Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Dan M. Spengler, MD*,
Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
Posted December 2006
The authors have presented an elegant prospective, double-blind,
randomized study to evaluate the efficacy of continuous infusion of local
anesthetic at iliac crest bone-graft sites for postoperative pain relief. This
subject is of interest to the readership of JBJS. Many anecdotal discussions have supported the use of local anesthetics in one
form or another with little evidence-based support. Although this study
reflects an optimal design, shortcomings exist in addition to those discussed
by the authors. The authors conclude that local anesthetic perfusion of an
iliac crest donor site was not an effective pain-control measure in patients
receiving systemic narcotic medication. Additionally, there was a consistent increase in recipient-site pain at
twenty-four hours in patients who received local anesthetic infusion. A
persuasive explanation for this result remains elusive.
Most orthopaedic surgeons would consider administering an
infusion of local anesthetic solution to decrease postoperative incision pain
at a donor site if the technique were safe, effective, reasonably priced, easy
to use, and if it meant that narcotic pain medication could be reduced.
My concerns regarding this paper are presented to encourage
dialogue and to challenge the authors and others to study the question further.
The authors did not discuss their choice of dosage (100 mL of 0.5% bupivacaine).
Since no local effect was observed, the dosage can be questioned. Likewise, the
risks of this procedure were only indirectly discussed by way of the exclusion
criteria. However, no warning information was provided to the reader with
respect to possible cardiac, renal, and/or hepatic issues. To consider such a
technique as wound perfusion, one must weigh the risks versus the benefits of
the procedure.
A variable not discussed in depth was the quantity and
nature of the donor-site harvest. Were structural autografts harvested, or only
trabecular bone grafts? Were vastly differing amounts of graft harvested from
the crest? The amount of graft necessary for a femoral nonunion would
presumably be much greater than that necessary for a clavicle fracture. Would
this alter the study conclusions? Most patients (fifty-four) in this study had
grafts harvested from the anterior iliac crest. Why even include those patients
(four) who had posterior crest harvests? This is a variable that could have
been eliminated. Even though the demographic data suggested no differences
between the patients with anterior versus posterior grafts, this variable should
have been eliminated by including only the patients with anterior crest harvest.
The authors note that patient-related factors constitute a
weakness of this study. I agree. Patients can have appreciable behavioral pain
problems and still have normal liver function studies and be able to use a
patient-controlled analgesia device.
Trauma patients would also be inclined to consume more
medication because of their prolonged exposure to hospitals and clinics due to
the lengthy recovery period for these patients, especially those who required
bone-grafting to achieve osteosynthesis for delayed union. This propensity
could also have affected the conclusions.
Two wound infections and one hematoma were reported in the fifty-eight
patients. Although this rate for infections appears acceptable, a wound
infection rate of 3% and a total complication rate of 5% could be considered
"high" since no non-infused control patients were incorporated into the study.
Finally, I believe that "trauma" patients may not represent
the best choice for study patients because of the many factors that can affect
their perceptions of pain. Likewise, the use of patients who had similar
recipient procedures would have provided a more optimal cohort of patients (e.g.,
lumbar spine fusion). Such a group of patients has been reviewed, with the
authors positing that patients with local anesthetic perfusion used 50% fewer
amounts of systemic narcotics than did control patients who received saline perfusion1.
I commend the authors on their study. I look forward to additional
information to affirm or refute their conclusions.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Singh K, Samartzis D, Strom J. Manning D, Campbell-Hupp M, Wetzel FT, Gupta P, Phillips FM. A prospective, randomized, double-blind study evaluating the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after spinal arthrodesis. Spine. 2005;30:2477-83; erratum in Spine. 2006;31:43.
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