the use of nsaids in pediatric scoliosis surgery a survey of physicians’ prescribing practice

The use of NSAIDs in pediatric scoliosis surgery –a survey of physicians’ prescribing practice

JASON HAYES M D F R C P CM D F R C P C*, CAROLYNE PEHORA R NR N*

AND BRUNO BISSONNETTE M DM D†

*Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario,Canada and †Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada

SummaryBackground: Pediatric scoliosis surgery is associated with considerable

postoperative pain requiring opioids for analgesia. Nonsteroidal

antiinflammatory drugs (NSAIDs) can be used as adjuvants for

analgesia; however, the potential of these agents to affect bone healing

raises concerns. No large-scale prospective studies have been per-

formed to evaluate the benefit-to-risk ratio of NSAID use after

pediatric scoliosis surgery. Given the lack of evidence in the literature,

a survey of practice patterns of anesthesiologists from around the

world was conducted with respect to the use of NSAIDs after pediatric

spinal fusion surgery for scoliosis.

Methods: One hundred and fourteen anesthesiologists from interna-

tional academic pediatric hospitals were asked to complete an online

survey. After 1 month, nonresponders were sent a second e-mail

asking for their participation. All questions were developed specifi-

cally for this study.

Results: Out of 80 anesthesiologists who responded 61 were included

in the final analysis. Fifty-nine percent routinely use NSAIDs, the most

common agents being intravenous ketorolac and oral ibuprofen. The

majority of respondents begin to administer NSAIDs within the first

three postoperative days for a duration of four or more days. The

primary reason for not routinely prescribing NSAIDs was the risk of

bone nonunion.

Conclusions: This survey demonstrates that the practice patterns of

pediatric anesthesiologists from around the world with respect to the

administration of NSAIDs for the management of postoperative pain

after pediatric spinal fusion reflects the conflicting evidence in the

literature and the lack of high-quality studies in humans.

Keywords: survey; nonsteroidal antiinflammatory drugs; spinal

fusion; complications; side effects; children

Introduction

Pediatric scoliosis surgery is associated with con-

siderable postoperative pain requiring parenteral

opioids for analgesia. The use of opioids is associated

Correspondence to: J. Hayes, The Hospital for Sick Children, 555University Avenue, Toronto, Ontario M5G 1X8, Canada (email:[email protected]).

Pediatric Anesthesia 2009 19: 756–763 doi:10.1111/j.1460-9592.2009.03060.x

756 � 2009 Blackwell Publishing Ltd

with side effects such as respiratory depression,

nausea, vomiting, urinary depression, and pruritus.

Furthermore, the sedating effects associated with

opioids may prevent patients from participating in

physical therapy (1).

Nonsteroidal antiinflammatory drugs (NSAIDs)

are used to provide postoperative analgesia in

pediatric patients. Numerous studies have shown

that children undergoing orthopedic surgery who

receive NSAIDs as an adjuvant to opioids had lower

pain scores and fewer opioid side effects than those

who did not (1–3). However, the potential of these

agents to affect bone healing raises concerns.

The inhibition of bone healing has been demon-

strated in vitro (4), in animal research (5–14), and in

human investigations (15,16). It has been suggested

that the effect of NSAIDs on bone healing may be

dependent on the duration of treatment and the dose

administered (17,18). Studies have demonstrated

that the administration of lower doses of ketorolac,

a nonspecific NSAID, or cyclooygenase-2 inhibitors,

such as celecoxib, does not affect the rate of bone

nonunion (18).

Many reviews have been written on this subject,

with opinions expressed on both sides of the debate

(17,19–21). Until well-designed prospective studies

in humans are performed to clarify this issue,

practitioners must decide how best to manage

patients after corrective spinal surgery. Given the

lack of clarity in the literature, a survey of practice

patterns of anesthesiologists from around the world

was conducted with respect to the use of NSAIDs

after pediatric spinal fusion surgery for scoliosis.

The emphasis of this survery was on reasons for and

against the use of NSAIDs.

Methods

With the approval by the Research Ethics Board at

the Hospital for Sick Children, anesthesiologists

from international academic pediatric hospitals were

contacted by e-mail or phone by one of the authors

(B. Bissonnette) during April and May 2008. Each

contact was asked whether they would be willing to

complete an online survey. If they agreed, an e-mail

containing a link to the survey was sent. Each

respondent was assigned a random identification

number that they recorded during the survey in

order to maintain confidentiality and to prevent the

recording of more than one response from each

participant. After 1 month, nonresponders were sent

a second e-mail asking for their participation. A

copy of the survey is included (Appendix 1). All

questions were developed specifically for this study.

