailla pregabaliini on osoittautunut olevan opioidien tarvetta ja kipua selkäleikkausten jälkeen vähentävä lääke. Lapsilla ja nuorilla on tehty hyvin vähän tutkimuksia koskien pregabaliinin käyttöä. Tutkimuksen tarkoituksena oli mitata pregabaliinin vaikutusta kivun voimakkuuteen ja opioidilääkityksen tarpeeseen lapsilla ja nuorilla selän luudutusleikkauksen jälkeen. Tavoitteena oli myös selvittää pregabaliinin vaikutusta leikkauksenaikaisen neuromonitoroinnin luotettavuuteen. Multimodaalisen kivunhoidon tavoitteena on vähentää vahvojen kipulääkkeiden tarvetta ja näin ollen vähentää opioidien aiheuttamia sivuvaikutuksia. Yksi näistä sivuvaikutuksista on leikkauksenjälkeinen virtsaumpi. Tämän väitöskirjan neljäs työ selvittää virtsaretention esiintyvyyttä nuorilla selkäleikkauksen jälkeen. Aiempien tutkimusten tulokset selkäkivun yhteydestä selkärangan virheasentoihin ovat olleet ristiriitaisia. Perinteinen näkemys on ollut, etteivät selän virheasennot aiheuta kipua. Tuoreemmat tutkimukset kuitenkin viittaavat siihen, että selän epäsymmetria ja skolioosi ovat riskitekijöitä selkäkivun esiintymiseen. Selkäleikkauksen jälkeisen pitkäkestoisen kivun esiintymistä lapsilla on hyvin vähän tutkittu. Kolmannen tutkimuksemme tavoite oli arvioida selkäkivun esiintyvyyttä selkäleikkaukseen tulevilla lapsilla ja nuorilla sekä lisäksi tutkia pitkäkestoisen selkäkivun esiintyvyyttä leikkauksen jälkeen. Tutkimuksemme osoittaa, että pregabaliini ei vaikuta neuromonitoroinnin luotettavuuteen, ei vähennä opioidikulutusta eikä kipua selkäleikkauksen jälkeen. Lapsilla, joilla todettu selän virheasento kärsivät kohtalaisesta kivusta. Leikkaushoito helpottaa kipua ja on leikkauksen jälkeen samanlainen kuin terveillä verrokeilla. Melkein joka toisella nuorella esiintyy virtsaamisvaikeutta selkäleikkauksen jälkeen

Perioperative Risk Factors for Bleeding in Adolescents Undergoing Pedicle Screw Instrumentation for Scoliosis

Progressive scoliosis eventually leads to extensive spinal fusion surgery, which carries a risk for significant bleeding. Neuromuscular scoliosis (NMS) patients have an additional inherent risk of major perioperative bleeding. The purpose of our research was to investigate the risk factors for measured (intraoperative, drain output) and hidden blood loss related to pedicle screw instrumentation in adolescents, divided into adolescent idiopathic scoliosis (AIS) and NMS patient groups. A retrospective cohort study with prospectively collected data of consecutive AIS and NMS patients undergoing segmental pedicle screw instrumentation at a tertiary level hospital between 2009 and 2021 was conducted. In total, 199 AIS (mean age 15.8 years, 143 females) and 81 NMS patients (mean age 15.2 years, 37 females) were included in the analysis. In both groups, levels fused, increased operative time, and smaller or larger size of erythrocytes were associated with perioperative blood loss (p < 0.05 for all correlations). In AIS, male sex (p < 0.001) and the number of osteotomies correlated with more drain output. In NMS, levels fused correlated with drain output, p = 0.00180. In AIS, patients’ lower preoperative MCV levels (p = 0.0391) and longer operation times, p = 0.0038, resulted into more hidden blood loss, but we did not find any significant risk factors for hidden blood loss in NMS patients

