SA3 - Peripheral Nerve Stimulation of the Peroneal Nerve Limits Opioid Consumption and Facilitates Early Ambulation Following Fibula Free Flap Harvest: A Case Series

Abstract: IntroductionReconstruction of maxillofacial defects with a composite fibula free flap (FFF) is a safe and functional solution for gnathic pathology or trauma; however, postoperative donor site pain is challenging task. Multi-modal analgesia (MMA) remains the standard for pain management; but this option employs opioids, putting patients at risk of substance use disorder and negative side effects. Recently, regional blocks using local anesthetics have gained traction in enhanced recovery after surgery (ERAS) protocols. This alternative has proven to reduce opioid usage but the success has been variable due to differences in metabolism, effect on flap perfusion, and inadvertent motor branch anesthesia that would delay functional recovery in gait independence. The purpose of this study was to investigate a novel pain management technique to place a peripheral nerve stimulator (PNS) on the peroneal nerve of the planned donor lower extremity preoperatively to mitigate the limitation of regional blocks. The authors believe PNS can deliver equivalent or superior analgesia than regional blocks while optimizing early functional gait rehabilitation.Materials and MethodsThe Department of Clinical investigation at NMCSD approved this investigation as a Process Improvement Project to enhance post-operative outcomes for fibula flap patients. In this case series, two adult patients underwent FFF reconstruction of the head and neck with preoperative placement of a SPRINTTM PNS device (SPRINT Therapeutics, Cleveland, OH). The device was used in conjunction with an established ERAS protocol (scheduled acetaminophen 650 mg q6h, ibuprofen 600 mg q6h, gabapentin 300 mg TID, 5mg Oxycodone IR tab q6h prn severe pain >8/10). The device was used in conjunction with an established ERAS protocol. The primary outcome was postoperative opioid usage. Secondary outcomes included subjective pain scores (0-10), days to out of bed to chair (OOBTC) and gait quality. ResultsPatient 1 took 10mg of oxycodone on POD1 and did not seek additional opioids. On POD3, she completed OOBTC and 5 feet gait with assistance. Patient 2 reported 0/10 pain on POD1 with no narcotic requirement and completed OOBTC. He ambulated 300 feet without assistive device on POD3 and reported no pain. Patient 3 completed OOBTC at POD1 and achieved 250 feet ambulation with front wheel walker at POD7. His oxycodone intake was minimal, totaling 95mg during his 7-day hospital course. On discharge, no narcotics were prescribed for pain control for all three patients. ConclusionOur findings demonstrate the possibility that peripheral nerve stimulating devices are a safe alternative in reducing opioid utilization among patients recovering from FFF reconstruction. Our initial outcomes demonstrate a novel analgesic alternative to opioids and regional anesthesia that is not dependent upon a patient's metabolism and mitigates the risk of anesthesia in both sensory and motor branches that would delay functional recovery and gait independence. A larger, prospective trial is needed to validate our initial findings.

Ilfed et al 2020 - Regional Analgesic Modalities
ERAS protocol
Patient 1 - Preop Xray