Results

Demographics

One hundred and fourteen anesthesiologists were

contacted. Sixty-seven responded to the initial

request and thirteen to the second request, for a

total response rate of seventy percent. Of the 80

respondents, 61 completed the survey satisfactorily

and were included in the analysis. (Figure 1) The

remaining respondents were excluded for the fol-

Survey requests sent114

Responses80

Included in analysis61

Excluded from analysis19

Use NSAIDs routinely36

Intravenous

Ketorolac 12 Ketoprofen 10 Parecoxib 2 Diclofenac 2

Oral*

Ibuprofen 20 Diclofenac 9 Naproxen 3 Ketoprofen 2 Celecoxib 1 Mefenic acid 1

Do not use NSAIDsroutinely

25Reasons**

Nonunion 20 Bleeding 12 Gastric ulcer 4 Kidney damage 2 Infection 1

Figure 1

Flow diagram of survey responses. *Ten respondents use two ormore oral agents. **Eleven respondents gave two or more reasons.NSAIDs, nonsteroidal antiinflammatory drugs.

THE USE OF NSAIDS IN PEDIATRIC SCOLIOSIS SURGERY 757

� 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 756–763

lowing reasons: (1) do not perform pediatric scoli-

osis correction cases (eight responses), (2) incom-

plete or no data entered (nine responses), and (3)

contradictory information entered regarding the use

of NSAIDs (two responses). The anesthesiologists

were classified by country and whether or not

NSAIDs are used (Table 1). The median number of

surgeries performed at each institution per year for

idiopathic and neuromuscular scoliosis by those

who do use NSAIDs when compared to those who

do not use NSAIDs were 30 (range 0–120) and 16

(range 1–60), respectively, and 45 (range 5–400) and

35 (range 5–200), respectively. Four respondents

who do use NSAIDs did not enter data for the

number of surgeries performed.

Use of NSAIDs

Thirty-six respondents (59%) who perform scoliosis

surgery replied that NSAIDs were routinely used in

their center, compared to 25 (41%) who replied that

NSAIDs were not routinely used.

The majority (72%) of those who prescribe NSA-

IDs use an intravenous agent, usually ketorolac,

followed by ketoprofen, parecoxib, and diclofenac.

The most common dosing regimen for ketoroloc was

0.5 mgÆkg)1 every 6–8 h, with a 24-h maximum of

40–120 mg. A slightly greater percentage (75%)

prescribes oral NSAIDs, ibuprofen being the most

common agent; however, many indicated that they

have a choice of two oral NSAIDs. Eighteen pre-

Table 1

Classification of respondentsincluded in analysis according toroutine use of NSAIDs andgeographic location

Geographiclocation

Number ofsurveys sent

Number of respondentswho perform scoliosis

surgery and use NSAIDspostoperatively

Number of respondents whoperform scoliosis surgery

and does not use NSAIDspostoperatively

North AmericaCanada 8 4 1USA 21 3 11Mexico 2

EuropeEngland 7 1Ireland 3 1Scotland 4 1France 19 7 2Belgium 1 1Switzerland 9 2 2Germany 2 1Austria 1 1Norway 1 1Poland 1Italy 2Spain 1Finland 1 1

AfricaAlgeria 1Morocco 1 1Tunisia 1 1South Africa 3 1 1Egypt 1 1

AustralasiaChina 2India 2 2Iran 2 2Saudi Arabia 1Singapore 1Australia 8 2 3New Zealand 5 3 1

South AmericaBrazil 3 2

Unknown 1Total 114 36 25

758 J . HAYES ET AL.


scribe both intravenous and oral NSAIDs postoper-

atively, and nine prescribe only intravenous or oral

NSAIDs.

Thirty anesthesiologists responded to question

five of the survey (Appendix 1) regarding the timing

of NSAIDs administration. All of the respondents

except one begin administering NSAIDs within the

first three postoperative days, with the majority

(60%) starting on the day of surgery (Figure 2). One

respondent indicated that they would not prescribe

NSAIDs until after the fifth postoperative day. Of

the twenty-nine respondents who administer NSA-

IDs within the first six postoperative days (including

the day of surgery), twelve (41%) prescribe NSAIDs

for up to 3 days, and seventeen (59%) for 4 days or

more (Figure 3). Six respondents administer NSAIDs

beyond the fifth postoperative day.

