Enhanced Recovery With Combined Epidural and General Anesthesia in Children With Cerebral Palsy Undergoing Hip Reconstructive Surgery A National Cohort Study

BACKGROUND: Pediatric patients with cerebral palsy (CP) undergoing hip reconstruction face significant postoperative pain challenges. This study aimed to assess the efficacy and safety of epidural anesthesia combined with general anesthesia compared with general anesthesia alone in reducing postoperative opiate usage, postoperative complications, and length of hospital stay in this vulnerable population.

METHODS: A retrospective cohort study was conducted, analyzing medical records of pediatric CP patients who underwent bilateral proximal femoral osteotomy between 2003 and 2023, using a large national US health care database. Patients were dichotomized into 2 groups based on anesthesia technique: general anesthesia only (General) and general anesthesia with adjunct epidural anesthesia (Epidural). The primary outcome measured was the use of IV opiates within the first 3 days postoperation. Secondary outcomes included the use of per os (PO) opiates, length of stay (LOS), and postoperative complications such as ICU admission, mortality, pneumonia, respiratory failure, urinary retention, and urinary tract infections within 90 days postoperatively. Patient characteristics, including age, BMI percentile, gastrostomy and tracheostomy status, as well as concomitant hamstring lengthening and pelvic osteotomy, were propensity matched between groups.

RESULTS: In total, 1303 CP patients were identified, including 502 patients with general plus epidural anesthesia and 801 patients with general anesthesia only. After matching, there remained 361 patients in each group (a total of 722 patients who were included for analysis). The Epidural group demonstrated a significantly lower proportion of IV opiate usage within the first 3 days postoperation. There were no significant differences in the rates of ICU admissions, mortality, pneumonia, respiratory failure, urinary retention, or urinary tract infections between groups. However, the general plus epidural anesthesia group demonstrated lower usage of PO opiates 90 days postoperatively compared with the general anesthesia only group. The epidural group further demonstrated a 1.3-days shorter LOS.

CONCLUSIONS: The addition of epidural anesthesia to general anesthesia in pediatric CP patients undergoing proximal femoral osteotomy reduces hospital stay and IV opioid use postoperatively, without increasing complications. These findings support considering epidural anesthesia to enhance recovery and reduce opioid-related side effects in these patients.

LEVEL OF EVIDENCE: Level III-therapeutic study.