A comparison of the effect of epidural patient-controlled analgesia with intravenous patient-controlled analgesia on pain control after posterior lumbar instrumented fusion.
ABSTRACT Retrospective analysis to compare the effect and complication of epidural patient-controlled analgesia (epidural PCA) with intravenous patient-controlled analgesia (IV PCA) for the treatment of the post-operative pain after posterior lumbar instrumented fusion.
Sixty patients who underwent posterior lumbar instrumented fusion for degenerative lumbar disease at our institution from September 2007 to January 2008 were enrolled in this study. Out of sixty patients, thirty patients received IV PCA group and thirty patients received epidural PCA group. The pain scale was measured by the visual analogue scale (VAS) score.
There were no significant difference between IV PCA group and epidural PCA group on the PCA related complications (p=0.7168). Ten patients in IV PCA group and six patients in epidural PCA group showed PCA related complications. Also, there were no significant differences in reduction of VAS score between two groups on postoperative 2 hours (p=0.9618) and 6 hours (p=0.0744). However, postoperative 12 hours, 24 hours and 48 hours showed the significant differences as mean of reduction of VAS score (p=0.0069, 0.0165, 0.0058 respectively).
The epidural PCA is more effective method to control the post-operative pain than IV PCA after 12 hours of spinal fusion operation. However, during the first twelve hours after operation, there were no differences between IV PCA and epidural PCA.
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ABSTRACT: This study evaluates the efficacy and side effects of a low dose of epidural morphine combined with clonidine for postoperative pain relief after lumbar disc surgery. In 36 of 51 patients who accepted the procedure, an epidural catheter was inserted (L1-L2 level). General anesthesia was induced with propofol and sufentanil, and maintained with sevoflurane in O2/N2O. After emergence from anesthesia, epidural analgesia was initiated according to two randomly assigned protocols: 1 mg of morphine with 75 microg of clonidine (Group M) or 12.5 mg of bupivacaine with 75 microg of clonidine (Group B), in 10 mL saline. Piritramide was administered during the first postoperative 24 hours using a patient-controlled analgesia device (PCA). The following parameters were recorded: piritramide consumption during the first 24 hours; pain at rest during the first postoperative hours (D0), during the first night (D1), and during the first mobilization; [visual analogue scale (VAS)]; and the occurrence of drowsiness, motor blockade, respiratory depression, nausea, vomiting, itching, micturition problems, and bladder catheterization during D0 and D1. Epidural administration of morphine-clonidine significantly improved postoperative pain relief and reduced piritramide consumption as compared to epidural bupivacaine-clonidine. Side effects did not differ between groups except for a higher incidence of micturition problems in Group M during D1. The occurrence of bladder catheterization was not significantly higher in that group. We conclude that a low dose of epidural morphine combined with clonidine offers a better postoperative analgesia than does bupivacaine-clonidine. The excellent analgesic conditions were obtained at the expense of a higher incidence of difficulties in initiating micturition.Journal of Neurosurgical Anesthesiology 02/2002; 14(1):1-6. · 1.67 Impact Factor
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ABSTRACT: Acute postoperative pain has seldom been assessed in head and neck cancer surgery. The estimation of actual pain is more difficult when communication is impaired by tracheotomy or tracheostomia. The aim of the present prospective study was the assessment of analgesia level during the first 48 postoperative hours after head and neck cancer surgery. The analgesic procedure involved intra-venous morphine injected by means of a PCA pump (Patient controlled analgesia). Thirty patients were thus treated after cancer surgery of the larynx or the oropharynx. The protocol included during 48 hours the assessment of pain, using a visual analogic scale (VAS) every fourth hour, while recording the total injected dose of morphine, the localisation of pains, as well as the occurrence of side-effects. The control of postoperative pain was shown to be satisfactory, with a VAS grade smaller than 3 at time zero and kept below this value during 48 hours. At the end of this period, the mean total dose of morphine injected was 38 mg. No case of respiratory depression was even seen. It can be concluded that PCA seems to be an efficient procedure for controlling postoperative pain in head and neck cancer surgery. This technique proved to be better than delivering analgesia on requirement.Annales d Otolaryngologie et de Chirurgie Cervico-Faciale 07/1999; 116(3):154-61.
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ABSTRACT: Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.Journal of neurosurgical anesthesiology 11/2008; 20(4):256-60. · 2.41 Impact Factor
the total amount of narcotic used and therefore less respiratory
depression and sedation are the benefits of the epidural PCA al-
though there were serious side effects including pruiritus, nau-
sea, urine retention and neurologic abnormality12,18). this prop-
erty should facilitate mobilization and improve patient outcome
and satisfaction5). This retrospective comparative study was de-
signed to compare the efficacy and complication of epidural
PCA with intravenous (IV) PCA in patients who underwent
posterior lumbar instrumented fusion at our institute.