Reasons for not prescribing NSAIDs

The most common reason for not routinely prescrib-

ing NSAIDs was the risk of bone nonunion, followed

by risks of bleeding, gastric ulcer, kidney damage,

and infection. One-quarter of respondents who do

not prescribe NSAIDs replied that NSAIDs are

unnecessary for adequate pain control.

Complications related to the use of NSAIDs

Thirteen respondents described one or more com-

plications related to their use. Gastric ulceration was

the most common (8 ⁄ 13), followed by nonunion

(5 ⁄ 13) and excessive bleeding (5 ⁄ 13). A respondent

described one case of nonunion in a patient with

neuromuscular scoliosis who developed an infected

hematoma, and another commented that it was

difficult to attribute excessive bleeding directly to

the use of NSAIDs.

Discussion

Despite many concerns regarding the use of NSAIDs

after pediatric scoliosis surgery, over one-half of

anesthesiologists from around the world who

responded to this survey prescribe NSAIDs for the

management of postoperative pain. The majority use

both intravenous and oral NSAIDs, and nonspecific

agents are used much more often than COX-2-

specific agents. NSAIDs are usually started within

the first 3 days after surgery and continued for 3 or

more days. There did not appear to be a qualitative

correlation between geographic location and the use

of NSAIDs, except perhaps for the United States,

where the majority of respondents (11 ⁄ 14) do not use

NSAIDs. Another difference with respect to the

demographics of NSAID use was the greater number

of cases, particularly for neuromuscular scoliosis,

performed in centers that do not use NSAIDs. The

primary reason for not routinely prescribing NSA-

IDs was the risk of bone nonunion.

The mechanisms by which NSAIDs inhibit bone

healing may include decreased production of pro-

Figure 2

The percentage of respondents who initiate NSAID administrationon each postoperative day. Postoperative day 0 = day of surgery.NSAID, nonsteroidal antiinflammatory drug.

Figure 3

The cumulative numbers of days NSAIDs are prescribed bypercentage of respondents. Six days = day of surgery to pos-toperative day 5. NSAIDs, nonsteroidal antiinflammatory drugs.



staglandins, which are essential to maintain osteo-

blast activity (22), a direct cytotoxic effect on

osteoblasts (4), and ⁄ or a negative effect on blood

flow across a healing fracture(13). Numerous stud-

ies in animals have reported impaired osteogenesis

after spinal fusion and an increased incidence of

fractures after treatment with NSAIDs (5,6,23,24).

Many of these animal studies used excessive doses

(ketorolac 1–4 mgÆkg)1Æday)1 and celecoxib 3–

50 mgÆkg)1Æday)1), or for extended periods of time

(up to 12 weeks). However, a recent study suggests

that even short-term use of NSAIDs at clinically

acceptable doses may be detrimental to fracture

healing (24). Fortunately, the negative effects of

NSAIDs on bone healing may be reversible after

discontinuation (7). In adult humans, two retro-

spective studies of NSAID use after spinal fusion

surgery found increased rates of bone nonfusion

(15). However, the duration of treatment

(>3 months) in one study and the dose of ketorolac

(>2 mgÆkg)1Æday)1) in the other are considered

excessive when compared to current pain manage-

ment practices in humans. A subsequent retrospec-

tive study showed that the effects of NSAIDs on

spinal fusion may be dose dependent (18). Ketorolac

doses greater than 110 mgÆday)1 for 5 days after one

or two level lumbar spinal fusion in adults resulted

in a higher incidence of bone nonunion when

compared to lower doses of ketorolac (£110 mgÆ-day)1), celecoxib (200–600 mgÆday)1), and rofecoxib

(50 mgÆday)1) (18). A prospective study in a similar

group of patients demonstrated that celecoxib

400 mg preoperatively followed by 400 mgÆday)1

for 5 days postoperatively did not increase the rate

of nonunion at 1 year (25). Two studies have

evaluated the use of ketorolac after posterior spinal

fusion for scoliosis in adolescents (2,26). A small

prospective study of 35 patients did not show an

increase in the incidence of bone nonunion at

2 years in patients who received ketorolac

0.5 mgÆkg)1 (maximum 15 mg per dose) every 6 h

for 36 h postoperatively compared to controls (2).

However, only 14 patients (eight in the ketorolac

group) were followed to the 2-year mark. A retro-

spective study of over 200 children found the same

rate of reoperation (13%) for bone nonunion in the

sixty patients who received ketorolac (0.5 mgÆkg)1

every 6 h intravenously for 2–3 days) and the

control patients (26).

