Effects of arthroscopy-guided suprascapular nerve block combined with ultrasound-guided interscalene brachial plexus block for arthroscopic rotator cuff repair: a randomized controlled trial

A Randomized Comparison Between Interscalene and Combined Interscalene-Suprascapular Blocks for Arthroscopic Shoulder Surgery: A Prospective Clinical Study

Background

To compare the analgesic effect of ISB with a combination of ISB-SSNB and patients who were given opioids with PCA without block in adult patients undergoing shoulder surgery, as measured by opioid consumption and pain intensity in the first 24 hours postoperatively.

Methods

Ninety patients who underwent shoulder surgery were randomly divided into three groups. Group I in which ISB was performed and patient-controlled analgesia (PCA) was inserted, Group II with; ISB and SSNB combined, and PCA was inserted, and Group III where; only PCA was used. Visual analog scale (VAS) pain scores at the second, fourth, sixth, 12th, and 24th hours, morphine consumption, additional analgesic requirement, and patient satisfaction were evaluated.

Results

Compared with Group III, the VAS pain score was significantly lower in Group I and Group II at 2, 4, 6, 12, and 24 hours postoperatively. In Group I, the VAS score at rest at the 6th hour was found to be higher than in Group II. The 24-hour total morphine consumption was higher in the control group than in Group I and Group II. The satisfaction score of the control group was lower than Group I and Group II.

Conclusion

The combined application of ISB and SSNB block is beneficial in shoulder surgery to provide both intraoperative and postoperative analgesia and opioid consumption.

Level of Evidence

Level I; Randomized Controlled Trial; Treatment Study.

Comparison of Analgesia Treatment Methods After Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of 42 Randomized Controlled Trials

Background

The optimal method for postoperative analgesia after arthroscopic rotator cuff repair (ARCR) is still unclear.

Purpose

To compare the efficacy of postoperative analgesic methods after ARCR through network meta-analysis of randomized controlled trials and prospective controlled trials.

Study Design

Systematic review; Level of evidence, 2.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched PubMed, Embase, and Web of Science from inception until April 12, 2022, for randomized controlled trials and prospective controlled trials evaluating neuraxial analgesia, peripheral nerve block, periarticular local anesthetic infiltration, intravenous patient-controlled analgesia, oral analgesia, or any combination of these methods for pain management after ARCR. Outcomes included pain scores at rest, morphine consumption, and complications (nausea and vomiting). Study quality was assessed using the Cochrane risk-of-bias tool. Network meta-analysis was used to assess the relative efficacy of the methods for postoperative analgesia. The best choice for postoperative analgesia was defined as the one with significant differences in pain scores and morphine consumption compared with placebo, with no significant difference in complications, during the initial 48 hours postoperatively.

Results

Included were 42 studies with 3110 patients. Only suprascapular nerve block (SSNB) was significantly superior to placebo in pain scores (mean difference [MD], -0.93 [95% CI, -1.31 to -0.54] at 6 hours; MD, -2.34 [95% CI, -3.49 to -1.19] at 12 hours) and morphine consumption (MD, -17.70 [95% CI, -32.98 to -2.42] at 24 hours) (P < .05 for all), with no difference in complications (odds ratio, 0.96 [95% CI, 0.21 to 4.32]; P > .05). Pain scores were significantly lower with interscalene nerve block compared with SSNB (MD, -0.69 [95% CI, -1.17 to -0.20] at 6 hours; MD, -1.44 [95% CI, -2.21 to -0.67] at 12 hours) and with SSNB + axillary nerve block compared with SSNB (MD, -3.09 [95% CI, -4.18 to -1.99] at 6 hours; MD, -0.87 [95% CI, -1.71 to -0.03] at 12 hours) (P < .05 for all).

Conclusion

Based on the current evidence, most analgesic methods lowered pain and morphine consumption compared with placebo. There were significant differences in pain scores between interscalene nerve block and SSNB during the first 12 hours postoperatively, and adding axillary nerve block to SSNB enhanced the analgesic effect.

Short-term clinical effectiveness of 5% lidocaine patch after arthroscopic rotator cuff repair: study protocol for a randomized, double-blinded, placebo-controlled clinical trial

BACKGROUND

Arthroscopic rotator cuff repair (ARCR) often causes unbearable postoperative pain, even more severe than before surgery. Opioids are the drugs of choice for temporary postoperative analgesia. However, this conventional approach also has some side effects and potential for drug abuse. The aims of this study are expected to verify the effect of 5% lidocaine patch (LP5) on the intensity of early postoperative pain, functional recovery and quality of life in patients undergoing ARCR.

