SA3 - Postoperative Opioid Use After Iliac Crest Bone Graft in Cleft Patients: Local Infiltration Versus TAP Block

Abstract: Statements of the Problem: Autogenous iliac crest bone is the gold standard for secondary alveolar bone grafting (SABG) due to its osteogenic potential and structural reliability. However, iliac crest harvest is associated with donor-site morbidity, most commonly postoperative pain. Optimizing perioperative analgesia in pediatric cleft populations is critical to facilitate early mobilization, minimize opioid exposure, and enhance recovery. Traditional local infiltration provides limited analgesia, whereas transversus abdominis plane (TAP) block offers broader regional anesthesia. This study compared opioid consumption and recovery outcomes between local infiltration and TAP block for iliac crest harvest during SABG.

Materials and Methods Used in the Investigation of the Problem: We conducted a retrospective cohort study of patients aged 6-18 years undergoing SABG with autogenous iliac crest harvest at the Mayo Clinic between 2005 and 2025. Patients were grouped by donor-site analgesic technique: local infiltration or landmark-guided TAP block. Demographic, clinical, operative, anesthetic, and postoperative data were extracted from electronic medical records. The primary outcome was total inpatient opioid consumption in oral morphine milligram equivalents (MME). Secondary outcomes included time to first opioid, hospital length of stay, discharge opioid prescription, donor-site complications, and need for additional surgery.

Method of Data Analysis: Sample Size: A total of 75 patients met inclusion criteria.

Duration of Study: Data were collected over a 20-year period (2005-2025).

Statistical Methods: Descriptive statistics and univariate regression analyses (t-test, Mann-Whitney U, Chi-square, Fisher's exact) were performed. Multivariate regression evaluated independent predictors of opioid consumption. Statistical significance was defined as P < .05.

Results of Investigation: Fifty-eight patients received local infiltration and 17 received TAP block. Baseline demographics and clinical characteristics were comparable. Local infiltration patients were more likely to receive intraoperative opioids (P = .011). TAP block patients received more postoperative NSAIDs (P = .006) and acetaminophen (P = .030). TAP block was associated with lower initial postoperative opioid requirements (median 5 vs 11 MME; P < .001), fewer discharge opioid prescriptions (18% vs 69%; P < .001), and shorter hospital stays (P = .016). Donor-site complications were rare and similar between groups. TAP block patients were significantly less likely to require additional surgery (18% vs 55%; P = .006). Univariate regression demonstrated that TAP block significantly reduced the likelihood of intraoperative opioid use (OR 0.063; 95% CI 0.003-0.465; P = .02) and decreased first intraoperative opioid dose by 22.0 MME (95% CI -43.4 to -0.58; P = .04). Postoperatively, TAP block patients were more likely to receive NSAIDs (OR 11.3; 95% CI 2.08-210.7; P = .02) and had a lower first postoperative opioid dose (-10.96 MME; 95% CI -18.61 to -3.31; P = .01). TAP block was also associated with a reduced likelihood of additional surgery (OR 0.174; 95% CI 0.037-0.602; P = .01).

Outcomes Data: TAP block for iliac crest harvest in SABG was associated with reduced perioperative opioid exposure, lower intraoperative opioid doses, increased use of non-opioid analgesics, shorter hospital stays, and lower likelihood of additional surgery without increased donor-site morbidity.

Conclusions Relevant to the Problem: In pediatric and adolescent SABG patients, TAP block provides effective perioperative analgesia, decreases opioid requirements, enhances multimodal pain management, and may reduce the need for additional surgery. Incorporation of TAP block into perioperative protocols may optimize recovery and support opioid-sparing strategies in this population.


References

1. Tsai H-C, Yoshida T, Chuang T-Y, Yang S-F, Chang C-C, Yao H-Y, et al. Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. BioMed Research International. 2017;2017(1):8284363.

2. Sowapark J, Sumphaongern T. Does Ultrasound-Guided Transversus Abdominis Plane Block Reduce Donor Site Pain After Harvesting Anterior Iliac Crest Bone Grafts. Journal of Oral and Maxillofacial Surgery. 2021;79(2):333-42.