Statistically significant but clinically unimportant: a systematic review and meta-analysis of the analgesic benefits of erector spinae plane block following breast cancer surgery

Efficacy of erector spinae plane block for postoperative pain management: A meta-analysis and trial sequential analysis of randomized controlled trials

BACKGROUND

Postoperative pain remains a major problem across a wide range of surgical procedures. The efficacy and clinical utility of the Erector Spinae Plane Block (ESPB) in reducing postoperative pain remains uncertain.

OBJECTIVE

To evaluate the efficacy and safety of the ESPB compared with placebo or sham block in perioperative pain management.

EVIDENCE REVIEW

We searched PubMed, Embase, Web of Science, Scopus, and Cochrane CENTRAL for randomized controlled trials (RCTs) comparing ESPB to placebo or sham block in surgical patients. Primary outcomes included postoperative pain at 2 h, 6 h, 24 h, and 48 h, intraoperative and cumulative postoperative opioid consumption (24 h), and postoperative nausea and vomiting, pruritus, and block-related adverse events. Subgroup and sensitivity analyses, as well as meta-regressions, were performed to explore sources of heterogeneity. Trial sequential analysis (TSA) was used to assess the quantitative robustness of the available data. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024583633.

FINDINGS

Forty-three RCTs were included, with 1361 patients randomized to the Erector Spinae Plane Block group. ESPB reduced postoperative pain at 2 h (MD -1.46;95 % CI -1.98 to -0.94;p < 0.001;I2 = 91 %), 6 h (MD -1.23;95 % CI -1.64 to -0.83;p < 0.001;I2 = 89 %), 24 h (MD -0.47;95 % CI -0.67 to -0.28;p < 0.001;I2 = 78 %), and 48 h (MD -0.24;95 % CI -0.39 to -0.09;p = 0.002;I2 = 10 %). Also, intraoperative opioid consumption (MD -137.43 μg;95 % CI -208.73 to -66.13;p < 0.001;I2 = 100 %), 24 h cumulative opioid consumption (MD -25.62 mg;95 % CI -31.31 to -19.93;p < 0.001;I2 = 99 %), and incidence of postoperative nausea and vomiting (RR 0.56;95 % CI 0.44 to 0.72;p < 0.001;I2 = 16 %) were significantly lower in patients submitted to ESPB. No significant differences were found in postoperative pruritus (RR 0.62;95 % CI 0.35 to 1.10;p = 0.105;I2 = 27 %). Notably, no block-related adverse events were reported in any study. Certainty of evidence was rated as low to moderate for most outcomes. TSA suggested that no further trials are needed to assess ESPB efficacy in the analyzed outcomes, except for postoperative pruritus.

CONCLUSION

ESPB is a safe and effective regional anesthesia technique that significantly reduces postoperative pain and opioid consumption across various surgical procedures.

The Utility of Erector Spinae Plane Blocks in Breast Surgery: A Practical Review

Background

In plastic surgery, breast surgery patients are among the most susceptible to postoperative pain. Amidst the opioid epidemic, healthcare goals seek to optimize nonopioid multimodal pain control by including regional analgesia. The erector spinae plane block (ESPB) is among several regional blocks used in breast surgery. Although the paravertebral block has previously served as the gold standard, new research focused on ESPB may shift standards.

Methods

A comprehensive PubMed review was performed in September 2023 to identify articles related to ESPB use in breast surgery. Non-English and unavailable articles were excluded. Data extracted included publication year, techniques, and outcomes.

Results

Sixty-eight publications were included, of which 31 were randomized control trials (45.6%). Most were published between 2021 and 2023 (n = 40, 58.8%). Most articles that evaluated pain and opioid use suggested that ESPB performed better than nonblocked groups (n = 26, 38.2% of total articles and n = 4, 5.88% of total articles) and performed similarly to other blocks. However, articles that evaluated the pectoral nerve block suggested it outperformed ESPB in these aspects (n = 6 articles, 8.82%). ESPB was shown to be a safe and procedurally short block to perform, effective in the hands of novice providers.

Conclusions

ESPB offers reliable outcomes, improving pain control and decreasing opioid consumption. In turn, this can decrease healthcare costs and patient morbidity.

Pro's and con's of different blocks for postoperative analgesia after video-assisted thoracic surgery

PURPOSE OF REVIEW

Although there are a lot of studies examining the effects of different blocks for postoperative analgesia after video-assisted thoracic surgery (VATS), the results are controversial.

RECENT FINDINGS

Paravertebral block, serratus anterior plane block and erector spinae plane block appear to be effective and beneficial for post-VATS analgesia, but probably in different manners.

SUMMARY

All three blocks can be suggested for daily practice, the choice should be based on personal experience and preference of the anesthetist. Better studies are required for objective decision.

Impact of Erector Spinae Plane Blocks on Pain Management and Postoperative Outcomes in Patients with Chronic Pain Undergoing Spine Fusion Surgery: A Retrospective Cohort Study

PURPOSE

To evaluate the impact of bilateral ultrasound-guided erector spinae plane blocks (ESPBs) on pain and opioid-related outcomes in a surgical population with chronic pain.

METHODS

A retrospective, observational cohort study. Clinical data were extracted from the electronic medical records of patients who underwent lumbar fusion (February 2018 - July 2020). Eligible patients had a confirmed history/diagnosis of chronic pain starting >3 months before surgery and received either bilateral ESPBs or no ESPBs. Patients were matched on demographic variables (sex, age, race, BMI, ASA Classification, and preoperative opioid use) in a 1:1 ratio. The primary outcome was median opioid consumption (morphine equivalent dose, MED) 24 hours post-surgery (hydromorphone iv-PCA and oral). Secondary outcomes included Numeric Rating Scale (NRS) pain scores, opioid consumption up to 48 hours post-surgery, and hospital length of stay (LOS). Group differences were analyzed using bivariable and multivariable regression.