MATERIALS AND METHODS
Indication and evaluation
We included consecutive 60 patients who underwent one or
two level posterior lumbar instrumented fusion for degenera-
tive disc disease, spondylolisthesis, or spinal instability between
Sep 2007 and Jan 2008. IV PCA group included 30 patients, 12
male and 18 female and epidural PCA group included 30 pa-
tients, 7 male and 23 female. Average age of epidural PCA was
57.66±10.38 and IV PCA was 57.06±9.79 (Table 1).
Traditional posterior lumbar interbody fusion and posterior
transpedicular screw fixation is associated with high degree of
postoperative pain. Most patients require parenteral adminis-
tration of analgesics especially during 2 days after operations or
more. High degree of postoperative pain precludes them from
early mobilization, which is known to lengthen hospital stay
and might result in various complications7,11).
Patient-controlled analgesia (PCA) has long been used for
pain control after spinal operations3,5,6,13,14,20). And, there were
various methods to administrate the analgesics such as epidural
or intravenous route. Excellent pain control and a decrease in
J Korean Neurosurg Soc 50 : 205-208, 2011
Copyright © 2011 The Korean Neurosurgical Society
Print ISSN 2005-3711 On-line ISSN 1598-7876
A Comparison of the Effect of Epidural
Patient-Controlled Analgesia with Intravenous
Patient-Controlled Analgesia on Pain Control
after Posterior Lumbar Instrumented Fusion
Sang Hoon Lee, M.D., Kyung Hyun Kim, M.D., Seong-Mee Cheong, M.D., Sumi Kim, M.D., Mirang Kooh, M.D., Dong Kyu Chin, M.D., Ph.D.
Department of Neurosurgery, The Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital,
Yonsei University College of Medicine, Seoul, Korea
Objective : Retrospective analysis to compare the effect and complication of epidural patient-controlled analgesia (epidural PCA) with intravenous
patient-controlled analgesia (IV PCA) for the treatment of the post-operative pain after posterior lumbar instrumented fusion.
Methods : Sixty patients who underwent posterior lumbar instrumented fusion for degenerative lumbar disease at our institution from September
2007 to January 2008 were enrolled in this study. Out of sixty patients, thirty patients received IV PCA group and thirty patients received epidural
PCA group. The pain scale was measured by the visual analogue scale (VAS) score.
Results : There were no significant difference between IV PCA group and epidural PCA group on the PCA related complications (p=0.7168). Ten
patients in IV PCA group and six patients in epidural PCA group showed PCA related complications. Also, there were no significant differences in re-
duction of VAS score between two groups on postoperative 2 hours (p=0.9618) and 6 hours (p=0.0744). However, postoperative 12 hours, 24
hours and 48 hours showed the significant differences as mean of reduction of VAS score (p=0.0069, 0.0165, 0.0058 respectively).
Conclusion : The epidural PCA is more effective method to control the post-operative pain than IV PCA after 12 hours of spinal fusion operation.
However, during the first twelve hours after operation, there were no differences between IV PCA and epidural PCA.
Key Words : Patient-controlled analgesia · Postoperative pain · Spinal fusion.
• Received : April 18, 2011 • Revised : June 20, 2011
• Accepted : September 8, 2011
• Address for reprints : Dong Kyu Chin, M.D., Ph.D.
Department of Neurosurgery, The Spine and Spinal Cord Institute,
Gangnam Severance Spine Hospital, Yonsei University College of Medicine,
211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea
Tel : +82-2-2019-3397, Fax : +82-2-3461-9229
E-mail : firstname.lastname@example.org
J Korean Neurosurg Soc 50 | September 2011
1) IV PCA medications : total mixture of Ketoracin® (ketorolac
tromethamine, Roche, Korea) 120 mg, Fentanyl citrate (Hana
Pharm CO LTD, Korea) 1,000 µg and Zofran® (Ondanstron de-
hydrate, GlaxoSmithKline) 16 mg with saline (100 mL).
2) Epidural PCA medications : total mixture of Morphine 5
mg and 0.75% Ropivacaine 20 cc with saline (100 mL).
Epidural catheter was inserted into the epidural space 5 cm
above laminectomy level under direct visualization and was
passed retrograde through the needle in the paraspinal muscles
after removal of the stylet by the surgeon before wound closure.
