Postoperative Pain Level and Narcotic Analgesic Medication Requirement Among Adults Undergoing Orthognathic Surgery

Introduction: Bimaxillary osteotomy comprising bilateral sagittal split osteotomy and LeFort I osteotomy is one of the most common major maxillofacial operations, and has the highest reported postoperative pain scores. [1] Due to the severity of this post-surgical pain, rapid onset and prolonged pain relief is ideal in this acute setting. Narcotic analgesics like Oxycodone have become successful for treating this acute postoperative pain as they have shown to provide a more rapid analgesic effect compared to most other non-opioid analgesic medications. Unfortunately, this rapid onset of opioid analgesics like Oxycodone has been shown to be a contributing factor to narcotic addiction potential [2]. Identifying clinical variables that help predict narcotic medication requirements in the acute setting can potentially direct prescribing practices and thus limit overmedication of narcotics and addiction.

Patients and Methods: This prospective cohort study took place at the Boston Medical Center from 2015 to 2016. ASA I and II non-syndromic patients between the ages of 18 and 65 who were listed for elective orthognathic surgery (not including SARPE) were included as part of the study. All patients underwent either a single jaw (LeFort I osteotomy, or BSSO) or a double jaw (LeFort I osteotomy and BSSO with or without genioplasty) surgery by a single practitioner. Post-operatively, the subjects were placed on scheduled 650 mg Acetaminophen every 6 hours together with 5 or 10 mg Oxycodone solution for mild/moderate or severe pain, as well as 0.25 or 0.5 mg Hydromorphone IV medication for breakthrough pain. At the time of administration of any of the narcotics pain medications, patient’s pain score was recorded by a visual analog scale (VAS) by the RN. Patient’s pain score was also recorded by a resident twice daily during morning and evening rounds. Patient’s total narcotics requirement was then recorded by adding mg equivalents of morphine (MEQ) that the patient received during the entirety of their hospital stay.

Statistical Analysis: 20 (13 female, 7 male) subjects were enrolled into the study. Student paired t-test with confidence interval of 95% was used to evaluate statistical significance of patient’s age, type of surgery, and gender with post-operative narcotic analgesia requirement. Probabilities of less than 0.05 were accepted as significant.

Results: 20 subjects (aged between 18 and 50, mean 26.35, SD 10.26) underwent 15 bimaxillary and 5 single jaw procedures (three BSSOs and two LeFort I osteotomies). Male patients on average had lower VAS pain scores (4.77 vs 6.43) and lower narcotics requirement compared to females (83.28 vs 134.25 MEQ). Patients who underwent single jaw surgery had similar pain scores to patients who underwent bimaxillary surgery (5.98 vs 5.8), but had lower narcotics requirement (80.7 vs 131.27). Patients older than 25 years of age had higher post-operative pain scores (6.37 vs 5.5) and narcotics requirement compared to patients 24 years and younger (130.8 vs 110.5 MEQ).

Conclusions: ASA I and II adult patients who undergo orthognathic jaw surgery require substantial post-operative narcotic analgesia (mean: 118.63 MEQ, range: 30-407 MEQ) in addition to scheduled non-narcotic medications. Age greater than 25 years of age, bimaxillary surgery and female gender account for higher post-operative narcotic analgesic requirements.

References:

[1] Ayþegül Mine Tüzüner Öncül, Emre Çimen^, , Zuhal Küçükyavuz, Mine Cambazoglu, Postoperative analgesia in orthognathic surgery patients: diclofenac sodium or paracetamol? British Journal of Oral and Maxillofacial Surgery Volume 49, Issue 2, March 2011, Pages 138–141

[2] Johan Ræder, Harald Breivik, Oral immediate and prolonged release oxycodone for safe and effective patient controlled analgesia after surgery: Can opioid for acute postoperative pain be improved by adding a peripheral opioid antagonist? Scandinavian Journal of Pain Volume 7, April 2015, Pages 25–27