RESULTS

Of 72 patients, 36 received ultrasound-guided ESPBs and 36 did not. Baseline demographics showed no significant differences. On bivariable analysis, ESPBs were associated with significantly lower 24-hour opioid consumption (79 mg MED vs 116 mg MED, p=0.024) and shorter LOS (82 hours, 95% CI 51-106 vs 126 hours, 95% CI 101-167, p<0.001). No significant differences in NRS pain scores were found up to 48 hours post-surgery. Multivariable analysis confirmed significant reductions in 24-hour opioid consumption (-44, 95% CI -1.06 - -87.55, p=0.044), IV-PCA use (-22, 95% CI -1.59 - -56.77, p=0.038), and LOS (-38, 95% CI -10.074 - -66.22, p=0.008) in the ESPB group without differences in NRS pain scores.

CONCLUSION

ESPBs were associated with statistically and clinically significant reductions in 24-hour opioid consumption and LOS, without differences in NRS pain scores after spinal fusion in a chronic pain surgical cohort. Given these effects, patients with chronic pain may disproportionately benefit from ESPBs for spine surgery.

Comparison of erector spinae plane and transversus abdominis plane block for postoperative analgesia after caesarean delivery under spinal anaesthesia: A randomised controlled trial

BACKGROUND

Truncal blocks contribute to multimodal analgesia that enhances early recovery after caesarean delivery. The transversus abdominis plane (TAP) block is an established technique that offers somatic abdominal wall analgesia. The erector spinae plane (ESP) block is a fascial plane technique that may offer additional visceral analgesic effects. This study hypothesized that ESP block would offer superior analgesic efficacy to TAP block in women undergoing caesarean delivery under spinal anaesthesia.

METHODS

Sixty-six ASA physical status grade 1-3 (≥18 years) patients undergoing elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided TAP (N = 33) or ESP blocks at the T9 vertebral level (N = 35). The primary outcome measure was 24-hour cumulative morphine consumption. The secondary outcomes included time to first analgesic request, duration of block placement, numeric rating scale (NRS) pain scores at rest and movement, effect of pain on activities of daily living (ADLs) and care for the infant, patient analgesic satisfaction, frequency and severity of opioid-related side effects.

RESULTS

There was no statistically significant difference in mean (95% CI) 24-hour cumulative morphine consumption between groups: 32.0 (27.0 to 37.0) mg with TAP versus 27.0 (19.9 to 34.0) mg with ESP (p = 0.16). The mean (SD) duration of block placement was longer for ESP than for TAP blocks (10.7 (2.2) minutes versus 9.0 (2.5) minutes; p = 0.004). There were no significant differences in the other secondary outcomes.

CONCLUSION

This study found similar postoperative opioid use and analgesic efficacy between ESP and TAP block after caesarean delivery performed under spinal anaesthesia.

TRIAL REGISTRATION

South African National Clinical Trial Registry (DOH-27-102022-5278): https://sanctr.samrc.ac.za/TrialDisplay.aspx?TrialID=8100, Pan African Clinical Trials Registry (PACTR202301645957324): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24267.

Comparative efficacy of erector spinae plane and quadratus lumborum blocks in managing postoperative pain for total abdominal hysterectomy: A randomized controlled trial

BACKGROUND

Effective postoperative pain management after total abdominal hysterectomy is crucial for patient recovery and satisfaction. This study compared the efficacy of the erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in reducing postoperative opioid consumption and pain in patients with total abdominal hysterectomy.

METHODS

In this prospective, randomized controlled trial, 90 patients undergoing total abdominal hysterectomy were divided into 3 groups: ESPB, QLB, and control. The primary outcome was postoperative opioid consumption. Secondary outcomes included pain scores assessed by the visual analog scale at predetermined times and the incidence of postoperative nausea and vomiting. Statistical significance was determined using analysis of variance, the Mann-Whitney U test, and the Kruskal-Wallis test.

RESULTS

The ESPB and QLB groups showed a significant reduction in postoperative opioid consumption compared with the control group (P < .001 for both comparisons). Pain scores were significantly lower in the ESPB and QLB groups than in the control group at 2, 6, and 24 hours postoperatively (P < .001 at each time point). The incidence of postoperative nausea and vomiting was lower in the ESPB and QLB groups than that in the control group; however, this difference was not statistically significant (P = .029). No significant differences were observed in opioid consumption or pain scores between the 2 groups.

CONCLUSION

Both the erector spinae plane and quadratus lumborum blocks effectively reduced postoperative opioid consumption and pain in patients with total abdominal hysterectomy. These techniques offer a promising approach for postoperative pain management, potentially reducing the need for opioids.

Comparative efficacy of ultrasound-guided erector spinae plane block versus wound infiltration for postoperative analgesia in instrumented lumbar spinal surgeries

OBJECTIVE

This study compared the efficacy of ultrasound-guided erector spinae plane block (ESPB) and wound infiltration (WI) for postoperative analgesia in patients who underwent lumbar spinal surgery with instrumentation.

METHODS

In this randomized controlled trial, 80 patients were divided into two groups: ESPB (n = 40) and WI (n = 40). Postoperative pain intensity was assessed via the visual analog scale (VAS) at multiple time points within 24 h. Additionally, opioid consumption, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV), and patient satisfaction were evaluated.

RESULTS

Both ESPB and WI provided effective postoperative pain management, with no significant differences in VAS scores. However, the ESPB group demonstrated a significantly longer duration of analgesia, a shorter time to first rescue analgesia, and lower total tramadol consumption (50 ± 60 mg vs. 100 ± 75 mg; p = 0.010) than did the WI group. Furthermore, a trend toward reduced PONV incidence was observed in the ESPB group, likely due to its opioid-sparing effect.

