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Liposomal bupivacaine provided pain relief similar to interscalene nerve block for shoulder arthroplasty
Patients who underwent shoulder arthroplasty and received liposomal bupivacaine experienced overall pain relief similar to that of patients who received interscalene nerve block, according to results. In addition, patients treated with liposomal bupivacaine had no increase in complications or length of stay and had a decrease in narcotic requirements on the day of surgery.
Researchers randomly assigned 57 patients undergoing primary shoulder arthroplasty to receive either intraoperative local infiltration of liposomal bupivacaine or a preoperative interscalene nerve block. Primary outcome was postoperative average daily VAS scores for 4 days, while secondary outcomes included opioid consumption, length of stay and complications.
Results showed a significant increase in pain in the first 8 hours postoperatively among patients who received liposomal bupivacaine. Investigators noted a significant increase in intravenous morphine equivalents at 13 hours to 16 hours in the interscalene nerve block group. However, on the day of surgery and 24 hours postoperatively, the overall average pain score did not significantly differ between the liposomal bupivacaine and interscalene nerve block groups.
In the first 24 hours after surgery, patients in the liposomal bupivacaine group had a significantly decreased opioid requirement. While researchers noted no significant differences in opioid requirements on postoperative day 1 between the two groups, the liposomal bupivacaine group had a trend toward higher narcotic requirements on postoperative day 2. However, on postoperative day 3, both treatment groups had no differences in opioid requirements. – by Casey Tingle
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopPostoperative 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.