METHODS

In this randomized, double-blind, and placebo-controlled clinical trial, a total of 102 postoperative patients undergoing ARCR will be randomly assigned to either the LP5 group, receiving topical lidocaine analgesia, or the placebo control group. The primary outcome measure will be the change in the American Shoulder Elbow Surgeons score from pre-operation to 90 days post-operation. Secondary outcomes will include pain scores, range of motion, opioid use, safety indicators, blinding assessment and several shoulder function score questionnaires. The effect of the allocated treatment will be assessed at preoperative baseline and at 7-, 14-, 30- and 90-day postoperatively.

DISCUSSION

In this study, the efficacy and safety of the 5% lidocaine patch will be evaluated in terms of short-term clinical symptoms in patients undergoing ARCR. The results of this study will help determine whether LP5 is effective in early functional recovery in ARCR and whether it relieves pain and reduces opioid consumption.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn ) ChiCTR2200060108. Registered on 19 May 2022.

Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients

The purpose of this study was to compare the complication risk of different treatments for displaced intra-articular calcaneal fractures (DIACFs). Randomized controlled trials comparing interventions for DIACFs were included: (1) interventions with conservative treatment, surgery with a minimally invasive approach (MIA) (sinus tarsi or small longitudinal), surgery with a percutaneous approach (PA) and open surgery with the extensive "L" lateral approach (ELA), and (2) complications and wound infections were also assessed. Twenty-six published trials met the inclusion criteria. The trials involved a total of 2538 patients surgically treated for acute DIACFs. For total complications, the mean incidence rate in the ELA was significantly higher than the rates in other treatments (conservative treatment vs ELA: odds ratio (OR), 0.36; p < .001; MIA vs ELA: OR, 0.23; p = .002; and PA vs ELA: OR, 0.18; p < .001). For wound infections, there were no significant differences among the groups (MIA vs PA: OR, 0.98; 95% CI, 0.32-3.01; p = .977; MIA vs ELA: OR, 0.45; 95% CI, 0.19-1.10; p = .081; and PA vs ELA: OR, 0.46; 95% CI, 0.19-1.11; p = .085). According to the surface under the cumulative ranking curve, the PA was most likely to be the best management for minimizing complications (surface under the cumulative ranking curve = 86.2). The ELA was significantly related to a higher risk of complications among all management methods. The PA was most likely to be the ideal choice when only complications were considered.

Network Meta-Analysis of Perioperative Analgesic Effects of Different Interventions on Postoperative Pain After Arthroscopic Shoulder Surgery Based on Randomized Controlled Trials

Background

Shoulder arthroscopic surgery is a common surgical method used in orthopedics. However, severe postoperative pain can significantly limit the early joint movement of patients and adversely affect the impact of the surgery. At present, there is no consistent and effective analgesic scheme for the management of postoperative pain after arthroscopic surgery of the shoulder.

Purpose

The aim of this study was to search for the most effective analgesic scheme to control pain in the perioperative period of arthroscopic surgery of the shoulder.

Study Design

Network meta-analysis.

Methods

We searched 5 different databases (i.e., Medline, PubMed, Embase, Web of Science, and the Cochrane Library) from January 2011 to January 2021 for English literature. Thereafter, we sifted out randomized controlled trials (RCTs), which compared different intervention schemes for pain management after shoulder arthroscopy and selected only 12 h, 24 h, or 48 h after the patient leaves the operating room as an optimal period for administration of analgesic intervention schemes. Only patients with shoulder disease who have undergone arthroscopic shoulder surgery were included in this study. The Cochrane “risk of bias” was used for the quality assessment. Moreover, some additional tests were performed to enhance the credibility of the results.

Results

Twenty-nine RCTs involving 1,885 patients were included in this frequentist network meta-analysis (NMA). These articles mainly were divided into two distinct groups, namely, the nerve block group and the non-nerve block group. Regarding the nerve block group, at postoperative 12 h, the intervention suprascapular nerve block + interscalene nerve block (SSNB + INB) was ranked first, whereas INB + intra-articular injection (INB + IAI) was ranked first at 24 h and 48 h postoperation. In the non-nerve block group, external application (EA) was ranked first at postoperative 12 h, but oral administration (OA) exhibited a better analgesic effect at postoperative 24 h and postoperative 48 h.