CONCLUSION

While both ESPB and WI provided effective postoperative pain management, ESPB demonstrated a distinct advantage by offering a longer duration of analgesia and significantly reducing opioid consumption. These findings suggest that ESPB is more effective than WI for postoperative analgesia in lumbar spinal surgeries, providing prolonged pain relief and improving patient outcomes. Further studies are warranted to explore its long-term benefits and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.govPRS: NCT06567964 Date: 08/21/2024 Retrospectively registered.

Bilateral erector spinae plane block by multiple injection for pain control in pseudomyxoma peritonei surgery: a single-blind randomized controlled trial

OBJECTIVE

Currently, the primary surgical treatment for pseudomyxoma peritonei (PMP) is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The perioperative period is frequently accompanied by severe pain. Erector spinae plane block (ESPB) can enhance analgesia for abdominal surgery. The purpose of this study was to compare the analgesic effects of bilateral multiple-injection ESPB in patients with PMP.

METHODS

Fifty patients with PMP were randomly divided into two groups: the ESPB combined with general anesthesia group (Group E) and the general anesthesia alone group (Group C). Prior to the induction, patients in Group E underwent ESPB at the T7 and T11 levels. The primary outcome was the visual analog scale (VAS) scores during rest at 6 h post-extubation. Secondary outcomes included intraoperative and postoperative opioid consumption, time for first rescue analgesia, frequency distribution of rescue analgesia, incidence of nausea and vomiting, adverse events associated with ESPB.

RESULTS

The Visual Analogue Scale (VAS) scores in Group E were significantly lower compared to Group C at immediate post-extubation (1.6 ± 0.9 vs. 2.4 ± 1.2, P = 0.008), and at 2 (1.9 ± 1.2 vs. 3.2 ± 1.1, P < 0.001), 4 (2.4 ± 1.5 vs. 3.7 ± 1.0, P = 0.001), and 6 h (2.7 ± 1.1 vs. 3.8 ± 1.4, P = 0.004) post-extubation during rest. Similarly, the VAS scores in Group E were significantly lower than those in Group C at immediate post-extubation (3.0 ± 1.4 vs. 4.6 ± 1.2, P < 0.001), and at 2 (3.8 ± 1.7 vs. 4.9 ± 1.4, P = 0.019), 4 (3.5 ± 1.3 vs. 5.3 ± 1.5, P < 0.001), and 6 h (3.9 ± 1.8 vs. 4.9 ± 1.3, P = 0.004) post-extubation during movement. In Group E, the intraoperative remifentanil administration (2319.3 ± 1089.5 vs. 2984.6 ± 796.1, P = 0.017) and the amount of rescue analgesia within 2 h post-extubation (0 vs. 4, P = 0.037) were significantly less than in Group C, and the first rescue analgesia time was shorter as well (231.4 ± 147.5 vs. 668.8 ± 416.7, P < 0.001).

CONCLUSION

Compared to general anesthesia alone, bilateral multiple-injection ESPB with 0.2% ropivacaine can enhance analgesia and reduce opioid administration in patients with PMP. However, the duration of analgesia with ESPB is relatively short due to the low concentration of the local anesthetic used.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300069504, 20/03/2023.

Differential nerve blockade to explain anterior thoracic analgesia without sensory blockade after an erector spinae plane block may be wishful thinking

Ultrasound-guided erector spinae plane block (ESPB) is currently used as a component of multimodal analgesic regimen in a multitude of indications but the mechanism by which it produces anterior thoracic analgesia remains a subject of controversy. This is primarily the result of ESPB's failure to consistently produce cutaneous sensory blockade (to pinprick and cold sensation) over the anterior hemithorax. Nevertheless, ESPB appears to provide 'clinically meaningful analgesia' in various clinical settings. Lately, it has been proposed that the discrepancy between clinical analgesia and cutaneous sensory blockade could be the result of differential nerve blockade at the level of the dorsal root ganglion. In particular, it is claimed that at a low concentration of local anesthetic, the C nerve fibers would be preferentially blocked than the Aδ nerve fibers. However, the proposal that isolated C fiber mediated analgesia with preserved Aδ fiber mediated cold and pinprick sensation after an ESPB is unlikely, has never been demonstrated and, thus, without sufficient evidence, cannot be attributed to the presumed analgesic effects of an ESPB.

Systematic reviews and meta-analyses in regional anesthesia and pain medicine (Part I): guidelines for preparing the review protocol

Comprehensive resources exist on how to plan a systematic review and meta-analysis. The objective of this article is to provide guidance to authors preparing their systematic review protocol in the fields of regional anesthesia and pain medicine. The focus is on systematic reviews of healthcare interventions, with or without an aggregate data meta-analysis. We describe and discuss elements of the systematic review methodology that review authors should prespecify, plan, and document in their protocol before commencing the review. Importantly, authors should explain their rationale for planning their systematic review and describe the PICO framework-participants (P), interventions (I),comparators (C), outcomes (O)-and related elements central to constructing their clinical question, framing an informative review title, determining the scope of the review, designing the search strategy, specifying the eligibility criteria, and identifying potential sources of heterogeneity. We highlight the importance of authors defining and prioritizing the primary outcome, defining eligibility criteria for selecting studies, and documenting sources of information and search strategies. The review protocol should also document methods used to evaluate risk of bias, quality (certainty) of the evidence, and heterogeneity of results. Furthermore, the authors should describe their plans for managing key data elements, the statistical construct used to estimate the intervention effect, methods of evidence synthesis and meta-analysis, and conditions when meta-analysis may not be possible, including the provision of practical solutions. Authors should provide enough detail in their protocol so that the readers could conduct the study themselves.

Systematic reviews and meta-analyses in regional anesthesia and pain medicine (Part II): guidelines for performing the systematic review

In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia.

