Pain Control in the Anterior Iliac Crest following Bone Graft Harvest

Sir: For the purpose of repairing the alveolar cleft, we most commonly use the anterior iliac crest as our primary donor site.1 Pain at this harvest site is a significant source of morbidity for many patients and the most frequently cited complication following bone grafting.2 There have been reports in other fields of continuous local anesthetic infusion by means of postoperative pain pump directly into the anterior iliac crest donor site.3,4 To date, there have been no reports of such techniques for postoperative pain control in the pediatric cleft population following alveolar bone grafting. Through the use of a local bupivacaine hydrochloride infusion pump at the donor site, we have significantly reduced postoperative pain and thus decreased narcotic usage and length of hospital stay in the pediatric population undergoing iliac crest bone graft harvest. Analysis of 40 consecutive alveolar bone grafts performed by a single surgeon (J.A.G.) between 2003 and 2008 revealed that the first 20 were managed for pain control primarily with postoperative analgesics, whereas the following 20 underwent insertion of a local 0.25% bupivacaine continuous infusion pump (2 cc/hour) at the iliac crest donor site. In addition, each of these pumps was programmed to deliver a bolus of 1 cc/hour when demanded by the patient. The groups were well matched for demographic characteristics, including mean age, sex, and the number of unilateral versus bilateral clefts in each group. Those patients receiving local bupivacaine infusion by means of the pain pump exhibited a shorter mean length of hospital stay. The mean length of hospital stay in the nontreatment population was 2.9 ± 0.8 days, compared with 1.4 ± 0.5 days in the treatment population. Furthermore, the bupivacaine treatment group also showed lower morphine and codeine requirements postoperatively and lower subjective pain scale ratings postoperatively. All these findings were statistically significant (Table 1).Table 1: Postoperative Data for Nontreatment and Treatment (Pain Pump) CohortsWe have further substantiated the findings of significant positive effects of continuous local anesthetic administration at the iliac crest bone graft donor site.5 For the first time, we have shown this to be the case in the pediatric cleft lip–cleft palate population. Our findings indicate that local bupivacaine administration, both at the cancellous bone harvest site and anterior to the periosteal and fascioaponeurotic planes, has a significant effect in reducing postoperative narcotic consumption and hospital stay. Furthermore, patients subjectively report lower pain levels when receiving this treatment. Our current protocol is to place indwelling catheters anterior to the fascial closure, in all patients without contraindications, at the time of bone harvest. Dosing parameters are weight based and have been determined by our department of pharmacology. Patients and their families are given the options of catheter removal at the time of discharge, self-removal at home, or return to clinic for removal after discharge. From a practical standpoint, placement of the catheter can result in increased drainage from the wound, and may require increased attention from the postoperative nursing staff. However, given the decrease in opioid use and length of hospital stay, this should result in an overall decrease in the nursing burden. DISCLOSURE No author has any financial disclosures or commercial associations to report. Hani Sbitany, M.D. Peter F. Koltz, M.D. Ashley N. Amalfi, M.D. Jeremy Waldman, M.D. John A. Girotto, M.D. Division of Plastic and Reconstructive Surgery University of Rochester Rochester, N.Y.