INTRODUCTION:Optimal pain control methods after total shoulder arthroplasty (TSA) achieve reduced opioid consumption, shortened hospital stay, and improved patient satisfaction in addition to adequate analgesia. Interscalene brachial plexus block is the gold standard for TSA, yet it typically does not provide pain relief lasting beyond 24 hours. Liposomal bupivacaine (LB) purportedly provides prolonged analgesia, yet it has been minimally explored for interscalene block, and it is significantly more expensive than standard bupivacaine. METHODS:This is a prospective, 2-arm, double-blinded randomized controlled trial. Subjects presenting for anatomic or reverse TSA were randomized in a 1:1 ratio to receive interscalene brachial plexus block with either LB plus bupivacaine (LBB group) or bupivacaine plus dexamethasone and epinephrine (BDE group). The primary outcome was 120-hour postoperative opioid consumption. Secondary outcomes were pain scores up to 96 hours postoperatively, pain control satisfaction, complications, level of distress from block numbness, and hospital stay. RESULTS:Ninety patients, 45 per group, were included in the intention-to-treat analysis and randomized. Because of withdrawal of consent and loss to follow-up, 40 in each group completed enrollment through postoperative day 60. Total 120-hour postoperative opioid consumption was similar between groups (P = .127), with no differences within 24- or 48-hour time intervals. Postoperative pain scores at 24-48 hours, 48-72 hours, 72-96 hours, and day 60 were significantly lower for the LBB group. DISCUSSION:LB interscalene brachial plexus block before total shoulder arthroplasty did not reduce 120-hour postoperative opioid consumption but significantly reduced postoperative pain between 24 and 96 hours and at postoperative day 60.

INTRODUCTION:Optimal pain management following video-assisted thoracoscopic surgery (VATS) is key to promoting efficient recovery while minimizing the incidence of postoperative complications. Regional anesthesia can help achieve greater pain control, fostering enhanced recovery and increased patient satisfaction, though debate remains over the most effective technique for VATS. This study sought to compare the analgesic efficacy of two continuous regional anesthetic techniques commonly used for VATS, the serratus anterior plane block (SAPB or CSAPB) and the erector spinae plane block (ESPB or CESPB). This study also sought to identify the clinical benefits of regional anesthesia (CSAPB or CESPB) versus no regional anesthesia in the setting of VATS. METHODS:A retrospective study was conducted, including 397 adult patients who underwent VATS and received multimodal analgesia. Postoperative outcomes were compared among patients who received CSAPB versus those who received CESPB; these outcomes were also compared between patients who received either regional anesthesia technique (CSAPB or CESPB, block group) and patients who did not receive regional anesthesia (non-block group). Co-primary outcomes included opioid consumption during hospital admission (presented as morphine milligram equivalents) and pain (minimum, maximum, and average numeric pain scale scores) in the first 72 postoperative hours. Secondary postoperative outcomes included post-anesthesia care unit (PACU) length of stay, time from procedure end to discharge, time to first opioid medication, ambulation distance on day one, medication use, and incidence of surgical or block-related complications. All data were retrospectively obtained from patients' electronic medical records. RESULTS:Comparing regional anesthesia techniques, patients who received CESPB reported lower pain with activity postoperatively than patients who received CSAPB (3.6 vs. 4.2, p=0.009). There were no other significant differences in postoperative outcomes between these groups. Comparing the block and non-block groups, the block group exhibited a higher overall comorbidity burden than the non-block group (p=0.001). Even so, the block group reported less postoperative pain at rest and with activity than the non-block group (mean: 3.6 vs. 4.1, p=0.012; mean 3.8 vs. 4.4, p=0.012). PACU stay and time to discharge were longer in the block group than non-block group (3.3 vs. 2.6 hours, p=0.004 and 3.1 vs. 2.9 days, p=0.012, respectively). However, the block group ambulated a significantly longer distance than the non-block group on the first postoperative day (median: 181.1 m vs. 73.2 m, p<0.001). The block group more often received acetaminophen and/or aspirin and gabapentinoids than the non-block group (94.5% vs. 75.0%, p<0.001 and 84.8% vs. 62.0%, p<0.001, respectively). CONCLUSION:Both CESPB and CSAPB are effective regional anesthesia techniques for VATS postoperative pain management with clear clinical benefits over no regional anesthesia. A direct comparison of the analgesic efficacy of CESPB versus CSAPB indicated that CESPB is more effective than CSAPB in terms of pain control. These findings are consistent with existing literature and most recent practice recommendations.