Conclusion

We conclude that the analgesic effect of SSNB+INB was the best at postoperative 12 h, and INB+IAI was the best at postoperative 24 h and 48 h in the nerve block group. For the non-nerve block group, the effect of EA was the best at postoperative 12 h, and the analgesic effect of OA at postoperative 24 h and 48 h was significantly better than any other interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021286777.

Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review

OBJECTIVE

Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB.

METHODS

Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery.

RESULTS

Fifty-five studies totalling 6,236 participants (median, 69; range, 30-910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences.

CONCLUSION

These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB.

STUDY REGISTRATION

PROSPERO (CRD42020148496); registered 10 February 2020.

Peripheral Nerve Blocks Outperform General Anesthesia for Pain Control in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to compare the effectiveness of different peripheral nerve blocks and general anesthesia (GA) in controlling postoperative pain after arthroscopic rotator cuff repair (ARCR).

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was conducted for the period of January 1, 2005, to February 16, 2021, by searching the following databases: PubMed, Cochrane, Embase, and Arthroscopyjournal.org. The primary outcomes of interest included 1-hour, 24-hour, and 48-hour pain scores on a numeric rating scale or visual analog scale (VAS). Inclusion criteria were English language studies reporting on adults (≥18 years) undergoing ARCR with peripheral nerve blockade. To synthesize subjective pain score data at each evaluation time point across studies, we performed random-effects network meta-regression analyses accounting for baseline pain score as a covariate.

RESULTS

A total of 14 randomized controlled trials with 851 patients were included in the meta-analysis. Data from six different nerve block interventions, single-shot interscalene brachial plexus nerve block (s-ISB; 37.8% [322/851]), single-shot suprascapular nerve block (s-SSNB; 9.9% [84/851]), continuous ISB (c-ISB; 17.5% [149/851]), continuous SSNB (c-SSNB; 6.9% [59/851]), s-ISB combined with SSNB (s-ISB+SSNB; 5.8% [49/851]), s-SSNB combined with axillary nerve block (s-SSNB+ANB; 4.8% [41/851]), as well as GA (17.3% [147/851]) were included. Our meta-analysis demonstrated that c-ISB block had a significant reduction in pain score relative to GA at 1-hour postoperation (mean difference [MD]: -1.8; 95% credible interval [CrI] = -3.4, -.08). There were no significant differences in VAS pain scores relative to GA at 24 and 48 hours postoperatively. However, s-ISB+SSNB had a significant reduction in 48-hour pain score compared to s-ISB (MD = -1.07; 95% CrI = -1.92, -.22).

CONCLUSIONS

It remains unclear which peripheral nerve block strategy is optimal for ARCR. However, peripheral nerve blocks are highly effective at attenuating postoperative ARCR pain and should be more widely considered as an alternative over general anesthesia alone.

LEVEL OF EVIDENCE

Level II Systematic review and meta-analysis of Level I and II studies.

The AAOS 2019 Clinical Practice Guidelines for the Management of Rotator Cuff Injuries Are Unbiased and Incorporate a Diverse Body of Literature

Purpose

To analyze the scientific research that formed the basis of the 2019 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for the management of rotator cuff injuries.

Methods

All studies cited in the 2019 AAOS clinical practice guidelines for the management of rotator cuff injuries were extracted and categorized. Extracted data included type of study, number of patients, level of evidence, journal of publication, impact factor, year of publication, country of origin, contributing authors, affiliated institutions, and significant findings. Data were analyzed to determine time from publication to implementation, level of evidence, and frequency of cited journals and authors.

Results

The studies cited in the guideline included 15,130 patients from 140 studies published between 1994 and 2018. The overall mean time from article publication to 2019 AAOS clinical practice guidelines was 4.76 ± 2.23 years. Of articles published in 2010 to 2019, 64 studies were cited in the strong recommendation strength subcategory, and 57 articles were cited in the moderate recommendation strength subcategory. Articles published in Journal of Shoulder & Elbow Surgery and Arthroscopy were cited most frequently. The most frequent authors were J. H. Oh, R. Z. Tashjian, S. H. Kim, N. Maffulli, and J. C. Yoo.

