Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial

Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy A pathway to reduce opioids

INTRODUCTION

Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL ) may be associated with significant pain. Challenges in pain control may prevent timely discharge (and expose patients to adverse effects of opioid use). We sought to evaluate whether our patients who underwent erector spinae plane (ESP) regional blocks experienced improved postoperative pain control and decreased opioid use after PCNL (compared with those who did not receive blocks).

METHODS

We retrospectively reviewed consecutive PCNL cases on patients admitted for greater than 24 hours without pre-existing opioid regimens for chronic pain. Cases were completed by a single high-volume surgeon. Patients who accepted an ESP block were compared to those who did not receive a block. Patients received either a single injection or a disposable pump delivering intermittent boluses of ropivacaine 0.2%. Demographic and perioperative data were analyzed. The primary outcomes were opioid use measured in morphine milligram equivalent (MME ) and patient-reported pain scores during the first 24 hours of hospitalization.

RESULTS

From March 2019 to August 2021, 44 patients were identified who met criteria - 28 of whom received an ESP block (including 14 continuous blocks). The patients who received blocks had significantly decreased opioid use (18.3 vs. 81.3 MME, p=0.004) and a longer mean time to first non-zero pain score (p=0.004). Continuous blocks had similar opioid use to single shot blocks (21.0 vs. 15.6 MME, p=0.952).

CONCLUSIONS

ESP regional blocks appear to offer an effective adjunct method for pain control after PCNL and may reduce post-PCNL opioid use while maintaining adequate patient analgesia.

Multi-site nerve block catheters for postoperative analgesia in extended scapulectomy and free-flap reconstruction

Scapulectomy is performed as a limb-sparing procedure in the management of tumours of the proximal humerus and shoulder girdle. Analgesic outcomes following this procedure are poorly documented in the literature. In our case, satisfactory analgesia following extended scapulectomy and free-flap reconstruction was achieved with a combination of multi-site continuous nerve block catheters and patient-controlled analgesia, for a patient with chronic pain who had a high pre-operative opioid requirement. Multiple continuous nerve block catheters were used, including interscalene and paravertebral catheters to provide analgesia for the shoulder resection, with a fascia iliaca compartment catheter providing analgesia to free-flap donor site on the the anterolateral thigh. These continuous nerve block catheters contributed to effective postoperative analgesia and low postoperative intravenous opioid requirements in this case.

Is There a Difference between Perineural Dexamethasone with Single-Shot Interscalene Block (SSIB) and Interscalene Indwelling Catheter Analgesia (IICA) for Early Pain after Arthroscopic Rotator Cuff Repair? A Pilot Study

Interscalene block is applied to control acute postoperative pain after arthroscopic rotator cuff repair (ARCR), typically with single-shot interscalene block (SSIB) or continuous interscalene indwelling catheter analgesia (IICA), and dexamethasone (Dex) for extending the analgesic effect. This study investigated whether perineural Dex can extend the postoperative analgesic effect of SSIB to match that of IICA. A total of 130 patients were recruited and divided into two groups (Group D, SSIB with perineural Dex, n = 94; Group C, IICA, n = 36). The surgical and anesthetic processes were identical except for the method of nerve block. Pain was measured by a visual analog scale (VAS) at 6, 12, 24, and 48 h after ARCR. The number of each and the total analgesics used and adverse effects were compared. The duration of ARCR was longer in group D. The VAS score was higher in group C 6 h after ARCR, but there was no difference at other time points. More postoperative analgesics were administered to group C, and there was no difference in the number of adverse effects. In conclusion, combining perineural Dex with SSIB can reduce rebound hyperalgesia after 6 h and extend the duration of the analgesic effect to that of IICA. Therefore, IICA could be substituted with SSIB and Dex between at 6 and 48 h after ARCR.

Early reduction in postoperative pain is associated with improved long-term function after shoulder arthroplasty: a retrospective case series

PURPOSE

Mixed modalities are frequently utilized in total shoulder arthroplasty (TSA) to control pain, improve patient satisfaction, reduce narcotics use and facilitate earlier discharge. We investigate the relationship between early postoperative pain control and long-term functional outcomes after shoulder arthroplasty.

METHODS

A retrospective review identified 294 patients (314 shoulders) who underwent anatomic or reverse TSA and received a continuous cervical paravertebral nerve block perioperatively. Opioid and non-opioid analgesics were also available to the patients in an "as needed" capacity to augment perioperative pain control. In addition to demographic and surgical characteristics, the impact on functional outcomes of relative pain (i.e., a patient's subjective pain relative to the entire cohort), pain gradient (i.e., the slope of a patient's subjective pain), and opioid consumption during the first 24 h postoperatively were assessed. Shoulder function was assessed using validated outcome measures collected at 2 year follow-up. Outcomes were measured using American Shoulder and Elbow Surgeons questionnaire (ASES), Shoulder Pain and Disability Index (SPADI), SPADI-130, Raw and Normalized Constant Score, SST-12 and UCLA score.

RESULTS

Patients younger than 65, females, reverse TSA, revisions, and preoperative opioid users had worse functional outcomes. On univariate analysis, increased pain perioperatively (> 50% percentile relative pain) was associated with decreased function at 2 years when analyzed with all seven outcome scores (P < .001 for all), reaching minimal clinically important difference (MCID) using the Constant Score. On multivariate analysis, increased pain in the first 24 h postoperatively (assessed on a continuous scale) was independently associated with worse ASES, SPADI, and SPADI-130 scores. Intraoperative ketamine administration and opioid consumption in the 24 h postoperative period did not influence long-term shoulder function.

CONCLUSION

Patients reporting reduced pain after TSA demonstrated improved shoulder function with the Constant score at 2 years postoperatively in both univariate and multivariate analysis. Larger-scale investigation may be warranted to see if this is true for other functional outcome measures.

LEVEL OF EVIDENCE

III, treatment study.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery

PURPOSE OF REVIEW

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients.

RECENT FINDINGS

FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.