BACKGROUND CONTEXT:Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery.PURPOSE:Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control.STUDY DESIGN/SETTING:Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital.PATIENT SAMPLE:Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021.OUTCOME MEASURES:Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room.METHODS:Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups.RESULTS:The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups.CONCLUSIONS:The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Editor—The ongoing opioid epidemic has highlighted a need for opioid-sparing methods of analgesia. Liposomal bupivacaine (EXPAREL®; Pacira, Parsippany-Troy Hills, NJ, USA) is presented as a non-opioid anaesthetic that provides postsurgical analgesia whilst reducing opioid consumption. However, empirical evidence supporting superior efficacy of liposomal bupivacaine compared with standard bupivacaine is contradictory, 1 Dinges H. Wiesmann T. Otremba B. et al. The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis. Reg Anesth Pain Med. 2021; 46: 490-498 Crossref PubMed Scopus (17) Google Scholar , 2 Abdallah F.W. Hussain N. Brull R. Analgesic efficacy of liposomal bupivacaine for surgical site infiltration: a single-outcome meta-analysis (the best we could do). Reg Anesth Pain Med. 2021; 46: 291-292 Crossref PubMed Scopus (3) Google Scholar , 3 Ma T.-T. Wang Y.-H. Jiang Y.-F. et al. Liposomal bupivacaine versus traditional bupivacaine for pain control after total hip arthroplasty: a meta-analysis. Medicine (Baltimore). 2017; 96e7190 Google Scholar and Pacira's recent legal proceedings raise concerns of the company's influence on the relevant research. In 2020, Pacira paid $3.5 million to resolve allegations that it paid physicians in the form of research grants to incentivise them to prescribe liposomal bupivacaine, 4 Pacira Biosciences, Inc. v. American Society of Anesthesiologists, Inc. n.j. 2, 21 (United States District Court District of New Jersey 2021). https://dockets.justia.com/docket/new-jersey/njdce/2:2021cv09264/469581. Accessed date: November 21, 2021 Google Scholar and in 2021, the company sued the ASA, its journal Anesthesiology, and several authors and editors for defamation. 5 United States Department of Justice, U.S. Attorney’s Office, District of New Jersey. Pharmaceutical company agrees to pay $3.5 million to resolve allegations of violating false claims act. Available from: https://www.justice.gov/usao-nj/pr/pharmaceutical-company-agrees-pay-35-million-resolve-allegations-violating-false-claims (accessed 2 February 2022). Google Scholar

Study Design: Retrospective. Objective: The purpose of this study was to determine the utility of the erector spinae plane regional anesthesia (ESP) block in reducing opioid medication usage and postanesthesia care unit length of stay (PACU-LOS) for patients undergoing either a posterior or transforaminal lumbar interbody fusions (PLIF/TLIF). Summary of Background Data: Posterior lumbar spine fusion is a common surgical procedure typically associated with significant postoperative pain. Poorly controlled postoperative pain can lead to a number of poor outcomes. Although opioids are a mainstay for pain control, they are associated with adverse effects and a risk of dependence. Therefore, multimodal pain control has become more prevalent in orthopedics and combines traditional opioid and nonopioid pain mediation with general anesthesia protocols and regional nerve blocks. Materials and Methods: A retrospective chart review was conducted for patients undergoing PLIFs or TLIFs between 2019 and 2021. Patients were placed into 2 groups, those receiving an ESP block and those that did not. T tests assuming unequal variances were used to assess differences in pain scores, opioid consumption, and PACU-LOS between groups. Results: The study group demonstrated a 35% reduction in opioid use (P=0.016), a 16% reduction in pain with activity (P=0.042), and a 9.7% reduction in pain at rest (P=0.219) compared with the control group. There were no significant differences in PACU-LOS between groups (P=0.314). Conclusion: The use of an ESP block for patients undergoing PLIFs and TLIFs appears to be a safe and effective means to manage postoperative pain and reduce opioid consumption.