Conclusions

The 2019 AAOS CPG reference a diverse number of journals and authors, appearing to be impartial. Furthermore, prompt time from publication to implementation in the Guidelines indicates that it is possible to influence clinical guidelines with recent work.

Clinical Relevance

An analysis of the scientific research that forms the basis of the AAOS Clinical Practice Guidelines for the Management of Rotator Cuff Injuries can provide valuable information about the quality of the Guidelines.

Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: Arthroscopy-Guided Continuous Suprascapular Nerve Block Versus Ultrasound-Guided Continuous Interscalene Block

PURPOSE

To compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block and ultrasound-guided continuous interscalene block in postoperative analgesia in patients undergoing arthroscopic rotator cuff repair.

METHODS

A prospective study was performed between March and November 2020. In total, 76 patients were enrolled and divided into 2 groups: in the 38 patients of group 1 (arthroscopy-guided continuous suprascapular nerve block), an indwelling catheter was introduced via the Neviaser portal under arthroscopic view before closing the portal at the end of the surgery; and in the 38 patients of group 2 (ultrasound-guided continuous interscalene block), an indwelling catheter was inserted and directed toward the interscalene brachial plexus prior to the surgery under ultrasound guidance. The primary outcome was the pain score measured by the visual analog scale at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of these events: neurologic complications, such as sensory/motor change in the upper extremities; hemidiaphragmatic paresis; dyspnea; dysphonia; and Horner's syndrome. Opioid usage until postoperative 3 weeks was compared between the groups.

RESULTS

The visual analog scale scores in groups 1 and 2 were comparable at each postoperative time point (analysis of variance, P = .919; trends, P = .132). Neurologic deficits were more common in group 2 than in group 1 (8 vs 32 patients, P < .001). Decreased excursion of the diaphragm was more common in group 2 (partial or complete paresis of the hemidiaphragm: 1 vs 29 patients, P < .001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, P = .195).

CONCLUSIONS

Our findings show that arthroscopy-guided continuous suprascapular nerve block is not inferior to ultrasound-guided continuous interscalene block for postoperative pain control after arthroscopic rotator cuff repair while showing fewer temporary neurologic complications.

LEVEL OF EVIDENCE

Level II, prospective cohort study, interventional study.

Multimodal nerve injection provides noninferior analgesic efficacy compared with interscalene nerve block after arthroscopic rotator cuff repair

PURPOSE

This randomized noninferiority trial aimed to evaluate whether combined suprascapular, axillary nerve, and the articular branch of lateral pectoral nerve block (3NB) is noninferior to interscalene nerve block (ISB) for pain control after arthroscopic rotator cuff repair (ASRCR).

MATERIALS AND METHODS

Eighty-five patients undergoing ASRCR were randomized to either 3NB (n = 43) or ISB (n = 42) group. We used 5 and 15 ml of 0.2% ropivacaine for each nerve in the 3NB and ISB groups, respectively. The primary outcome was the visual analog scale (VAS) pain score at 4 h postoperatively measured assessed on an 11-point scale (ranging from 0 = no pain to 10 = worst pain) that was analyzed using noninferiority testing. The secondary outcome was VAS pain scores in the recovery room and at 8, 12, 24, 36, 48, and 72 h postoperatively. Rebound pain, IV-PCA usage during 48 h, dyspnea, muscle weakness, and satisfaction were evaluated.

RESULTS

Regarding the primary outcome, the mean difference in VAS pain scores between the 3NB (2.5 ± 1.6) and ISB (2.2 ± 2.3) groups at 4 h postoperatively was 0.3, with a 95% confidence interval (CI) of -0.56 to 1.11. The upper limit of 95% CI is lower than the noninferiority margin of 1.3 (p < 0.001). At all other time points, except in the recovery room, 3NB showed noninferior to ISB. Rebound pain, IV-PCA usage during the second 24 h, and muscle weakness were lower in the 3NB group (all p < 0.005). The satisfaction was similar in both groups (p = 0.815).

CONCLUSION

Combined 3NB is noninferior to ISB in terms of pain control after ASRCR; and is associated with low levels of rebound pain, IV-PCA usage, and muscle weakness.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Comparison of Ultrasound-Guided Supra-scapular Plus Axillary Nerve Block with Interscalene Block for Postoperative Pain Management in Arthroscopic Shoulder Surgery; A Double-Blinded Randomized Open-Label Clinical Trial

Background

Post-arthroscopic shoulder surgery pain is severe enough to interfere with initial recovery and rehabilitation.