Excessive perioperative bleeding was the second

most common reason cited for avoidance of NSA-

IDs. The two studies in children cited above did not

detect an increase in volume of blood lost or rate of

transfusion during or after the administration of

ketorolac (2,26). However, neither study was de-

signed specifically to detect a difference in bleeding.

The use of COX-2-specific agents was low com-

pared to nonspecific agents. The analgesic activity of

NSAIDs is mediated primarily via the COX-2 iso-

forms, whereas the side effects are mediated through

the COX-1 isoforms (27). The COX-2 agents may

have less negative effects on bone healing when

compared to nonspecific agents (4–6) and are asso-

ciated with a lower incidence of NSAID-related side

effects (28,29). In particular, the COX-2 inhibitors

have no effect on platelets and do not increase

perioperative bleeding (25). The COX-2 inhibitors

may also play a role in the prevention of central

sensitization of dorsal horn neurons, which can

result in secondary hyperalgesia (29). It was some-

what surprising to us that COX-2 agents were used

so infrequently given their many advantages when

compared to nonspecific NSAIDs. However, we

speculate that the higher cost of COX-2-specific

agents, such as celecoxib, and also the recent

withdrawal of rofecoxib and valdecoxib from the

market by the manufacturers following the United

States Food and Drug Administration warning

against their use, may have contributed to this

important observation.

It was also interesting that many respondents did

not think NSAIDs were beneficial for the manage-

ment of pain after scoliosis surgery when numerous

studies have demonstrated a significant reduction

in opioid consumption and decrease in pain scores

when ketorolac and COX-2-specific NSAIDs were

used after orthopedic surgery, including spine

procedures, in adults and children (2,3,24,25,30,

31). The use of NSAIDs in the immediate postop-

erative period may also reduce the incidence of

chronic pain at the operative site (32). Although

most investigations do not demonstrate a reduction

in opioid-related side effects, we believe that any

reasonable attempt to reduce morbidity associated

with opioid consumption, particularly respiratory

depression, should be considered. These inves-

tigations showed that NSAIDs are not without

risk and almost 25% of respondents were directly

760 J . HAYES ET AL.


aware of the potential complications related to their

use.

The weaknesses of the present study is similar to

all other surveys reported (33). First, did the choice

of sampling frame from around the world accurately

represent the practices of anesthesiologists, as well

as their institutions? Sampling was not carried out in

a random fashion, but instead it was based on one of

the author’s (B.B.) knowledge of individual anesthe-

siologists practicing at recognized academic centers

internationally. This was performed in an attempt to

obtain the best response rate possible from anesthe-

siologists who have experience with these types of

cases. The response rate of 70% suggests that our

approach was somewhat successful. Although the

purpose was to obtain an international sample of

responses, the majority of the respondents were

from the United States and Western Europe. It is

difficult to know the degree of nonresponse bias

present in the present findings. However, all anes-

thesiologists contacted have a similar type of

practice, and there does not appear to be a geo-

graphic bias to the nonresponders. Secondly, the

validity and reliability of the questions in this survey

were not determined a priori. Eleven of 79 respon-

dents did not complete the survey properly, and a

pilot study may have been helpful in this respect.

Language may have played a role as the questions

were available in English only.

In summary, it is believed that the results of the

present survey reflect the discrepancy in the

literature regarding the use of NSAIDs after

pediatric spinal fusion for scoliosis. Clearly, many

believe that the benefits of NSAIDs for the man-

agement of postoperative pain outweigh the low,

but potentially serious, risks of bone nonunion and

excessive bleeding. Additional prospective studies

to further define the risk-to-benefit ratio of

NSAIDs, particularly with respect to nonunion,

are needed. However, such investigations may be

difficult to perform given the low incidence of

adverse events, and thus large number of subjects

are required.

References1 Eberson CP, Pacicca DM, Ehrlich MG. The role of ketorolac in

decreasing length of stay and narcotic complications in thepostoperative pediatric orthopaedic patient. J Pediatr Orthop1999; 19: 688–692.

2 Munro HM, Walton SR, Malviya S et al. Low-dose ketorolacimproves analgesia and reduces morphine requirements fol-lowing posterior spinal fusion in adolescents. Can J Anaesth2002; 49: 461–466.

3 Sutters KA, Shaw BA, Gerardi JA et al. Comparison of mor-phine patient-controlled analgesia with and without ketorolacfor postoperative analgesia in pediatric orthopedic surgery.Am J Orthop 1999; 28: 351–358.