Porvoo Works -tapahtuman elämykselliset teemapäivät

Tämä opinnäytetyö kertoo Porvoo Works -nimisen tapahtuman järjestämisestä ja kahden Fun@Work!-nimisen teemapäivän tapahtumakoordinaattorina toimimisesta. Työn teoriaosuus koostuu projektin hallinnan sekä elämyksellisyys teeman tarkastelusta tapahtuman järjestämisen näkökulmasta. Porvoo Works -tapahtuma järjestettiin, jotta nuorten työelämään liittyviä pelkoja saataisiin hälvennettyä ja että nuoret ja työelämä saataisiin kohtaamaan. Tapahtumasta pyrittiin tekemään mahdollisimman informatiivinen ja hyödyllinen hauskalla tavalla. Toimeksiantajana tapahtumalle toimi Symbio Living Lab -hanke, joka on Euroopan sosiaalirahaston osin rahoittama hanke. Hankkeen tarkoituksena on tutkia ja kehittää alueen asukkaiden hyvinvointia edistäviä palveluita käyttäjälähtöisesti. Tapahtuma järjestettiin 7.-11. maaliskuuta 2011 uudella Porvoo Campuksella. Tapahtumaviikko koostui erilaisista teemapäivistä. Torstain ja perjantain teemapäivien teemanimi oli Fun@Work! ja kohderyhmänä olivat Linnankosken lukion sekä Porvoo Campuksen opiskelijat. Tapahtumassa oli mahdollisuus osallistua ammattiseikkailuun sekä kahvilatoriin, joiden tarkoituksena oli jakaa tietoa työelämään liittyvistä asioista elämyksellisellä tavalla. Tietoa jakamassa oli useita eri tahoja. Tapahtumaa voidaan pitää onnistuneena tapahtumasta saadun palautteen perusteella. Lukiolaiset kokivat oppineensa tapahtumasta uusia asioita ja he pitivät tapahtumaa hyödyllisenä. Myös käytännön järjestelyt onnistuivat palautteen ja tapahtuman sujuvan kulun perusteella erinomaisesti. Tapahtuma olisi kuitenkin voinut palautteiden perusteella olla entistä osallistavampi, minkä vuoksi sisällön suunnitteluun ja toteutukseen tulisi jatkossa kiinnittää erityistä huomiota ja varata siihen tarpeeksi resursseja. Porvoo Works -tapahtumasta kannattaisi tehdä jatkuva ja kehittää sille oma brändi, jolloin sitä olisi helpompi tehdä tunnetuksi.This thesis outlines the organising of an event called Porvoo Works, and also tells about what it was like to act as an Event Coordinator with responsibility for two theme days called Fun@Work!. The theoretical subtext comprises theory on both project management and experience themes from the point of view of the event organiser. The goal for the Porvoo Works event was to dispel young people’s fears related to working life. The objective was to implement the event in as an informative and funny way as possible. The event was part of a Symbio Living Lab project which was partly funded by the European Social Fund. The aim of the Symbio Living Lab is to involve the users in the research and development processes aimed to contribute to the wellness of the people living in the area. The event was organised on the new Porvoo Campus 7-11 March 2011. The event week consisted of different kinds of theme days. The theme name for Thursday and Friday was Fun@Work! and the target group were students from Linnankosken lukio and Porvoo Campus. A professional adventure game was held and there was also a Café square where you could obtain information about working life. The information was provided by different working life representatives. Based on the feedback received, the event can be considered a success. The participants from Linnankosken lukio experienced that they had acquired new knowledge and they considered the event useful. According to response, also the practical arrangements were carried out very smoothly. The Porvoo Works event should be organised also in future and its own brand developed. The brand would make it easier to make the event known

The Extension of Surgery Predicts Acute Postoperative Pain, While Persistent Postoperative Pain Is Related to the Spinal Pathology in Adolescents Undergoing Posterior Spinal Fusion

