How Much Pain Medication Do Patients Require After Posterior Iliac Crest Bone Graft to the Alveolar Cleft?

Abstract

Objective

The purpose of this study was to quantify analgesic use following alveolar cleft bone grafting (ABG) utilizing a posterior iliac crest (PIC) donor site.

Design

This is a prospective cohort study of consecutive patients that underwent ABG with PIC in a 10 month period from November 2022 to September 2023.

Setting

Tertiary care free-standing pediatric hospital.

Participants

Patients with cleft lip and alveolus with or without cleft of the secondary palate undergoing alveolar bone graft with cancellous marrow from the PIC.

Interventions

All patients underwent ABG and recorded analgesic use afterwards.

Main Outcome Measure

The main outcome variable was total pain medication utilization during the first 10 postoperative days (PODs).

Results

22 subjects (72.7% male, 54.5% Caucasian 72.7% unilateral and 27.3% bilateral clefts) recorded pain medication use. Total duration of analgesic use (any type) was 3.86 ± 1.7 postoperative days. 10 subjects (45.5%) did not use opioid medication postoperatively. The remaining 12 subjects (54.5%) used a median of 12 (0, 19) morphine milli-equivalents (MME), equal to 1.6 (0, 2.53) doses of 5 mg oxycodone. An average of 9.9 ± 5.6 doses of acetaminophen and 9.1 ± 4.7 doses of a non-steroidal anti-inflammatory drug (NSAID) were administered. No subject used opioids after POD3. Patients with unilateral clefts used more acetaminophen (p = 0.02); otherwise, there were no significant differences in outcomes based on any predictor variable (p > 0.05).

Conclusions

Analgesic requirements after ABG with PIC were minimal, with nearly half of patients taking no postoperative opioids. As such, judicious opioid prescribing is prudent.  

Keywords

cleft lip cleft palate alveolar bone grafting pain medication

Get full access to this article

View all access options for this article.

References

Eshkevari

Kushner

. Pediatrics, craniofacial and orthognathic surgery track: Do scheduled non-opioid analgesics reduce the amount of inpatient opioid intake in orthognathic surgeries? J Oral Maxillofac Surg. 2023;81(10):e11–e13. doi:https://doi.org/10.1016/j.joms.2023.08.191

Friedman

Shover

. Charting the fourth wave: Geographic, temporal, race/ethnicity and demographic trends in polysubstance fentanyl overdose deaths in the United States, 2010–2021. Addiction. 2023;118(12):2477–2485. doi:https://doi.org/10.1111/add.16318

Som

Santosa

Skolnick

Lapidus

Waljee

Patel

. Opioid use among adolescents undergoing surgical repair of facial trauma. Plast Reconstr Surg. 2021;147(3):690–698. doi:https://doi.org/10.1097/PRS.0000000000007643

Bennett

Harbaugh

, et al. Persistent opioid use among children, adolescents, and young adults after common cleft operations. J Craniofac Surg. 2018;29(7):1697–1701. doi:https://doi.org/10.1097/SCS.0000000000004762

Eid

DePesa

Nordestgaard

, et al.

Variation of opioid prescribing patterns among patients undergoing similar surgery on the same acute care surgery service of the same institution: Time for standardization?

Surgery. 2018;164(5):926–930. doi:https://doi.org/10.1016/j.surg.2018.05.047

Thiels

Anderson

Ubl

, et al. Wide variation and overprescription of opioids after elective surgery. Ann Surg. 2017;266(4):564–573. doi:https://doi.org/10.1097/SLA.0000000000002365

Bicket

Long

Pronovost

Alexander

. Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg. 2017;152(11):1066–1071. doi:https://doi.org/10.1001/jamasurg.2017.0831

Resnick

Calabrese

Afshar

Padwa

. Do oral and maxillofacial surgeons over-prescribe opioids after extraction of asymptomatic third molars? J Oral Maxillofac Surg. 2019;77(7):1332–1336. doi:https://doi.org/10.1016/j.joms.2019.02.011

Bousquet

Green

Caillouette

Simon

Padwa

Resnick

. How much opioid medication do patients need after orthognathic surgery? J Oral Maxillofac Surg. 2022;80(7):1174–1182. doi:https://doi.org/10.1016/j.joms.2022.04.002

10.