4 Chang JK, Wang GJ, Tsai ST et al. Nonsteroidal anti-inflammatory drug effects on osteoblastic cell cycle,cytotoxicity, and cell death. Connect Tissue Res 2005; 46: 200–210.

5 Brown KM, Saunders MM, Kirsch T et al. Effect of COX-2-specific inhibition on fracture-healing in the rat femur. J BoneJoint Surg Am 2004; 86-A: 116–123.

6 Gerstenfeld LC, Thiede M, Seibert K et al. Differential inhibi-tion of fracture healing by non-selective and cyclooxygenase-2selective non-steroidal anti-inflammatory drugs. J Orthop Res2003; 21: 670–675.

7 Gerstenfeld LC, Al-Ghawas M, Alkhiary YM et al. Selectiveand nonselective cyclooxygenase-2 inhibitors and experimen-tal fracture-healing. Reversibility of effects after short-termtreatment. J Bone Joint Surg Am 2007; 89: 114–125.

8 Ho ML, Chang JK, Wang GJ. Antiinflammatory drug effects onbone repair and remodeling in rabbits. Clin Orthop Relat Res1995; 00: 270–278.

9 Long J, Lewis S, Kuklo T et al. The effect of cyclooxygenase-2inhibitors on spinal fusion. J Bone Joint Surg Am 2002; 84-A:1763–1768.

10 Martin GJ Jr, Boden SD, Titus L. Recombinant human bonemorphogenetic protein-2 overcomes the inhibitory effect ofketorolac, a nonsteroidal anti-inflammatory drug (NSAID), onposterolateral lumbar intertransverse process spine fusion.Spine 1999; 24: 2188–2193.

11 Meunier A, Aspenberg P. Parecoxib impairs early metaphysealbone healing in rats. Arch Orthop Trauma Surg 2006; 126: 433–436.

12 Mullis BH, Copland ST, Weinhold PS et al. Effect of COX-2inhibitors and non-steroidal anti-inflammatory drugs on amouse fracture model. Injury 2006; 37: 827–837.

13 Murnaghan M, Li G, Marsh DR. Nonsteroidal anti-inflam-matory drug-induced fracture nonunion: an inhibition ofangiogenesis? J Bone Joint Surg Am 2006; 88(Suppl. 3): 140–147.

14 Reikeraas O, Engebretsen L. Effects of ketorolac tromethamineand indomethacin on primary and secondary bone healing. Anexperimental study in rats. Arch Orthop Trauma Surg 1998; 118:

50–52.15 Deguchi M, Rapoff AJ, Zdeblick TA. Posterolateral fusion for

isthmic spondylolisthesis in adults: analysis of fusion rate andclinical results. J Spinal Disord 1998; 11: 459–464.

16 Glassman SD, Rose SM, Dimar JR et al. The effect of postop-erative nonsteroidal anti-inflammatory drug administration onspinal fusion. Spine 1998; 23: 834–838.

17 Dumont AS, Verma S, Dumont RJ et al. Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusionsurgery: a pharmacological quandary. J Pharmacol ToxicolMethods 2000; 43: 31–39.

18 Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth2005; 52: 506–512.

19 Gajraj NM. The effect of cyclooxygenase-2 inhibitors on bonehealing. Reg Anesth Pain Med 2003; 28: 456–465.



20 Maxy RJ, Glassman SD. The effect of nonsteroidal anti-inflammatory drugs on osteogenesis and spinal fusion. RegAnesth Pain Med 2001; 26: 156–158.

21 Wedel DJ, Berry D. ‘‘He said, she said, NSAIDs’’. Reg AnesthPain Med 2003; 28: 372–375.

22 Kawaguchi H, Pilbeam CC, Harrison JR et al. The role ofprostaglandins in the regulation of bone metabolism. ClinOrthop Relat Res 1995; 00: 36–46.

23 Dimar JR, Ante WA, Zhang YP et al. The effects of nonsteroidalanti-inflammatory drugs on posterior spinal fusions in the rat.Spine 1996; 21: 1870–1876.

24 Simon AM, O’Connor JP. Dose and time-dependent effects ofcyclooxygenase-2 inhibition on fracture-healing. J Bone JointSurg Am 2007; 89: 500–511.

25 Reuben SS, Ekman EF. The effect of cyclooxygenase-2 inhibi-tion on analgesia and spinal fusion. J Bone Joint Surg Am 2005;87: 536–542.