Effects of transcutaneous electrical acupoint stimulation on early postoperative pain and recovery: a comprehensive systematic review and meta-analysis of randomized controlled trials

Background

Previous studies have indicated beneficial outcomes of transcutaneous electrical acupoint stimulation (TEAS), but high-quality and comprehensive meta-analyses are lacking. The aim was to quantitatively analyze the efficacy and safety of perioperative TEAS on postoperative pain and recovery.

Methods

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched through July 2022. Randomized controlled trials (RCTs) that examined the perioperative application of TEAS in adults compared with sham-TEAS and/or non-TEAS were eligible. Cumulative analgesic consumption within 24 h and rest pain scores at 2, 6, 12, and 24 h postoperatively were the two co-primary outcomes.

Results

Seventy-six RCTs (n = 9,665 patients) were included. Patients treated with TEAS experienced a reduction in clinical importance in cumulative analgesic (morphine equivalent) consumption (WMD: -14.60 mg, 97.5% CI: -23.60 to -5.60; p < 0.001) and a reduction in statistical importance in rest pain scores at multiple time points within the first 24 postoperative hours. The secondary outcome analysis also identified clinically significant recovery benefits to TEAS during the first 24 h after surgery. Furthermore, TEAS could effectively reduce opioid-related side effects and did not increase serious side effects.

Conclusion

This article describes current evidence about TEAS intervention on early postoperative pain and recovery. The results support the effectiveness of TEAS, but more high-quality evidence of clinical applicability is also needed.

Systematic review registration

PROSPERO (CRD42021249814).

Effects of erector spinae plane block on opioid consumption in patients undergoing hand-assisted laparoscopic donor nephrectomy: a randomized controlled trial

BACKGROUND

The erector spinae plane block is a relatively new regional anesthesia technique that is expected to provide some benefits for postoperative analgesia. This study investigated the effects of erector spinae plane block on postoperative opioid consumption in kidney donors undergoing hand-assisted laparoscopic donor nephrectomy for renal transplantation.

METHODS

Fifty-two donors scheduled for elective hand-assisted laparoscopic donor nephrectomy were randomly divided into the block (25 donors) and control (27 donors) groups. Donors in the block group received 30 mL of 0.25% bupivacaine under ultrasound guidance, whereas the control group received no block treatment. The primary outcome measure was the amount of fentanyl administered via patient-controlled analgesia at 24 h. Secondary outcomes included the duration of stay, opioid consumption in the post-anesthesia care unit, and pain scores during the recording hours.

RESULTS

No significant differences were observed between the groups regarding total opioid consumption converted to intravenous morphine equivalent administered via patient-controlled analgesia (33.3±21.4 mg vs. 37.5±18.5 mg; P=0.27) and in the postanesthesia care unit (1.5±0.9 mg vs. 1.4±0.8 mg; P=0.55). The duration of stay in the postanesthesia care unit (86.3±32.6 min vs. 85.7±33.6 min; P=0.87) was similar between the groups. There was no significant difference between the groups in the postoperative donor-reported NRS pain scores (P>0.05 for all the time points).

CONCLUSIONS

Preoperative erector spinae plane block is not an effective strategy for reducing postoperative pain or opioid consumption in patients undergoing hand-assisted laparoscopic donor nephrectomy. Different block combinations are needed for optimal pain management in hand-assisted laparoscopic donor nephrectomy.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Pain management for hospitalized patients with rib fractures: A systematic review of randomized clinical trials

STUDY OBJECTIVE

Rib fractures (RF) are common injuries. Multiple analgesia strategies are available for treatment of pain associated with RF. However, the optimal multimodal technique for pain management is not known. The primary aim of this review was to evaluate the status of evidence derived from randomized clinical trials (RCTs) on the effectiveness of pain management modalities for rib fracture pain. Other patient-centered outcomes were secondary objectives.

METHODS

Searches were conducted in MEDLINE, Embase, Scopus, and Cochrane Library. The screening process involved two phases, two researchers independently screened the title and abstract and subsequently screened full text. RCT data were extracted independently by two research team members. Consensus was achieved by comparison and discussion when needed. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 tool.

RESULTS

A total of 1344 citations were identified. Title and abstract screening excluded 1128 citations, and full text review excluded 177 articles. A total of 32 RCTs were included in the full review. Multiple analgesia techniques and medications were identified and their effect on pain score and need for rescue opioid analgesia. None of the included studies were judged to have a high risk of bias, while only 10 studies were assessed as having a low risk of bias.

CONCLUSIONS

This systematic review found that studies are of low quality with diverse methodologies and outcomes. A reduction in pain scores was found for epidural analgesia when compared with other modalities. However, the low quality of the evidence necessitates cautious interpretation of this finding. PROSPERO registration: CRD42022376298 (Nov, 16, 2022).

Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part II): Guidelines for Performing the Systematic Review

In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia .

Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part I): Guidelines for Preparing the Review Protocol

Comprehensive resources exist on how to plan a systematic review and meta-analysis. The objective of this article is to provide guidance to authors preparing their systematic review protocol in the fields of regional anesthesia and pain medicine. The focus is on systematic reviews of health care interventions, with or without an aggregate data meta-analysis. We describe and discuss elements of the systematic review methodology that review authors should prespecify, plan, and document in their protocol before commencing the review. Importantly, authors should explain their rationale for planning their systematic review and describe the PICO framework-participants (P), interventions (I), comparators (C), outcomes (O)-and related elements central to constructing their clinical question, framing an informative review title, determining the scope of the review, designing the search strategy, specifying the eligibility criteria, and identifying potential sources of heterogeneity. We highlight the importance of authors defining and prioritizing the primary outcome, defining eligibility criteria for selecting studies, and documenting sources of information and search strategies. The review protocol should also document methods used to evaluate risk of bias, quality (certainty) of the evidence, and heterogeneity of results. Furthermore, the authors should describe their plans for managing key data elements, the statistical construct used to estimate the intervention effect, methods of evidence synthesis and meta-analysis, and conditions when meta-analysis may not be possible, including the provision of practical solutions. Authors should provide enough detail in their protocol so that the readers could conduct the study themselves.

