Dynamics of Cognitive and Emotional Spheres in Different Methods of Pain Relief after Surgical Interventions for Scoliosis in Children
Introduction. Currently there are a lot of new fusions in pediatric orthopedic surgery that enable to correct spinal deformities. The surgery requires optimization and improvement of anesthetic management, including the selection of techniques of postoperative analgesia. One of the most important goals is the rapid rehabilitation of patients. In the early postoperative period it is necessary not only to support the vital functions, but also to minimize the mental disturbances, which are expressed at 30 % of the patients. The severity of these disorders varies — from minor memory impairment to subdepressive emotional background and deteriorating quality of life. In the majority of works on the theme the cognitive disorders are associated with general anesthesia, and no studies have examined the mental functions would be combined with various methods of postoperative pain relief.
Objective of the study: to investigate the dynamics of cognitive function and level of pain under the influence of different methods of analgesia after scoliosis surgery in pediatric patients to optimize post-operative analgesia.
Study design: cohort, prospective, controlled study.
Methods. The study included 100 pediatric patients who underwent scoliosis surgery in the Institute of spine and joint pathology in 2010–2011. Correction of deformity using pedicle screw fixation was carried out according to the indications. Inclusion criteria: diagnosis of idiopathic scoliosis, age from 10 to 18 years, the value of scoliosis 60–90° by Cobb, female patients. Exclusion criteria: hypersensitivity or idiosyncratic reaction to opioids, any contraindication to administration of local anesthetics, coagulation and neurological disorders, long-term pain syndrome, which is not associated with the planned operation.
Depending on the method of post-operative analgesia, patients were divided into 2 groups. The first group included 50 patients who received promedol during the three postoperative days. Opioids were administered intramuscularly in pediatric dosages.
Second group included 50 patients who used a postoperative epidural analgesia (EA). Continuous infusion of local anesthetic ropivacaine was held for three days after surgery. At the expiration of this period, the epidural catheter was removed. In both groups, pain relief after the third postoperative day continued with a non-opioid drug.
Epidural catheter was placed in epidural space, the opposite end of the catheter supplied on the skin. Syringe pump was held constant infusion of 0.2% ropivacaine with rate 10–20 mg/h.
To evaluate the quality of analgesia we determined level of pain using visual analogue scale. The level of pain was recorded prior to surgery, on the first, third and seventh day after surgery in both groups.
Assessment of cognitive function was conducted by analyzing the dynamics of the short- and long-term memory condition using Luria test. Patients tried to remember 10 words before surgery and in the postoperative period on the first, third and the seventh day. The emotional state of patients in the perioperative period was evaluated by the Lüscher test.
Research data processed by variation statistics.
Results. There was no difference in age, weight, and time of the surgical intervention between the groups.
There was no difference in preoperative pain scale between each of the groups. Postoperative pain intensity was significantly lower (p < 0.01) in the epidural group compared with the promedol group. Pain control in the II group was significantly better than that in the I group on postoperative days 1 and 3 (p < 0.01). There was also a statistically insignificant difference on postoperative day 7 (p > 0.05).
Prior to treatment of the short-term memory performance between the two groups did not differ significantly (p > 0.05). In the first postoperative day the mean date of the test were decreased. On the first postoperation day we observed a decrease of memory function in group I compared with patients in group II (p < 0.001). On the third day there was also a significant difference between the rates in the groups (p < 0.001). On the seventh postoperative day average values were not significantly different.
The dynamics of long-term memory was similar.
Preoperative investigation of the emotional sphere with Lüscher test revealed the high level of anxiety, fear of doctors, upcoming surgery and subsequent pain in all patients. Postoperatively, the emotional state of the patients demonstrated a tendency to stabilize, but patients of group I, unlike patients in group II, on the third postoperative day had increased disturbing and asthenic symptoms.
On the seventh day of the survey both groups improved emotional state, more significant in children of group II.
Conclusions. Dynamics of indicators short-term and long-term memory showed better resistance in EA group. All patients were characterized by a high level of anxiety prior to surgery, with subsequent improvement in the emotional state on the seventh day. The direct dependence of the severity of pain and cognitive impairment were identified in the groups. Epidural analgesia provides adequate protection from perioperative stress after scoliosis surgery and provides more comfortable emotional state compared to opioid analgesia.
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