Patient profile and homogeneity
There were a total of 60 patients. Thirty patients were in IV
PCA group and 30 patients were in epidural PCA group. There
were no statistically significant differences in regards to patients’
demographic data, number of fused level and operative time be-
tween two groups (Student’s t-test, chi-square test) (Table 1).
Pain score results
There was no significant difference
about preoperative pain score between
two groups. Average preoperative pain
score of IV PCA group was 6.25±2.80,
and epidural PCA was 6.08±2.35 (p=
0.7935). There was also no significant
difference between two groups about
postoperative pain score at 2 hours and 6
hours (p=0.9618, p=0.0744 respectively).
However, epidural PCA group showed
significant lower pain score than IV PCA
group at 12 hours, 24 hours and 48 hours
postoperatively (all p<0.05) (Table 2).
We also reviewed, based on medical
records, for the number of injection of
additional analgesics (intravenous ke-
toracin 30 mg/ample) in patients who
did not remove PCA until 48 hours. Al-
though there was no significant differ-
ence between two groups, epidural PCA
group (aver 3.10±2.26) required less ad-
ditional analgesics than IV PCA group
(aver 1.91±1.69) (p=0.0543) (Table 3).
There was no significant difference in
regard to adverse effect between two
PCA had to be removed in 10 patients
of IV PCA group versus 6 patients of
epidural PCA group. Of 10 patients of
Pain was assessed using a printed copy of both verbal numer-
ical analogue scale and faced pain scale by researcher and
members of this research (nurses) and recorded for time peri-
ods of 2, 6, 12, 48 hours after surgery unless PCA was removed
before 48 hours (Fig. 1).
All symptoms such as nausea, vomiting, headache, dizziness,
chest discomfort, urine retention and neurologic deficit were
recorded as adverse effects. Among patients who were not re-
moved the PCA until 48 hours after surgery, the number of ad-
ditional analgesics injected were counted.
All data were compared statistically using chi-square test and
Student’s t-test for homogeneity between two groups, Fisher’s
exact test for adverse effect and Student’s t-test for pain scale
(SAS 9.1) and significance was defined as p<0.05.
Technique and protocol
Using continuous and bolus infusion kit (continuous and bo-
lus ambix anaplus), the PCA medication were dosed in the fol-
lowing manners : flow rate was 2mL/hr and additional doses of
0.5 mL/5 min with 20-minute lockout are given by patient-con-
Table 1. Demographics of patients
IV PCA (M±SD)
Epidural PCA (M±SD)
Preoperative pain score
IV : intravenous PCA : patient-controlled analgesia
Fig. 1. VAS score. Pain was assessed using the VAS ranging from “0” (no pain) to “10” (worst imag-
inable pain). VAS : visual analogue scale.
No pain everMild painModerate pain Severe pain Worst pain
Table 2. Postoperative pain scores
IV PCA (M±SD)
Epidural PCA (M±SD)
Postop 2 hrs
postop 6 hrs
postop 12 hrs
postop 24 hrs
postop 48 hrs
*p<0.05. preop : preoperatively, postop : postoperatively, hrs : hours, IV : intravenous PCA : patient-controlled
Epidural PCA vs. IV PCA | SH Lee, et al.
sea and vomititng can be reduced1,10,15,17,19). Nausea and vomiting
are the most common and distress side effect of IV PCA, al-
though the pain control medication is morphine or fentan-
yl14,16,20). Because of small amount of morphine used in epidural
PCA, some patients have nausea symptom but patients with
vomiting are usually tolerable8,10,15,17,19).
Other side effects associated with epidural PCA include, re-
spiratory depression and motor deficit and infection18). Mild re-
spiratory depression occurred rarely in patients with epidural
PCA, which was unresponsive to naloxone, but needed no ven-
tilator support, and the resolved uneventfully16,18,20). In this study,
none of patients suffered from respiratory depression.
Although spine surgery causes severe postoperative pain, epi-
dural PCA is not commonly used16). The main reason is that it
might cause some complications such as motor block16,18,20). The
motor block can make difficulty in early detection of surgical
related neurologic deficit16,18,20). In our study, one patient in epi-
dural PCA group had temporary hypoesthesia of bilateral lower
extremities, we assumed that the cause of hypoesthesia might
be associated with local analgesics (ropivacane), not epidural
procedure, surgery or opioid because it showed bilaterally in-
volved whole dermatome of the lower extremities10). Thus, we
thought this problem could be resolved by controlling the amount
of medication and as soon as we removed the epidural PCA,
the symptom had disappeared10,14,18). A small number of pa-
tients showed significant postoperative ileus. But it was recov-
ered shortly (1 or 2 days) and no adverse sequelae16).