Persistent pain after posterior spinal fusion affects 12 to 42% of patients with adolescent idiopathic scoliosis. The incidence of persistent pain among surgically treated children with Scheuermann kyphosis and spondylolisthesis is not known. The aim of our study was to determine the predictors and incidence of acute and chronic postoperative pain in adolescents undergoing posterior spinal fusion surgery. The study was a retrospective analysis of a prospectively collected pediatric spine register data. The study included 213 consecutive patients (158 AIS, 19 Scheuermann kyphosis, and 36 spondylolisthesis), aged 10–21 years undergoing posterior spinal fusion at a university hospital between March 2010 and March 2020. The mean (SD) daily postoperative opioid consumption per kilogram was significantly lower in the spondylolisthesis patients 0.36 mg/kg/day (0.17) compared to adolescent idiopathic scoliosis 0.51 mg/kg/day (0.25), and Scheuermann kyphosis 0.52 mg/kg/day (0.25) patients after surgery (p = 0.0004). Number of levels fused correlated with the daily opioid consumption (rs = 0.20, p = 0.0082). The SRS-24 pain domain scores showed a statistically significant improvement from preoperative levels to two-year follow-up in all three groups (p ≤ 0.03 for all comparisons). The spondylolisthesis patients had the lowest SRS pain domain scores (mean 4.04, SD 0.94), reporting more pain two years after surgery, in comparison to AIS (mean 4.31, SD 0.60) (p = 0.043) and SK (mean 4.43, SD 0.48) patients (p = 0.049). Persistent postoperative pain in adolescents undergoing posterior spinal fusion is related to disease pathology while higher acute postoperative pain is associated with a more extensive surgery. Spondylolisthesis patients report more chronic pain after surgery compared to AIS and SK patients

Intraoperative 3D Imaging Reduces Pedicle Screw Related Complications and Reoperations in Adolescents Undergoing Posterior Spinal Fusion for Idiopathic Scoliosis : A Retrospective Study

Widely used surgical treatment for adolescent idiopathic scoliosis (AIS) is posterior spinal fusion using pedicle screw instrumentation (PSI). Two-dimensional (2D) or three-dimensional (3D) navigation is used to track the screw positioning during surgery. In this study, we evaluated the screw misplacement, complications, and need for reoperations of intraoperative 3D as compared to 2D imaging in AIS patients. There were 198 adolescents, of which 101 (51%) were evaluated with 2D imaging and 97 (49%) with 3D imaging. Outcome parameters included radiographic correction, health-related quality of life (HRQOL), complications, and reoperations. The mean age was 15.5 (SD 2.1) years at the time of the surgery. Forty-four (45%) patients in the 3D group and 13 (13%) patients in the 2D group had at least one pedicle screw repositioned in the index operation (p < 0.001). Six (6%) patients in the 2D group, and none in the 3D group had a neurological complication (p = 0.015). Five (5%) patients in the 2D group and none in the 3D group required reoperation (p = 0.009). There were no significant differences in HRQOL score at two-year follow-up between the groups. In conclusion, intraoperative 3D imaging reduced pedicle screw-related complications and reoperations in AIS patients undergoing PSI as compared with 2D imaging.Peer reviewe

Intraoperative 3D Imaging Reduces Pedicle Screw Related Complications and Reoperations in Adolescents Undergoing Posterior Spinal Fusion for Idiopathic Scoliosis : A Retrospective Study

Widely used surgical treatment for adolescent idiopathic scoliosis (AIS) is posterior spinal fusion using pedicle screw instrumentation (PSI). Two-dimensional (2D) or three-dimensional (3D) navigation is used to track the screw positioning during surgery. In this study, we evaluated the screw misplacement, complications, and need for reoperations of intraoperative 3D as compared to 2D imaging in AIS patients. There were 198 adolescents, of which 101 (51%) were evaluated with 2D imaging and 97 (49%) with 3D imaging. Outcome parameters included radiographic correction, health-related quality of life (HRQOL), complications, and reoperations. The mean age was 15.5 (SD 2.1) years at the time of the surgery. Forty-four (45%) patients in the 3D group and 13 (13%) patients in the 2D group had at least one pedicle screw repositioned in the index operation (p < 0.001). Six (6%) patients in the 2D group, and none in the 3D group had a neurological complication (p = 0.015). Five (5%) patients in the 2D group and none in the 3D group required reoperation (p = 0.009). There were no significant differences in HRQOL score at two-year follow-up between the groups. In conclusion, intraoperative 3D imaging reduced pedicle screw-related complications and reoperations in AIS patients undergoing PSI as compared with 2D imaging.Peer reviewe