Analgesic efficacy and safety of erector spinae versus serratus anterior plane block in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) are regional anesthesia techniques that have shown favorable results in pain management following thoracic surgeries; however, their relative superiority is unclear. This review (PROSPERO: CRD42023443018) aims to compare the analgesic efficacy of ESPB and SAPB in patients undergoing thoracic surgeries through the pooled analysis of co-primary outcomes: postoperative oral-morphine-equivalent (mg) consumption in 24 h and pain scores (static) at 24 h.

METHODS

A literature search was conducted across PubMed, Cochrane Library, and Google Scholar to identify randomized controlled trials (RCTs) from inception to May 2023, comparing ESPB and SAPB in thoracic surgeries. Statistical pooling was done using Review Manager 5.4.1. Bias assessment employed the Cochrane Collaboration Risk-of-Bias 2.0 tool. The strength of evidence was assessed using the guidelines from the GRADE working group.

RESULTS

Nine RCTs (485 patients) were included in the study. Postoperative pain scores (static) at 24 h (mean difference (MD) =  - 0.31 [- 0.57, 0.05], p = 0.02) and postoperative oral-morphine-equivalent (mg) consumption in 24 h (MD =  - 19.73 [- 25.65, - 13.80], p < 0.00001) were significantly lower in the ESBP group. However, the MDs did not exceed the set threshold for clinical importance. No significant differences were observed in the opioid-related adverse effects and block-related complications.

CONCLUSION

Our statistically significant results imply that ESPB has superior analgesic efficacy compared to SAPB; however, this difference is clinically unimportant. The safety profile of the two blocks is comparable; hence, current evidence cannot define the relative superiority of one block over the other. Our findings warrant further research with standardized methodologies and a longer duration of analgesic efficacy assessment to yield robust evidence for better clinical applications.

Regional anaesthesia training in the UK - a national survey

Background

Adequate training of anaesthetists in regional anaesthesia is important to ensure optimal patient access to regional anaesthesia.

Methods

We undertook a national survey of UK trainee anaesthetists and Royal College of Anaesthetists (RCoA) tutors to assess experiences of training in regional anaesthesia. We performed descriptive statistics for baseline characteristics, and logistic regression of training indices and tutor confidence that their hospital could provide regional anaesthesia training at all three stages of the RCoA 2021 curriculum.

Results

A total of 492 trainees (19.2%) and 114 tutors (45.2%) completed the survey. Trainees were less likely to have received training in chest/abdominal wall compared with upper/lower limb blocks {erector spinae vs femoral block (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.16-0.39), P<0.001}, or achieved >20 chest/abdominal wall blocks by Stage 3 of training (chest vs lower limb block [OR 0.09, 95% CI 0.05-0.15, P<0.001]. There was a strong association between training received, number of blocks performed (>20 vs 0-5 blocks), and self-reported ability to perform blocks independently, OR 20.9 (95% CI 9.38-53.2). 24/182 (13%) and 10/182 (5.5%) of trainees had performed ≥50 non-obstetric lumbar and thoracic epidurals, respectively, by Stage 3 training. There was a positive association between having a lead clinician for regional anaesthesia, particularly those with paid sessions, and reported confidence to provide regional anaesthesia training at all stages of the curriculum (Stage 3 OR 7.27 [95% CI 2.64-22.0]).

Conclusion

Our results confirm the importance of clinical experience and access to training in regional anaesthesia, and support the introduction of departmental regional anaesthesia leads to improve equity and quality in training opportunities.

The Use of Erector Spinae Plane Block Reduces Opioid Consumption and Pain Score in Postoperative Period After Hip Surgery: A Meta-Analysis

Erector spinae plane block (ESPB) is a relatively new regional anesthesia block that has been used in thoracic and abdominal surgeries with variable success. ESPB can easily be administered using an ultrasound technique with a safer profile. Recently, there have been few randomized controlled trials (RCTs) regarding the role of ESPB in hip surgeries. A current meta-analysis was done to evaluate the role of ESPB block in controlling postoperative pain after hip surgeries. PRISMA guidelines were followed to perform this meta-analysis. We used online databases including Science Direct, PubMed, Google Scholar, and Cochrane Library. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database as ID-CRD42023445516 in July 2023. We included studies that reported opioid use, pain control after surgery, and side effects associated with ESPB for hip surgeries. The ReviewManager software, i.e., RevMan for Mac 5.4 (Cochrane Collaboration, Oxford, UK), was utilized to conduct this meta-analysis. We included five RCTs during this meta-analysis. Our results demonstrated that the use of ESPB in hip surgery caused a significant decrease in 24-hour postoperative opioid consumption (p=0.02). ESPB also resulted in a significant decrease in pain scores up to nine hours postoperatively (p<0.05).

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis.

MATERIALS AND METHODS

The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective.

RESULTS

The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6).

CONCLUSIONS

TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

Analgesic Efficacy of Quadratus Lumborum Block in Patients Undergoing Nephrectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the analgesic efficacy of quadratus lumborum block (QLB) in adults undergoing nephrectomy.

DESIGN

Systematic review and meta-analysis.

PATIENTS

Adult patients (≥18 years of age) received nephrectomy under general anesthesia.

METHODS

We searched PubMed, Embase, the Cochrane Library, and Web of Science on January 10, 2022, including randomized controlled trials that evaluated the analgesic efficacy of QLB for patients undergoing nephrectomy.