IV PCA has been more commonly accepted postoperative
pain control method for several reason2). First, IV PCA needs
no additional surgical procedure2,5,18). Second, because fentanyl,
the main pain killer of IV PCA, usually does not cause neuro-
logic deficit, it is possible to detect surgical procedure related
neurologic deficit immediately after operation2,5,10,16).
However, nausea and vomiting are the most common and
distress side effect of fentanyl in IV PCA4,5,14,18,20). In our study,
PCA had to be removed in 10 patients of IV PCA group. The
most common cause to discontinue PCA infusion in IV PCA
group was intolerable nausea and vomiting.
The two limitations of this study are as follows. The first, the
IV PCA group, 6 patients complained
nausea, 1 patient had vomiting, and 3
patients had both symptoms. Among 6
patients of epidural PCA group, 4 pa-
tients complained nausea, 1 patient had
both nausea and vomiting, and 1 patient
had both leg hypoesthesia. These symp-
toms and neurologic deficit were im-
proved after removal of PCA (Table 4).
In posterior lumbar instrumented fu-
sion, appropriate postoperative pain
management is essential for early ambulation, reduced hospital
stay, avoidance of additional analgesics, and consequently for
improvement of patient outcome. PCA via ether intravenous or
epidural route has been considered standard management after
major orthopedic or spinal surgery2,8,9) and there have been
many comparative studiess on the effectiveness and complica-
tion of epidural PCA with intravenous PCA10,15,17,19). Postopera-
tive pain score (visual analog scale) were significantly lower in
the epidural PCA group when compared with that in the IV
PCA group16,20). Epidural PCA group showed superior result in
pain control on post-operation day 1 and 2 than on the day of
Other studies have reported that the capacity of excellent pain
control in Epidural PCA were probably due to the higher con-
centration of ropivacaine, the higher infusion rate and the use
of an epidural opioid lately14,16). But, the total amount of opioid
used in epidural PCA was less than IV PCA group14).
In present study, epidural PCA group showed superior postop-
erative pain control after 6 hours of operation to IV PCA group
(p=0.0744 respectively at 6 hours, all p<0.05 at 12 hours, 24 hours
and 48 hours postoperatively). Also, in patients who was not re-
moved PCA until 48 hours, epidural PCA group required less
additional analgesics than IV PCA group although it was not
statistically significant (p=0.0543).
In addition, although we did not investigate in this study, short-
er hospital stay and earlier full diet were other positive effects of
the epidural PCA20). Van Boerum et al., reported that the patient
in the epidural PCA group could start a full diet earlier and were
discharged earlier in one and half days on average than the IV
PCA group10,15,17,19). Also, patients in the epidural PCA group
started ambulation earlier than in the IV PCA group16,20). More-
over, patients in the PCEA group were significantly more satis-
fied with pain therapy16).
Common side effects associated with epidural administration
of local anesthetics or opioids, such as nausea and vomiting or
pruritus were not evaluated systematically by all authors14,16,20).
Pruritus was described with an incidence between 7% and 43%,
nausea and vomiting with an incidence between 14% and 86%16).
Because of the amount of opioid used in PCA is small, the nau-
Table 3. Number of additional analgesic injections
IV PCA (M±SD)
Epidural PCA (M±SD)
IV : intravenous, PCA : patient-controlled analgesia
Table 4. Adverse effects
IV PCA (n=10)
Epidural PCA (n=6)
Nausea and vomiting
IV : intravenous, PCA : patient-controlled analgesia
J Korean Neurosurg Soc 50 | September 2011
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main medications of two PCA were different, we used mor-
phine in epidural PCA and fentanyl in IV PCA. Fentanyl is the
most common medication which used in IV PCA2,4,5,14,16). Be-
cause morphine is usually associated with nausea and vomiting
symptom (incidence being 10%), morphine is commonly used
rather than fentanyl in IV PCA2,4,5,14,18). Secondly, we investigat-
ed only pain relief for patient’ outcome in two PCA groups. The
future prospective randomized controlled study should be done
for patient’s functional outcome, hospital stay, time to ambula-
tion and time to start full diet beyond pain control.
Epidural PCA group showed significant lower pain score than
IV PCA group after 6 hours postoperatively (p<0.05). There
was no statistically significant difference in adverse effect of
PCA between two groups. The number of additional analgesics
injection in epidural PCA group was lower than IV PCA group
(p=0.0543). Prospective randomized controlled study should be
needed for pain control, functional outcome, duration of hospi-
tal stay, time to ambulation, and time to start full diet.
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