Beam-Like rods do not Provide Additional Improvement to Thoracic Kyphosis Restoration when Compared to Sagittal Reinforced rods in Adolescents Undergoing Spinal Fusion with Pedicle Screw Instrumentation for Idiopathic Scoliosis

Publisher Copyright: © 2022 The AuthorsObjective: Operative treatment of adolescent idiopathic scoliosis (AIS) with posterior spinal fusion aims for three-dimensional correction of coronal curve and thoracic kyphosis. Our aim was to compare two different designs of asymmetrical rods in adolescents who underwent a posterior spinal fusion with pedicle screw instrumentation for AIS with an emphasis on thoracic kyphosis restoration. Methods: This study was made with 76 consecutive adolescents (mean age 15.6 years, SD 2.0). Thirty-nine patients were operated with sagittal reinforced rods and 37 patients were operated with beam-like rods. The clinical and radiological results were assessed preoperatively, postoperatively, and during the follow-up visits at the outpatient clinic 6 months and 2 years after the surgery. Results: At the last follow-up, the mean (SD) major thoracic curves were 13° (6.2°) and 13° (6.0°) (P = 0.717). Correction percentages were 75% in the sagittal reinforced group and 73% in the beam-like rod group (P = 0.517). The mean (SD) thoracic kyphosis was 24° (11°) and 22° (7.8°) at the two year follow-up in the sagittal reinforced rod group and beamlike rod group (P = 0.517). There was a slight negative correlation between the major curve correction and thoracic kyphosis change in both groups, although this was not statistically significant (R = −0.19, P = 0.094 in the sagittal reinforced rod group, R=−0.16, P = 0.180 in the beam like rod group). Conclusions: There are no significant differences in the coronal or sagittal deformity restoration in adolescent patients who underwent a posterior spinal fusion with sagittal reinforced rods and beam-like rods for adolescent idiopathic scoliosis.Peer reviewe

Health-related quality of life outcomes in adolescent Scheuermann's kyphosis patients treated with posterior spinal fusion : A comparison with age- and sex-matched controls

Purpose: To assess the health-related quality of life and radiographic outcomes of surgically treated adolescent Scheuermann's kyphosis patients after minimum of 2-year follow-up and to compare the health-related quality of life with age- and sex-matched healthy controls. Methods: Twenty-two consecutive adolescents (mean age = 16.7 years) undergoing posterior spinal fusion for Scheuermann's kyphosis were included and matched by age and sex with two healthy controls. The health-related quality of life was evaluated using the Scoliosis Research Society-24 questionnaire. Radiographic parameters were measured for comparison preoperatively and at 6 months and 2-year follow-ups. The health-related quality of life parameters were compared with healthy controls at 2 years of follow-up. Results: The mean maximal thoracic kyphosis improved from 79 degrees (range = 75 degrees-90 degrees) to 55 degrees (range = 45 degrees-75 degrees) (p < 0.001), and the mean lumbar lordosis was reduced from 71 degrees (range = 51 degrees-107 degrees) to 52 degrees (range = 34 degrees-68 degrees) (p < 0.001) after 2 years postoperatively. Incidence of proximal junctional kyphosis (PJK) was 18%. The scores of the Scoliosis Research Society-24 improved, with statistical significance observed in pain and self-image domains from preoperative to 2-year follow-up (p = 0.002 in both domains). The self-image and function were significantly lower in the operated patients at their 2-year follow-up visit compared to controls (p = 0.023 for self-image and p < 0.001 for function). Conclusion: Instrumented posterior spinal fusion improves the health-related quality of life of Scheuermann's kyphosis patients during the 2-year follow-up. The greatest improvement is observed in pain and self-image domains. The health-related quality of life in pain and activity domains reaches the level of healthy individuals, while function and self-image remain at a statistically lower level.Peer reviewe

Students' formal written communication

This work is part of Swedish Institute for Educational Research grant 2020-00066