Objectives

We aimed to evaluate the analgesic effects of postoperative ultrasound-guided suprascapular plus axillary nerve blocks superficial subepidermal axon bundles (SSAB) with interscalene block (ISB) in arthroscopic shoulder surgery.

Methods

In this single-blind randomized, open-label clinical trial, 80 candidates of elective arthroscopic shoulder surgery were randomly allocated to receive either SSAB or ISB at a postoperative care unit. The severity of resting and changing position pain was measured using visual analogue scale (VAS) score at 4h, 8h, 12h, 16h, and 24h, postoperatively. Timing of first opioid request, 24h dose requirement, patients' satisfaction rate, and side effects were also recorded. All registered data were analyzed using SPSS software version 23 for Windows (SPSS, Chicago, IL).

Results

Resting and changing position pain scores were comparable between SSAB and ISB groups in the most time intervals. At 12h, moving and resting pain was significantly lower in ISB than SSAB group, while moving pain was more severe in ISB group at 24h assessment. Patient satisfaction scores were comparable between the two groups except for 12h assessment. Time to first analgesic requirement and total dose of 24h opioid requirement were not significantly different between the two groups.

Conclusions

Suprascapular plus axillary nerve block could be an effective and safe alternative for interscalene block for pain management after arthroscopic shoulder surgery.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair

PURPOSE

Interscalene brachial plexus block (ISB) is one of the most commonly used regional blocks in relieving postoperative pain after arthroscopic rotator cuff repair. Dexmedetomidine (DEX) is an alpha 2 agonist that can enhance the effect of regional blocks. The aim of this study was to compare the effects of DEX combined with ISB with ISB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair.

METHODS

Fifty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single center, double-blinded randomized controlled trial study. Twenty-five patients were randomly allocated to group 1 and received ultrasound-guided ISB using a mixture of 1 ml (100 μg) of DEX and 8 ml of 0.75% ropivacaine preemptively. The other 25 patients were allocated to group 2 and underwent ultrasound-guided ISB alone using a mixture of 1 ml of normal saline and 8 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were checked within 48 h postoperatively. The plasma interleukin (IL)-6, -8, -1β, cortisol, and substance P levels were also measured within 48 h, postoperatively.

RESULTS

Group 1 showed a significantly lower mean VAS score and a significantly higher mean SAT score than group 2 at 1, 3, 6, 12, and 18 h postoperatively. Compared with group 2, group 1 showed a significantly lower mean plasma IL-6 level at 1, 6, 12, and 48 h postoperatively and a significantly lower mean IL-8 level at 1, 6, 12, 24, and 48 h postoperatively. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (12.7 h > 9.4 h, p = 0.006).

CONCLUSIONS

Ultrasound-guided ISB with DEX in arthroscopic rotator cuff repair led to a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h postoperatively than ISB alone. In addition, ISB with DEX showed lower mean plasma IL-6 and IL-8 levels than ISB alone within 48 h postoperatively, with delayed rebound pain.

LEVEL OF EVIDENCE

I.

TRIAL REGISTRATION

2013-112, ClinicalTrials.gov Identifier: NCT02766556.

Editorial Commentary: Postoperative Pain Management After Arthroscopic Rotator Cuff Repair: The Journey to Pain Relief

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.

Upper extremity regional anesthesia techniques: A comprehensive review for clinical anesthesiologists

Surgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular, and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound-guided techniques, whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords, and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.

[Peripheral nerve block and rebound pain: literature review]

BACKGROUND AND OBJECTIVES

To investigate, describe, and assess the phenomenon of "rebound pain" as a clinically relevant problem in anesthetic practice.

CONTENT

The phenomenon of "rebound pain" has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 to 24hours after surgery and adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies.

CONCLUSION

Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the "rebound pain" phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.

Peripheral nerve block and rebound pain: literature review

Background and objectives

To investigate, describe, and assess the phenomenon of “rebound pain” as a clinically relevant problem in anesthetic practice.

Content

The phenomenon of “rebound pain” has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 and 24 hours after surgery and, adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies.

Conclusion

Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the “rebound pain” phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.

Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review

Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol, cyclo‐oxygenase‐2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre‐operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α‐2‐adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra‐articular injection, and for surgical technique‐linked interventions, such as platelet‐rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non‐steroidal anti‐inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.