Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS Quality, Safety and Value (QSVI)

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Amy L. McIntosh
Christopher McLeod


Background: Our previous standardized postoperative pain management plan for AIS patients undergoing PSF included the placement of an epidural (EPI) catheter by the spine surgeon prior to fascial closure. The epidural was used for 24 hours, in conjunction with a multi-modal post-operative pain protocol.

Local Problem: The 2020 COVID-19 pandemic highlighted the need for our surgical AIS patients and their families to have private rooms/bathrooms. Epidural catheters require arterial line blood pressure monitoring to ensure safety. Unfortunately, the arterial lines could not be utilized in the private rooms due to lack of appropriate monitors, therefore we transitioned away from epidurals.

Liposomal bupivacaine (LB) is an encapsulated local anesthetic that has a duration of action up to 72 hours.

Specific Aims: This quality initiative (QI) focused on the enhancement of the standardized postoperative care pathway for AIS patients undergoing PSF. The aims of the initiative were to 1) minimize narcotic usage, and 2) allow for earlier mobilization.

Intervention: The (2020) LB cohort had a mixture of LB, bupivacaine HCL and normal saline injected into the fascial and subcutaneous layers of the incision prior to fascial closure. The (2019) control cohort had an epidural (EPI) catheter placed prior to fascial closure. The epidural infusion consisted of ropivacaine 0.1% (0.1-0.2 ml/kg/hr.) The cohorts received the same pain protocol (intravenous opioid with transition to oral opioid, as well as dexmedetomidine, acetaminophen, ketorolac, and diazepam).

Measures and Analysis: Two cohorts of prospective AIS patients that underwent PSF were retrospectively reviewed. They were compared regarding age, BMI, average preoperative major Cobb angle, average preoperative kyphosis, VAS pain scores and narcotic consumption. Time to ambulation, and length of stay (LOS) were also evaluated. 

Results: 159 AIS patients were reviewed. There were no preoperative differences between the 2020 LB cohort (n =101) and the 2019 EPI cohort (n = 58) when comparing age (14.3 vs.15.0 years), average BMI (21.7 vs.20.8 kg/m2), preoperative major Cobb (60.7° vs.60.3°), or average preoperative kyphosis (25.7° vs. 27.1°). The LB cohort consumed similar morphine equivalents during the initial 24 hrs. (37.8mg vs.37.3mg), but less at 24-48 hrs. (37.2mg vs 41.0mg) (p=0.031), and 48-72hrs (23.3mg vs. 29.6mg) (p=0.015). The LB cohort ambulated 6.8 hrs. sooner (17.1 vs 23.9 hrs.) (p=.0001).

Summary: LB associated with less consumption of post-operative morphine equivalents and earlier ambulation.

Article Details

How to Cite
McIntosh, A. L., & McLeod, C. (2022). Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS : Quality, Safety and Value (QSVI). Journal of the Pediatric Orthopaedic Society of North America, 4(2). https://doi.org/10.55275/JPOSNA-2022-0024
Author Biography

Amy L. McIntosh

Amy McIntosh is a Professor of Orthopedic Surgery and the medical director of patient safety at Texas Scottish Rite Hospital (TSRH) for Children in Dallas, TX. She has been married to her husband, Rich, for 25 years. She has 2 children Quincy (boy: 13 years) and Campbell (girl: 10 years).

She was born and raised in the Upper Peninsula of Michigan. She graduated from Gladstone High School in 1992. She received her Bachelor of Science degree (Summa Cum Laude) in Sports Medicine from Central Michigan University in 1996. She then matriculated to Michigan State University College of Human Medicine and graduated with honors and AOA induction in 2001.

She completed her orthopedic surgery residency at the Mayo Clinic in 2006, followed by her fellowship in pediatric orthopedic surgery and scoliosis at TSRH in 2007.

She then returned to the Mayo Clinic for 7 years as a staff orthopedic surgeon. In 2014, she transitioned her practice back to TSRH, where she currently remains in practice.


Awards include: 

2001 Medical Student of the Year - MSU-KCMS

2005 OREF Zimmer Resident Leadership Forum - American Orthopaedic Association

2013 Mayo Clinic Coventry Award Winning Paper

2013 AAP Section on Orthopedics: Young Investigators Award: Clinical Science

2013 Mayo Clinic Continuing Medical Education Outstanding Course Director of the Year

2014 Minnesota Orthopedic Society: Best Clinical Research Award

2014 Mid-America Orthopaedic Association E.W. Johnson, Jr. Award

2015 POSNA/APPOS Traveling Fellowship

2016 POSNA/ Peter Armstrong Best QVSI Award

2017 POSNA / Medtronic Spine Research Grant

2018 Texas Hospital Association Bill Aston Quality Improvement Award

2019 Women Who STEAM Award

2020 SRS OREF Spine Grant

2021 POSNA QVSI Grant