Liposomal bupivacaine provided pain relief similar to interscalene nerve block for shoulder arthroplasty

Patrick J. Denard, MD

Postoperative pain control is a component of total shoulder arthroplasty (TSA). It has become increasingly important in with the move toward outpatient TSA. An interscalene nerve block (ISB) has been a common approach for obtaining postoperative pain control but carries the risk, albeit small, of nerve injury and is associated with rebound pain. Liposomal bupivacaine (LB) has recently become available and has the reported advantage of an extended half-life for extended pain relief. Okoroha and colleagues recently published their experience in a randomized controlled trial of ISB vs. local LB in patients undergoing TSA. Patients in the ISB group had better pain control in the first 8 hours following the procedure, but beyond this timepoint there was no difference in pain between the ISB and LB groups. Interestingly, although LB is reported to have an extended effect of up to 72 hours, the patients in the LB group did not have lower pain scores at 1, 2 or 3 days postoperative compared to the ISB group (which presumably wore off by those timepoints). This calls into question the actual duration of LB, but nonetheless demonstrates LB is at least equivalent to ISB for postoperative pain control after the first 8 hours. Opioid use was actually higher in the ISB group due to increased consumption between 13 hours to 16 hours postoperative, presumably due to bounce-back pain when the ISB wore off. The authors concluded LB provides similar pain relief compared to an ISB for TSA. There are several considerations from this well-done study. First, the benefit of an ISB is actually short-lived (first 8 hours to 12 hours), but carries risk, including nerve injury, and is associated with increased cost and time of the procedure. Second, the increased opioid consumption in the ISB group highlights the problem of bounce-back pain that occurs with this procedure. LB appears to be a safe alternative to an ISB for pain management following TSA and LB may be an important part of a multimodal approach as we continue to move toward outpatient TSA while minimizing risk.