Opioid-sparing analgesic effects of peripheral nerve blocks in percutaneous nephrolithotomy: a systematic review

Paravertebral versus Pectoralis-II (Interpectoral and Pectoserratus) Nerve Blocks for Postoperative Analgesia after Nonmastectomy Breast Surgery: A Randomized, Controlled, Observer-masked Noninferiority Trial

BACKGROUND

Pectoralis-II and paravertebral nerve blocks are both used to treat pain after breast surgery. Most previous studies involving mastectomy identified little difference of significance between the two approaches. Whether this is also accurate for nonmastectomy procedures remains unknown.

METHODS

Participants undergoing uni- or bilateral nonmastectomy breast surgery anticipated to have at least moderate postoperative pain were randomized to a pectoralis-II or paravertebral block (90 mg ropivacaine per side for both). Surgeons and recovery room staff were masked to treatment group assignment, and participants were not informed of their treatment group. Injectate for pectoralis-II blocks was ropivacaine 0.3% (30 ml) per side. Injectate for paravertebral blocks was ropivacaine 0.5% (9 ml in each of two levels) per side. This study hypothesized that pectoralis-II blocks would have noninferior analgesia (numeric rating scale) and noninferior cumulative opioid consumption within the operating and recovery rooms combined (dual primary outcomes). The study was adequately powered with n = 100, but the target enrollment was raised to n = 150 to account for higher-than-anticipated variability.

RESULTS

The trial was ended prematurely with 119 (79%) of the original target of 150 participants enrolled due to (masked) surgeon preference. Within the recovery room, pain scores were higher in participants with pectoralis-II (n = 60) than paravertebral blocks (n = 59): median [interquartile range], 3.3 [2.3, 4.8] versus 1.3 [0, 3.6] (95% CI, 0.5 to 2.6; P < 0.001). Similarly, intravenous morphine equivalents were higher in the pectoralis-II group: 17.5 [12.5, 21.9] versus 10.0 mg [10, 20] (95% CI, 0.1 to 7.5; P = 0.004). No block-related adverse events were identified in either group.

CONCLUSIONS

After nonmastectomy breast surgery, two-level paravertebral blocks provided superior analgesia and opioid sparing compared with pectoralis-II blocks. This is a contrary finding to the majority of studies in patients having mastectomy, in which little significant difference was identified between the two types of blocks.

EDITOR’S PERSPECTIVE

The effect of erector spinae plane block on postoperative pain and quality of recovery in patients undergoing percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PNL) is the preferred surgical procedure for treating renal stones larger than 2 cm. Patients may experience significant pain in the postoperative period due to factors such as the catheter entry site and tension in the renal capsule. Erector Spinae Plane (ESP) block provides perioperative muscle relaxation and reduces analgesic use. In this study, we investigated the effect of ESP block on postoperative pain scale and quality of recovery in patients undergoing PNL. The study was conducted with a total of 96 patients, with 45 patients receiving the ESP block and 51 patients not receiving the ESP block. Following the surgery, the visual pain scale (VAS) was completed at 0, 2, 6, 12, and 24 h, and the Quality of Recovery-15 (QoR-15) scale along with the willingness scale were completed at the 24-hour mark. The normal distribution of data was evaluated with the Kolmogorov-Smirnov test, histogram, and skewness-kurtosis coefficients. For comparing paired groups, the Student's T-test was used for normally distributed variables, while the Mann-Whitney U test was used for parameters that did not have a normal distribution. The comparison of postoperative pain, as measured by VAS scores between the groups, revealed statistically significantly lower scores in the ESP block group at 0, 2, 6, 12, and 24 h (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.010, respectively). Our study results indicated that patients who received the ESP block experienced reduced pain levels and had higher QoR-15 scores compared to those who did not receive the ESP block.

Nonopioid Pain Management Pathways for Stone Disease

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Comparison of the effects of spinal anesthesia, paracervical block and general anesthesia on pain, nausea and vomiting, and analgesic requirements in diagnostic hysteroscopy: A non-randomized clinical trial

Background

The aim of this study was to compare the effect of spinal anesthesia (SPA), paracervical block (PB), and general anesthesia (GA), on pain, the frequency of nausea and vomiting and analgesic requirements in diagnostic hysteroscopy.

Methods

This single-center, non-randomized, parallel-group, clinical trial was conducted on 66 diagnostic hysteroscopy candidates who were selected by convenience sampling at Fatemieh Hospital, in Hamadan, Iran, in 2021.

Results

The mean pain score during recovery and the need for analgesic injections was found to be significantly higher in the GA group compared to that in the SPA group (pain: 3.77 ± 2.25 vs. 0.10 ± 0.30, P < 0.001), (analgesic: 50 vs. 0%, P < 0.001) and PB group (pain: 3.77 ± 2.25 vs. 0.90 ± 1.37, P < 0.001), (analgesic 50 vs. 10%, P < 0.001), respectively. However, no statistically significant difference was observed between the mean pain score between SPA and PB groups (0.10 ± 0.30 vs. 0.90 ± 1.3, P = 0.661). In addition, there were no significant differences between groups on nausea/vomiting after operation (P = 0.382). In adjusted regression analysis (adjusting for age, weight, gravid, abortion, and cause of hysteroscopy), the odds ratio (OR) of pain score during recovery was increased in PB (OR: 4.471, 95% CI: 1.527-6.156, P = 0.018) and GA (OR: 8.406, 95% CI: 2.421-9.195, P = 0.001) groups compared with the SPA group. However, in adjusting based on times of surgery duration, anesthesia duration, recovery and return of motor function, the ORs of pain score between groups was not statistically significant.

Conclusion

Despite reduced pain during recovery in patients receiving SPA, duration of anesthesia, recovery period, and return of motor function were significantly prolonged compared to those receiving PB or GA. It seems that PB with less recovery time and faster return of motor function than SPA and also mild pain during recovery compared to GA can be a good option for hysteroscopy.

Clinical trial registration

http://www.irct.ir, identifier IRCT20120915010841N26.