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Peripheral nerve blocks: An added value to TJA
Pain-relieving protocol can offer drastic results and is reproducible.
I believe there is added value in using peripheral nerve blocks to achieve pain management after total hip arthroplasty.
I think it is clear to all orthopedic surgeons, that effective pain management improves patients’ satisfaction. It allows us to decrease hospital stays and facilitates discharges to home instead of to assisted-care facilities. Thus the benefit for surgeons is that we get thankful patients who progress faster through all phases of recovery after their total hip or total knee arthroplasty.
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We have to remember that postoperative pain is still a patient’s number one concern after total joint arthroplasty and there is an emerging body of research suggesting that postoperative pain management correlates with the quality of recovery at the long-term for these patients. There have been substantial recent gains in our knowledge on how to deal with pain after surgery. Clearly, we should be multimodal as that will allow us to stay below the threshold for side effects for any one particular treatment option.
We should also be preemptive. If we stay ahead of the pain we will limit the total analgesia requirements for our patients. Finally we should aim to avoid the use of parenteral narcotics whenever possible.
Added value?
The question is: Is there any added value from using peripheral nerve blocks? Why shouldn’t you and I just use the components of the multimodal protocol and combine it with a traditional PCA (patient-controlled analgesia) pump to control breakthrough pain, or use simple injections of local anesthetics around the wound?
If we take pooled data from the literature, using the traditional PCA pump we get visual analog pain scores in the 5 to 6 range routinely in the first 3 days after surgery. If we use multimodal pain approaches in addition to the pain pump, we get a little bit of a benefit, but it is only when we add peripheral nerve blocks that we get the pain under control to the point that pain is virtually nonexistent in the first 3 days.
Peripheral nerve blocks are the subject of growing interest, in part because the introduction of nerve-stimulating catheters allows anesthesiologists to do these techniques more reliably and reproducibly. Peripheral nerve blocks have certain benefits: The contralateral limb is not affected by these blocks, so you can get patients up and out of bed soon after surgery; only local anesthetic is injected so there are no narcotics; and it does not limit your choice of anticoagulation after surgery, even if you combine these with an indwelling nerve catheter.
‘Dramatic results’
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We investigated 100 patients in our practice to address the reliability, the reproducibility, and the safety of peripheral nerve blocks. The reliability was very good compared to the traditional PCA pump. The pain was much better managed with the nerve blocks. Patients had virtually no pain in the first 3 days after surgery. We also found that the nerve blocks were reproducible, with 97 out of 100 consecutive patients able to be treated with the nerve blocks without parenteral narcotics. Our patients were able to get up and out of bed early after surgery. We were actually better in getting patients up and out of bed using these nerve blocks than we were with the traditional PCA pump. Finally, and this is an area of substantial interest to us, the prevalence of certain medical complications actually decreased substantially when we used the nerve blocks, this included urinary retention, ileus, and cognitive disfunction compared to PCA pumps.
I think it is fair to say that the results of these nerve blocks can be dramatic. Patients are alert and oriented early after surgery and most are up out of bed soon after the operation.
However, there are some drawbacks. The techniques require training. There is added time to perform the blocks before the operation and there are rare but disconcerting cases of nerve injury from directly injecting the nerve. Some technological advances, such as ultrasound guided injection techniques, will minimize those complications as we go forward.
Variations in acceptance
As we look at the pain management options as individual surgeons and in individual practices, we need to take advantage of the best pain relief available and couple that with simple and efficient techniques — all while trying to have the fewest side effects. Each of us values those things differently.
We may come to different conclusions about what the most effective strategy for our own practice situation.
At the Mayo Clinic in 2008, a multi-modal analgesia approach that focuses on the use of peripheral nerve blocks is what we do routinely. I would encourage you to optimize the pain management for your patients because you will get thankful patients who then progress faster through all phases of recovery after their hip and knee arthroplasties.
For more information:
- Mark W. Pagnano, MD, can be reached at Mayo Clinic, 200 1st St. SW, Rochester, MN 55905; 507-284-5276; e-mail: pagnano.mark@mayo.edu. He receives royalties through Mayo Clinic Health Solutions for intellectual property licensed to DePuy, a Johnson & Johnson Company and Zimmer, Inc.
Reference:
- Pagnano MW. Optimal method to achieve a painless THA — Affirms. Paper # 103. Presented at Current Concepts in Joint Replacement Spring 2007 Meeting. May 20-23, 2007. Las Vegas.