To the Editor:
We read with great interest the article of Rullander, Lundstrom, Ostlund, and Lindh (2017) in a recent issue of the journal. The authors performed a mixed-methods study to evaluate postsurgical pain in adolescents after scoliosis surgery and highlighted areas of potential improvement in perioperative scoliosis care in terms of nursing support and pain management. The authors should be congratulated for performing a well-designed study in an important topic (e.g., acute pain) in patients undergoing orthopaedic surgical procedures (Harbell et al., 2016; Quinlan et al., 2017). If patients at high risk for poor postoperative pain control can be identified, effective multimodal analgesic strategies may be tailored to improve postoperative pain for these patients (Sakae, Marchioro, Schuelter-Trevisol, & Trevisol, 2017; Vora, Nicholas, Kassel, & Grant, 2016).
Although the study of Rullander et al. (2017) was well conducted, there are some questions regarding the study that need to be clarified in order to confirm the authors' findings. First, it is unclear whether the authors standardized the intraoperative and postoperative analgesic regimens for these patients, as this can significantly alter the studied outcomes. Second, the authors reported a high patient dropout rate and the observed clinical differences between patients who remained in the study and patients who dropped out of the study suggests that the authors' results are likely not generalizable and more likely underestimated. Finally, pain may not be an ideal outcome after surgery if patients appropriately follow instructions. Opioid consumption would be a possible alternative when patients are instructed to titrate oral analgesics to keep a low pain score rating.
We would welcome comments to address the aforementioned issues, as they were not discussed by the authors. This would help further confirm the findings of this important study.
-Lucas J. Castro Alves, MD
-Mark C. Kendall, MD
Anesthesiology Department
Rhode Island Hospital
The Warren Alpert Medical School of Brown University
Providence, RI
Harbell M. W., Cohen J. M., Kolodzie K., Behrends M., Braehler M. R., Kinjo S., Aleshi P. (2016). Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: A randomized controlled clinical trial. Journal of Clinical Anesthesia, 33, 68-74. [Context Link]
Quinlan P., Davis J., Fields K., Madamba P., Colman L., Tinca D., Cannon Drake R. (2017). Effects of localized cold therapy on pain in postoperative spinal fusion patients: A randomized control trial. Orthopaedic Nursing, 36(5), 344-349. [Context Link]
Rullander A. C., Lundstrom M., Ostlund U., Lindh V. (2017). Adolescents' experiences of scoliosis surgery and the trajectory of self-reported pain: A mixed-methods study. Orthopaedic Nursing, 36(6), 414-423. [Context Link]
Sakae T. M., Marchioro P., Schuelter-Trevisol F., Trevisol D. J. (2017). Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: A randomized, double-blinded clinical trial. Journal of Clinical Anesthesia, 38, 133-136. [Context Link]
Vora M. U., Nicholas T. A., Kassel C. A., Grant S. A. (2016). Adductor canal block for knee surgical procedures: Review article. Journal of Clinical Anesthesia, 35, 295-303. [Context Link]
Response From the Authors
Dear Editor:
Concerning the letter with comments on our study, we thank you for your comments and questions. We will try to clarify some of the questions raised regarding the study.
Regarding the first question regarding standardization of pain management: during surgery, the patients received the same kind of anesthesia and analgesia. Postoperatively, the participants received somewhat different pain management, but there were no significant correlations between types of pharmacological pain management and levels of pain or postoperative well-being during recovery.
All patients received opioids to self-administer orally at home during the first days of recovery, but the adolescents occasionally experienced high levels of pain despite the use of opioids; for example, during the night, when they were doing physical activities, and so on. There were also other types of difficulties such as constipation and nausea, partly a side effect from the opioids and aggravated by opioids, which in turn had a negative effect on the level of pain. Therefore, we do not see opioid consumption as an outcome to measure patient experience of well-being during recovery.
The dropouts in VAS ratings are carefully discussed in the "Methods" section.
We believe that our conclusions are reasonable in this study, but there are many difficulties concerning performing a multicenter study, and we will have your comments and questions in mind during the next study on this topic.
-Anna-Clara Rullander, PhD, RN