RESULTS

A total of 12 randomized controlled trials (N = 821 patients) were included in the study. Compared with the non-block, single-shot QLB reduced postoperative opioid consumption (mean difference [MD], -8.37 mg intravenous morphine equivalent; 95% confidence interval [CI], -12.19 to -4.54 mg) and pain scores at 2 hours, 6 hours, 12 hours, and 24 hours at rest and during movement after nephrectomy. Single-shot QLB also prolonged the time to first analgesic request (MD, 6.44 hours; 95% CI, 2.23 to 10.65 hours), shortened the length of hospital stay (MD, -0.32 day; 95% CI, -0.55 to -0.09 day), and decreased the incidence of postoperative nausea and vomiting (risk ratio, 0.48; 95% CI, 0.36 to 0.65). Compared with continuous epidural anesthesia, repeated QLB could provide comparable postoperative analgesic benefits.

CONCLUSIONS

Single-shot QLB provided a statistically significant but clinically small improvement in postoperative analgesia and recovery for patients undergoing nephrectomy. The QLB would be beneficial as part of multimodal analgesia. Future research might need to determine which approach of QLB is superior for postoperative analgesia after nephrectomy.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial

BACKGROUND

Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery.

MATERIALS AND METHODS

Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications.

RESULTS

The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction.

CONCLUSION

In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone.

TRIAL REGISTRATION NUMBER

NCT03621345 LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study

INTRODUCTION

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia.

MATERIAL AND METHODS

A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII).

RESULTS

Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar.

CONCLUSION

This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Efficacy and safety of erector spinae plane block for postoperative analgesia in breast cancer surgery-A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

We aim to evaluate the analgesic efficacy and safety of erector spinae plane block (ESPB) for postoperative analgesia in breast cancer surgeries.

METHODS

PubMed, Web of Science, CBM, Embase, Cochrane, Wanfang, VIPP, and CNKI were searched to identify published eligible randomized controlled trials. The primary results were the postoperative 24 h morphine consumption and pain scores, while the secondary outcomes included pain scores at other times, press times of patient-controlled intravenous analgesia (PCIA), times to request for first rescue analgesia, the incidence of request for rescue analgesia, opioid-related complications, nerve blocks related complications and patient satisfaction.

RESULTS

We included 20 studies meeting the inclusion criteria, which involved 1293 participants. The morphine consumption and the pain scores during 24 h postoperatively were significantly decreased in the ESPB group versus the control group (p < 0.00001). Furthermore, ESPB also reduced pain scores at other time points, press times of PCIA, and times to first rescue analgesia requirement. Meanwhile, there was a lower incidence of postoperative nausea and vomiting, and skin pruritus in the ESPB group than in the control group.

CONCLUSIONS

Compared to general anesthesia alone, ESPB combined with general anesthesia can effectively reduce the postoperative pain intensity within 48 h and opioid consumption within 24 h after breast cancer surgery, and reduce the incidence of opioid and nerve blocks related complications.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Efficacy and Safety of Methylprednisolone for Lung Surgery: a Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The administration of methylprednisolone (MP) is a component of perioperative multimodal analgesia that mitigates the potentially deleterious effects of postoperative pain and opioid consumption. However, a systematic evaluation of the efficacy and safety of MP is lacking. The present systematic review and meta-analysis was performed to quantify the potential clinical benefits and risks of perioperative MP in lung surgery.

METHODS

We searched seven electronic databases for randomized controlled trials (RCTs) comparing MP with placebo. Coprimary outcomes were rest pain scores, dynamic pain scores, and cumulative morphine equivalent consumption within 24 h postoperatively.

RESULTS

A total of 11 trials including 643 participants were selected for our meta-analysis. The results demonstrated that the MP group had a significant difference in coprimary outcomes (rest pain scores, dynamic pain scores, and cumulative morphine equivalent consumption) compared with the placebo group; nevertheless, the improvement was not clinically meaningful based on minimum clinically important differences (MCID). Notably, MP administration reduced serum levels of interleukin (IL)-6 at 6 h (weighted mean difference -20.49 pg/mL; 95% CI -29.94 to -11.04), and decreased the incidence rate of acute lung injury (rate ratio 0.18; 95% CI 0.03-0.98) and cognitive dysfunction (rate ratio 0.43; 95% CI 0.21-0.88) compared with the placebo group.

CONCLUSIONS

Our findings suggest that the administration of MP contributed to an insignificant relief in acute postoperative pain for lung surgery in a clinical setting. Future studies should focus on exploring the role of MP in reducing pulmonary and surgical-related complications after lung surgery.

CLINICAL TRIAL NUMBER

PROSPERO registration number CRD42022314224.

A Meta-Analysis Showing the Quantitative Evidence Base of Preemptive Pregabalin for Postoperative Pain from Cancer-Related Surgery

Background and Objectives: As an adjunct to postoperative multimodal analgesic regimens, pregabalin has been reported in reducing postoperative acute pain and opioid consumption. However, there is only a small amount of evidence for preemptive pregabalin in patients undergoing cancer-related surgery. This systematic review was conducted to integrate high-quality evidence to evaluate the preemptive analgesic effects of pregabalin in cancer-related surgery. Materials and Methods: Seven electronic databases were searched in a combination of subject terms and free words. Efficacy and safety of preemptive pregabalin on postoperative pain for cancer-related surgery were evaluated by assessing resting and dynamic pain scores postoperatively, cumulative morphine equivalent consumption, time to first analgesic request, hemodynamic parameters, and the safety indicators. Results: Thirteen trials were incorporated for quantitative synthesis. The pooled results showed administration of pregabalin preoperatively is clinically significant for improving resting (weighted mean difference (WMD), -1.53 cm; 95% CI, -2.30 to -0.77) and dynamic (WMD, -1.16 cm; 95% CI, -2.22 to -0.11) pain severity scores at 2 h postoperatively and prolonging time to first analgesic request (WMD, 2.28 h; 95% CI, 0.79 to 3.77) in cancer-related surgery. Preemptive pregabalin was also statistically effective in some other pain indicators but would increase the risk of pregabalin-related side effects after surgery. Conclusions: Our findings do not support the administration of pregabalin in doses larger than 300 mg when put in cancer-related surgery. Taken together, more high-quality research particularly focused on the optimal dosages and timing of pregabalin in cancer-related surgery is needed in the future to establish stronger evidence for therapeutic effects.

