Pre-operative Nerve Blocks in Orthopedic Multimodal Pain Management

SIMRAN F. SHAMITH, BS

Drexel University College of Medicine

DAVID I. PEDOWITZ, MD

Rothman Orthopaedic Institute at Thomas Jefferson University

SUMMARY POINTS

• Pre-operative nerve blocks are utilized to control orthopedic post-operative pain.

• Longer acting nerve blocks are reducing the need for opioids and other pain medications.

• The data regarding the best anesthetic formulation to use in nerve blocks is inconsistent. 

• New research is focusing on the use of liposomal bupivacaine combined with steroids to create consistent and longer lasting analgesic effects. 

ANALYSIS

Background

Pain following orthopedic procedures has historically been a major contributor to fear and avoidance of surgery (1). Opioids were often a first line option in postoperative pain relief, with little regard to future complications. Through education of the opioid crisis, medical professionals began to realize the need for alternative approaches to pain management. An emerging ideal in pain control has been multimodal pain relief, which utilizes multiple interventions simultaneously to combat pain (3). Multimodal pain relief in orthopedic procedures may involve preoperative medications like acetaminophen or gabapentin, a peripheral nerve block, and postoperative medications such as opioids supplemented with NSAIDs (2). The use of multiple medications is thought to work synergistically to reduce pain and the need for opioids postoperatively (2). 

Preoperative nerve blocks have gained recent attention as a promising method to reduce postoperative pain. Depending on the surgery needed, an anesthesiologist will conduct a nerve block specific to that extremity. The most common nerve block currently being conducted is the interscalene block, which targets the brachial plexus (5). This block can be used to provide shoulder analgesia and is useful in procedures such as shoulder arthroplasty or rotator cuff repair (6). Similarly, an adductor canal nerve block can be used to provide postoperative pain relief in total knee arthroplasty (7). In foot and ankle surgeries, a popliteal and sciatic nerve block may be administered to provide 8-12 hours of pain relief postoperatively (4). 

While hours of pain relief reduced opioid use postoperatively, the time frame of pain relief was increased by utilizing continuous nerve catheters (6,7). These catheters allowed for patients to be discharged earlier from the hospital, but they required immense patient education regarding safety of the system (5). Rather than relying on catheters to cause slow release of the medication, research next focused on extending the length of time of the initial block. However, there is a lack of consensus over the best formulation of medication to use in the blocks (8). As each orthopedic procedure has different levels of intensity and postoperative care, the nerve blocks must also be specific to each procedure. 

Some of the primary reasons for the use of preoperative nerve blocks include decreased pain scores, longer analgesic effect, and reduced use of opioids. In one study, an interscalene nerve block using the anesthetic bupivacaine increased the length of analgesic effect to about 8 hours when compared to local analgesia efforts (9). However, there was not a significant effect on postoperative opioid use and patient reported pain scores (9). To further increase the length of time that the nerve block lasts, liposomal bupivacaine or Exparel, was approved by the U.S. Food and Drug Administration (FDA) in interscalene nerve blocks (10). The medication is encapsulated in a liposomal coating allowing for a slower release of bupivacaine and providing longer term pain relief (10). The use of Exparel in interscalene nerve blocks provided up to 72 hours of pain relief due to the extended release of bupivacaine (6). Exparel has shown promising effects not only in interscalene blocks but has also been used in adductor canal blocks prior to total knee arthroplasty (7). While promising, some studies have shown inconsistent results, demonstrating the need for further research of an ideal formulation to use in nerve blocks. 

Baessler et al. utilized a randomized controlled trial to observe the effects of bupivacaine, liposomal bupivacaine, or liposomal bupivacaine with dexamethasone in a brachial plexus block. They found a prolonged analgesic effect of the block when using the liposomal bupivacaine and a decrease in the number of opioids needed by patients following a total shoulder arthroplasty or rotator cuff repair (8). This confirmed the previously studied benefits of Exparel. The third group of patients with the addition of dexamethasone also increased the length of time that the block lasted, but it was not seen to be clinically significant. However, this synergistic effect of dexamethasone on Exparel warrants further study into its potential utility in nerve blocks (8). 

Discussion

The current complications in the research of the effects of Exparel stem from the lack of consistency across studies. For instance, there are a variety of methods of injection as well as locations of injections that may introduce confounding factors. In addition, the use of various control groups makes it difficult to compare studies to analyze trends in the efficacy of Exparel in its analgesic and opioid sparing effects. This points to the need for further study into Exparel, especially whether dexamethasone has a positive synergistic impact on the length of pain relief. More specifically, very little research has been done in the realm of foot and ankle procedures regarding the use of Exparel or dexamethasone in nerve blocks. Utilizing longer lasting nerve blocks prior to orthopedic foot and ankle procedures may allow for opioid sparing effects and minimal pain following orthopedic surgical procedures. However, future study is needed in this domain to form educated decisions regarding the ideal nerve block formulation. 

REFERENCES:

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