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The Evolution of Iliac Crest Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious
Peter F. Koltz, MD, Imran Punekar, PhD, Sara A. Neimanis, MD, Nobuyuki Tran, MD, Daryl Smith, MD, Clinton S. Morrison, MD.
University of Rochester Medical Center, Rochester, NY, USA.

Background:
We have previously reported the benefit of continuous bupivicaine infusion analgesia in iliac crest bone graft harvest for alveolar bone grafting in the cleft lip and palate population. Compared to control patients who underwent iliac crest bone graft harvest but did not receive any indwelling catheter, these patients had significantly shorter lengths of stay, lower morphine usage, lower codeine usage, and lower pain scores on the evening of the day of surgery as well as on postoperative day #1 with minimal associated morbidity. The transversus abdominis plane (TAP) block has been increasingly utilized as a means of abdominal wall analgesia. Benefitting from one-time administration under ultrasound guidance, the procedure first described in 2006 has demonstrated reduced visual analog scale pain scores and decrease morphine requirements over the first 24 hours postoperatively, as well as reduction in pain scores at 6 hours postoperatively and morphine consumption at both 6 and 24 hours postoperatively. Rare minor complications have been reported. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft.
Methods: Three groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone and various forms of analgesia were examined in a retrospective fashion. Group 1 received bupivacaine pain pump analgesia and Group 2 received intraoperative TAP block under
ultrasound guidance. Group 3 consisted of patients who received neither TAP nor pain pump analgesia. Demographic data, pharmacologic utilization, and hospital length of stay was examined. Wilcoxon rank-sum test and Fisher’s exact test were used where appropriate for statistical analysis.
Results: The groups were not significantly different with regard to race (p=1.0), age (p=0.80), or BMI(p=0.93), but Group 2 contained more females (p=0.01). Length of stay was similar between groups 1 and 2 (Group 1: 1.16 +/- 0.37; Group 2: 1.05 +/- 0.23 days; t-test p = 0.33). The average LOS in the control group was 2.9 +/- 0.8 days. Group 2 patients required significantly less morphine over 24 hours (p-value=0.04) and Ibuprofen in the first 6 hours (p-values=0.04) than Group 1. Tylenol and Ondansetron usage as well as pain scores at 6, 24 and total were insignificantly different between Groups 1 and 2. No adverse events were reported with the TAP block procedure.
Conclusion: Patients undergoing alveolar bone grafting with cancellous iliac bone who received postoperative analgesia with both continuous bupivacaine pain pump infusion and TAP blocks enjoyed the benefit of similarly improved pain control compared to the control. Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter with decreased short term NSAID and 24 hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia in the management of postoperative pain in this population.


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