Steinbacher

Padwa

Mulliken

. Simultaneous harvesting of cancellous iliac bone for alveolar cleft closure and dermis for augmentation of median tubercle. Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2009;46(3):295–298. doi:https://doi.org/10.1597/07-122.1

11.

Ahlmann

Patzakis

Roidis

Shepherd

Holtom

. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am. 2002;84(5):716–720. doi:https://doi.org/10.2106/00004623-200205000-00003

12.

Abramowicz

Katsnelson

Forbes

Padwa

. Anterior versus posterior approach to iliac crest for alveolar cleft bone grafting. J Oral Maxillofac Surg. 2012;70(1):211–215. doi:https://doi.org/10.1016/j.joms.2011.02.044

13.

Arnold

Weissman

. Calculating opioid dose conversions #36. J Palliat Med. 2003;6(4):619–620. doi:https://doi.org/10.1089/109662103768253731

14.

Ferrara

Tehrany

Chen

, et al. Evaluation of an enhanced recovery after surgery protocol (ERAS) for same-day discharge and reduction of opioid use following bimaxillary orthognathic surgery. J Oral Maxillofac Surg. 2022;80(1):38–46. doi:https://doi.org/10.1016/j.joms.2021.07.002

15.

Han

Susarla

Dodson

Lang

. Are oral and maxillofacial surgeons prescribing fewer opioids and more non-narcotic analgesics for postoperative pain after third molar removal? J Oral Maxillofac Surg. 2019;77(9):e29. doi:https://doi.org/10.1016/j.joms.2019.06.050

16.

Chorath

Moreira

Rajasekaran

. Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review. World J Otorhinolaryngol- Head Neck Surg. 2022;08(02):107–117. doi:https://doi.org/10.1002/wjo2.62

17.

Frants

Garber

Lafer

, et al. Prospective randomized trial comparing opioids versus nonsteroidal antiinflammatory drugs for postoperative analgesia in outpatient rhinoplasty. Plast Reconstr Surg. 2021;147(1):56–62. doi:https://doi.org/10.1097/PRS.0000000000007427

18.

Nguyen

Liu

Chang

, et al. A randomized single-blinded trial of ibuprofen- versus opioid-based primary analgesic therapy in outpatient otolaryngology surgery. Otolaryngol Neck Surg. 2019;160(5):839–846. doi:https://doi.org/10.1177/0194599819832528

19.

Dawson

Egbert

Myall

RWT

. Pain following iliac crest bone grafting of alveolar clefts. J Cranio-Maxillofac Surg. 1996;24(3):151–154. doi:https://doi.org/10.1016/S1010-5182(96)80048-5

20.

Lopez

Zech

Linton

Blackwell

. Dexmedetomidine decreases postoperative pain and narcotic use in children undergoing alveolar bone graft surgery. Cleft Palate Craniofacial J. 2018;55(5):688–691. doi:https://doi.org/10.1177/1055665618754949

21.

Tache

Mommaerts

. Pain management at iliac donor sites after grafting of alveolar clefts. Int J Oral Maxillofac Surg. 2022;51(1):62–69. doi:https://doi.org/10.1016/j.ijom.2021.05.004

22.

Meara

Livingston

Sittitavornwong

, et al. Continuous infusion of bupivacaine for pain control after anterior iliac crest bone grafting for alveolar cleft repair in children. Cleft Palate Craniofacial J. 2011;48(6):690–694. doi:https://doi.org/10.1597/09-267.1

23.

Bykowski

Sivak

Garland

Cladis

Goldstein

Losee

. A multimodal preemptive analgesic protocol for alveolar bone graft surgery: Decreased pain, hospital stay, and health care costs. Cleft Palate Craniofacial J. 2019;56(4):479–486. doi:https://doi.org/10.1177/1055665618791943

24.

Amin

Khor

Rosich-Medina

Beale

Alveolar bone grafting: Donor site review of 100 consecutive cases in cleft lip and palate. Cleft Palate Craniofacial J. 2017;54(2):137–141. doi:https://doi.org/10.1597/15-180