26 Vitale MG, Choe JC, Hwang MW et al. Use of ketorolac tro-methamine in children undergoing scoliosis surgery. Ananalysis of complications. Spine J 2003; 3: 55–62.

27 Hawkey CJ. COX-2 inhibitors. Lancet 1999; 353: 307–314.28 Gilron I, Milne B, Hong M. Cyclooxygenase-2 inhibitors in

postoperative pain management: current evidence and futuredirections. Anesthesiology 2003; 99: 1198–1208.

29 Sinatra R. Role of COX-2 inhibitors in the evolution of acutepain management. J Pain Symptom Manage 2002; 24: S18–S27.

30 Reuben SS, Connelly NR. Postoperative analgesic effects ofcelecoxib or rofecoxib after spinal fusion surgery. Anesth Analg2000; 91: 1221–1225.

31 Vetter TR, Heiner EJ. Intravenous ketorolac as an adjuvant topediatric patient-controlled analgesia with morphine. J ClinAnesth 1994; 6: 110–113.

32 Reuben SS, Ekman EF, Raghunathan K et al. The effect of cy-clooxygenase-2 inhibition on acute and chronic donor-site painafter spinal-fusion surgery. Reg Anesth Pain Med 2006; 31: 6–13.

33 Burmeister LF. Principles of successful sample surveys. Anes-thesiology 2003; 99: 1251–1252.

Accepted 5 May 2009

Appendix 1

1. Approximately how many pediatric spinal fusion

cases for scoliosis correction are performed at your

institution per year?

Idiopathic scoliosis _______

Neuromuscular ⁄ secondary scoliosis _______

2. Are nonsteroidal antiinflammatory drugs (NSA-

IDs) routinely (i.e usual practice for the majority of

practitioners) administered for pain management in

the immediate (first 5 days) postoperative period at

your institution?

Yes

No

3a. Which intravenous NSAID(s) are routinely used

(check all that apply)?

None

Ketorolac

Parecoxib

Other nonspecific NSAIDs or COX-2 inhibitors

(please specify)

3b. For each drug, please specify the dose (per

kilogram body weight, e.g. mgÆkg)1) and frequency

(e.g. every 8 h, t.i.d., q8h) of intravenous NSAID

administration that is routinely used at your insti-

tution:

3c. If there is a limit on the maximum dose of

intravenous NSAID that is routinely administered at

your institution, please specify the absolute amount

(e.g ketorolac 15 mg per dose or 60 mg per 24 h):

No

Yes (please specify limitations)

4a. Which oral NSAID(s) are routinely used (check

all that apply)?

None

Ibuprofen ⁄ diclofenac ⁄ naproxen

Celecoxib

Other nonspecific NSAIDs or COX-2 inhibitors

(please specify)

4b. For each drug, please specify the dose (per

kilogram body weight, e.g. mgÆkg)1) and frequency

(e.g. every 6 h, q.i.d., q6h) of oral NSAID adminis-

tration that is routinely used at your institution:

4c. If there is a limit on the maximum dose of oral

NSAID that is routinely administered at your insti-

tution, please specify the absolute amount (e.g

ibuprofen 400 mg per dose or 1600 mg per 24 h):

No

Yes (please specify limitations)

5. On which postoperative days are NSAIDs rou-

tinely administered to patients after spinal fusion

surgery (please check all that apply):

Postoperative day 0 (day of surgery)

Postoperative day 1

Postoperative day 2

Postoperative day 3

Postoperative day 4

Postoperative day 5

After postoperative day 5

(please provide details, if you wish)

6. If NSAIDs are NOT routinely administered, please

estimate what percentage of patients, if any, are

administered NSAIDs in the immediate postopera-

tive period:

Unknown

Percentage (please enter) ______

762 J. HAYES ET AL.


7. To the best of your knowledge, please specify why

NSAIDs are NOT administered (check all that apply):

Risk of nonunion (as determined by radiologic

studies i.e. X-ray ⁄ CT or examination by surgeon)

Risk of bleeding

Risk of gastric ulceration

Unnecessary for adequate postoperative pain

control

Other (please specify)

8. Are you aware of any patients who have experi-

enced any of the following complications as a result

of NSAID administration in the immediate postop-

erative period in the last 5 years? (check all that

apply). Please do not supply any identifiable patient

information.

Nonunion of fusion (as determined by radiologic

studies i.e. X-ray ⁄ CT or examination by surgeon)

Excessive bleeding

Kidney damage

Gastric ulceration

Other (please specify)



the use of nsaids in pediatric scoliosis surgery a survey of physicians’ prescribing practice

Documents