Local infusion of ropivacaine for pain control after osseous free flaps: Randomized controlled trial

Impact of peripheral nerve blocks on opioid use following flap reconstruction involving the lower extremity: A systematic review and meta-analysis

BACKGROUND

Peripheral nerve blocks (PNBs) are recommended by several multimodal pain regimens, but the evidence supporting their use in lower extremity surgery is limited. This study aimed to evaluate the association between PNBs and opioid use for free flap reconstruction involving the lower extremity.

METHODS

We conducted a systematic review on the use of PNBs in lower extremity surgery, followed by a blind, dual extraction of the study outcomes. Variables of interest included opioid use (intravenous [IV] morphine milligram equivalents [MMEs]), patient-reported pain, length of surgery (hours), and length of stay (days). We then performed meta-analyses using random effects models for mean difference (MD).

RESULTS

We included 11 studies comprising 417 patients for analysis. PNBs were significantly associated with reduced 24-hour (MD=-15.4 IV MMEs, p<0.05) but not total postoperative opioid use (MD=-80.3 IV MMEs, p>0.05). Patients who received PNBs reported significantly less pain at 24 h (standardized MD=-0.72 IV MMEs, p<0.05) but not 48 h (standardized MD=-0.21, p>0.05). Length of stay was 0.6 days shorter for patients who received PNBs (p<0.05), but length of surgery was not significantly different (MD=0.06 h, p>0.05). When considering the data from only randomized controlled trials, total opioid use was significantly reduced for patients who received PNBs (MD=-19.62 IV MMEs, p<0,05), but there was no difference in the length of stay (MD=-0.28 days, p>0.05).

CONCLUSION

Peripheral nerve blocks may offer statistically significant reductions in postoperative opioid use, particularly within the first 24-hours postoperatively, but the clinical significance of this reduction is relatively minor (approximately 4 to 6 oxycodone 5-mg equivalents).

Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic

PURPOSE

Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF.

METHODS

Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated.

RESULTS

Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively.

CONCLUSION

Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.

Effects of popliteal nerve blocks on postoperative pain management in fibula-free flap patients for head and neck cancer reconstruction

Objective

To determine if performing popliteal nerve blocks preoperatively in patients undergoing fibula-free flap surgery for head and neck cancer reconstruction decreases subjective pain scores decreases narcotic usage, and improves mobility in the acute postoperative time period when compared to alternative pain control regimens.

Methods

A retrospective review of the medical records of patients who underwent fibula-free flap reconstruction for head and neck malignancy at SUNY Upstate Medical University during the time period from 2015 to 2022 was performed. Collected data consisted of patient demographics and clinical characteristics, postoperative pain management modalities, reported pain scores, postoperative narcotic usage, length of hospital stay, and days until out of bed without personal assistance.

Results

A total of 40 patients were included in the study. The average reported pain score was reduced in the nerve block group compared to the control group (1.7 vs. 4.0, p-value = .003). Similarly, the average maximum reported pain score was also lower in patients who received a nerve block (3.4 vs. 6.9, p-value = .002). None of the patients who received popliteal nerve blocks required pain control with parenteral narcotics postoperatively, whereas 82.9% of patients without a nerve block did. Patients who received a popliteal nerve block consumed an average of 103.5 MME, whereas those who did not receive a block consumed an average of 523.0 MME. No statistically significant difference was found between the groups regarding time from surgery until transfer without personal assistance or length of hospital stay.

Conclusion

Popliteal nerve blocks can reduce postoperative pain in patients undergoing fibula-free flap reconstruction for head and neck cancer.

Pain management with popliteal block for fibular graft harvesting in head and neck reconstruction; a randomised double-blind placebo-controlled study

BACKGROUND AND OBJECTIVES

Curative treatment for locally advanced head and neck tumours often includes reconstructive surgery using a microvascular free flap. Effective recuperation is essential but may be impeded by postoperative donor site pain. The aim of this study was to evaluate the effects of a continuous popliteal block on postoperative pain after fibular graft harvesting.

MATERIAL AND METHODS

In this randomized double-blind placebo-controlled study adult patients scheduled for reconstructive head and neck surgery with a microvascular free fibular graft received an indwelling popliteal nerve block catheter and were randomized to receive continuous levobupivacaine/ropivacaine or placebo during the first postoperative week. Primary outcome was postoperative extremity pain assessed using the numerated rating scale (NRS). Secondary outcomes included opioid consumption.

RESULTS

In total 24 patients were included. The median (median, IQR [range]) postoperative extremity NRS scores was lower in the local anaesthetic (LA) group (2, 0-3 [0-10]) compared to the placebo group (2, 1-4 [0-10]), p = 0.008. The LA group also experienced fewer episodes of breakthrough pain, defined as NRS ≥ 4 (17% vs 33% of observations), p = 0.009. Furthermore, median (median, IQR [range]) opioid consumption the first postoperative week was lower in the LA group (109 mg, 74-134 [19-611]) compared to the placebo group (202 mg, 135-241 [78-749]), p = 0.010. No complications attributed to the blocks were observed.

CONCLUSION

Continuous popliteal block significantly reduced postoperative extremity pain and opioid consumption in patients undergoing fibular graft harvesting for head and neck reconstructive surgery.