Dexamethasone Does Not Provide Additional Clinical Analgesia Effect to Local Wound Infiltration: A Comprehensive Systematic Review and Meta-Analysis

Objective: Although the use of dexamethasone as an adjunct agent is associated with alleviating pain and prolonging analgesic duration in local wound infiltration (LWI), efficacy and safety of dexamethasone infiltration have not been fully explored. The study sought to quantify the pooled effects of dexamethasone infiltration on postoperative pain, analgesic consumption, and side effects through a review of randomized controlled trials (RCTs). Approach: RCTs comparing dexamethasone + LWI with LWI alone were retrieved from seven electronic databases. Co-primary outcomes were rest pain scores and cumulative morphine equivalent consumption within 24 h postoperatively. The study followed PRISMA, AMSTAR, and the Cochrane Collaboration. Results: Eight trials comprising 609 patients were included in the final analysis. Results indicated that dexamethasone infiltration effects were only statistical but not clinically significant at individual time points of rest pain and patient satisfaction scores. Notably, the effect of dexamethasone infiltration therapy on other pain-related parameters, including cumulative morphine consumption (mean difference, -9.05 mg; 95% CI: -22.47 to 4.37), was not significantly different compared with the control group. Analysis showed no significant differences in safety indicators between the two groups. The overall quality of evidence was high to very low. Innovation: Although statistically significant effects of dexamethasone infiltration were observed for some outcomes of postoperative wound pain, the overall benefits were below the expected minimal clinically important difference. Conclusions: In summary, the current evidence does not support routine clinical use of dexamethasone in LWI. However, further studies should explore the clinical value of preemptive analgesia and safety of a combination of dexamethasone with ropivacaine for LWI.

Erector spinae plane block versus thoracic paravertebral block for the prevention of acute postsurgical pain in breast cancer surgery: A prospective observational study compared with a propensity score-matched historical cohort

BACKGROUND

Preventing acute postsurgical pain (PSP) following breast cancer surgery is a major issue. Thoracic paravertebral block (TPVB) has been widely studied for this indication. Erector spinae plane block (ESPB) has been assumed to be effective. We aimed to compare the efficacy and safety of ESPB over TPVB in preventing acute PSP.

METHODS

In this prospective observational study, 120 patients admitted for unilateral major oncologic breast surgery received T2/T3 ESPB (ropivacaine 0.75%, 0.35 ml.kg-1), and 102 were analysed. Then, the ESPB cohort was compared to a TPVB cohort from the experimental arm of a randomized controlled study with the same protocol (NCT02408393) using propensity score matching analysis. The primary outcome was the need for morphine consumption in the PACU. Secondary outcomes were the morphine total dose, the incidence of ESPB and TPVB complications, and discontinuous visual analogue scale measurement trends at rest and at mobilization in the 24 hours after surgery.

RESULTS

A total of 102 patients completed the study between December 2018 and August 2019. Propensity score matching formed 94 matched pairs. The proportion of morphine titration in the PACU was higher in the ESPB group than in the TPVB group (74.5% vs. 41.5%, p<0.001), with a between-group difference of 33.0% (95% CI [19.3%, 46.7%]). No ESPB-related complications were observed.

CONCLUSION

ESPB is less effective in preventing morphine consumption in the PACU than TPVB. Our findings do not support the use of ESPB as the first-line regional anaesthesia for major breast cancer surgery. Randomized trials comparing ESPB and TPVB are needed.

Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis

BACKGROUND

The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.

METHODS

This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.

RESULTS

The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).

CONCLUSIONS

In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.

TRIAL REGISTRATION

PROSPERO; CRD42022315497.

The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials

Liposomal bupivacaine (LB) has consistently been considered a potential analgesic for surgical wound infiltration. However, the evidence of its analgesic effectiveness remains unclear. In this meta-analysis, we attempted to identify the potential clinical role of LB wound infiltration in different surgical procedures. Randomised controlled trials (RCTs) comparing LB with non-liposomal local anaesthetics and placebos were retrieved from six electronic databases. The primary outcome was cumulative morphine equivalent consumption within 24, 48, and 72 hours after surgery. Approximately 2659 patients from 22 studies were included in the meta-analysis. Compared to the control, LB-wound infiltration did not reduce the postoperative morphine consumption at 24 hours (weighted mean difference [WMD], -0.60 mg; 97.5% confidence interval [CI], -2.78 to 1.59 mg; P = 0.54), 48 hours (WMD, -1.00 mg; 97.5% CI, -3.23 to 1.24; P = 0.32) or 72 hours (WMD, 0.50 mg; 97.5% CI, -0.67 to 1.67; P = 0.33). Similarly, secondary outcome analysis did not reveal any additional benefits of LB in any other pain-related outcomes. LB was not associated with any adverse effects. Overall, LB does not appear to improve the postoperative analgesic, rehabilitation, or safety outcomes. Current evidence does not support the routine use of LB for wound infiltration following surgical procedures.

Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery: A systematic review and meta-analysis of randomized trials

Objectives

Erector spinae plane block (ESPB) has been used for many thoracic and abdominal surgeries. However, evidence of its analgesic efficacy following abdominal surgery, compared with that of thoracic analgesia, is insufficient. Our study explored the analgesic effect of ESPB after abdominal surgery.

Methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Primary outcomes were pain scores at 6, 12 and 24 h and 24-h opioid consumption. Secondary outcomes included time to first rescue analgesia, length of hospital stay, and incidence of postoperative nausea and vomiting (PONV). We calculated standardized mean differences (SMDs) with 95% confidence intervals (CIs) for primary outcomes and mean differences (MDs) and risk ratios (RRs) with 95% CIs for secondary outcomes.

Results

We systematically included 1,502 cases in 24 trials. Compared with placebo, ESPB significantly reduced pain scores at 6 h (SMD -1.25; 95% CI -1.79 to -0.71), 12 h (SMD -0.85; 95% CI -1.33 to -0.37) and 24 h (SMD -0.84; 95% CI -1.30 to -0.37) and 24-h opioid consumption (SMD -0.62; 95% CI -1.19 to -0.06) post-surgery. ESPB prolonged the time to first rescue analgesia and decreased the incidence of PONV. Compared with transversus abdominal plane block (TAPB), ESPB significantly reduced pain scores at 6, 12, and 24 h and 24-h opioid consumption and prolonged the time to first rescue analgesia postsurgically. Furthermore, subgroup analysis showed that ESPB significantly reduced pain scores at various time points and opioid consumption within 24 h after laparoscopic cholecystectomy, percutaneous nephrolithotomy and bariatric surgery.

Conclusion

Compared with placebo, ESPB improves the postoperative analgesic efficacy after abdominal surgery. Furthermore, our meta-analysis confirmed that ESPB provides more beneficial analgesic efficacy than TAPB.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPEROFILES/301491_STRATEGY_20220104.pdf], identifier [CRD42022301491].

Efficacy and Safety of Lidocaine Patch in the Management of Acute Postoperative Wound Pain: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study sought to quantify the pooled effects of lidocaine patch (LP) on postoperative pain and side-effects through a comprehensive review and meta-analysis.

APPROACH

The study followed PRISMA, AMSTAR and the Cochrane Collaboration. Randomized controlled trials s comparing LP with placebo were retrieved from five electronic databases. Primary outcome in the study was cumulative intravenous morphine equivalent consumption (mg) within 24 hours postoperatively.

RESULTS

Twelve trials comprising 617 patients were included in the final analysis. Primary result indicated that the analgesic effects LP were only statistical but not clinically significant of postoperative intravenous morphine consumption within 24 hours (mean difference, -4.61 mg; 95% CI, -8.09, -1.14). Interestingly, the results of subgroup and meta-regression analysis indicated that preoperative administration of LP had potential advantages in postoperative wound pain management. It is also worthwhile to mention that LP provided a clinically important benefit in rest pain scores within 24-hour postoperatively. Apart from these, other secondary outcome analysis did not uncover any particularly significant analgesic or safety advantages to LP. Finally, LP also does not increase the risk of any local anesthetic-related side effects.

INNOVATION

This systematic review and meta-analysis provides moderate-to-high quality evidence undermining the role of LP for management of acute postoperative wound pain following surgical procedures and the justification for the associated extra costs.

CONCLUSION

Taken together, the current evidence does not support LP as part of a routine multimodal analgesia strategy to alleviate early postoperative acute pain. However, further studies should explore the clinical value of preoperative administration and the long-term effect of LP.

A comparison of regional anesthesia techniques in patients undergoing video-assisted thoracic surgery: A network meta-analysis

BACKGROUND

Postoperative pain control remains challenging in patients undergoing video-assisted thoracoscopic surgery (VATS). This study aimed to investigate the relative efficacy of different regional anesthesia interventions for VATS using a Network Meta analysis (NMA).

METHODS

A literature search was conducted for NMA using Pubmed, The Cochrane Library, Embase, and the Web of Science databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of different regional analgesia techniques from inception to February 2022. The primary outcome was opioid consumption during the first 24 h postoperatively. The secondary outcomes were morphine consumption at 48 h postoperatively, pain intensity, postoperative nausea and vomiting, and hospital length of stay. Pain scores at two different intervals from different regional analgesia techniques were measured and investigated in this NMA.

RESULTS

A total of 38 RCTs (2224 patients) were included. Two studies compared three arm interventions of intercostal nerve block (ICNB) vs. thoracic paravertebral block (TPVB) vs. erector spinae plane block (ESPB) in intravenous morphine consumption at 24 h and 48 h postoperatively, and showed patients who received TPVB had less demand for morphine than ICNB and ESPB (P = 0.001, P = 0.001). For resting pain scores at 24 h postoperatively, ESPB was superior to serratus anterior plane block (SAPB) (P = 0.01), and TPVB provided effective analgesia compared to ICNB, retrolaminar block (RLB), and ESPB (P = 0.05, P = 0.01, P = 0.03). Similarly, pain scores at rest at 48 h, SAPB and TPVB showed the best results (P = 0.04, P = 0.001, P = 0.01) compared with local infiltration analgesia (LIA), ICNB, RLB, and ESPB. Additionally, pain scores at coughing at 24 h and 48 h, TPVB showed superior results compared with RLB,ESPB(P = 0.02, P = 0.02, P = 0.03). SAPB was superior to LIA in reducing the incidence of postoperative nausea and vomiting (P = 0.04).

CONCLUSION

In regional anaesthesia, TPVB is a better option than other analgesic methods, and its combination with other methods can be beneficial. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Regional analgesia techniques for video-assisted thoracic surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). This study aimed to determine the relative efficacy of regional analgesic interventions for VATS using a network meta-analysis (NMA).

METHODS

We searched the Medline, EMBASE, Cochrane Controlled Trial Register, Web of Science, and Google Scholar databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of the following interventions: control, thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus plane block (SPB), and intercostal nerve block (INB). The primary outcome was opioid consumption during the first 24-h postoperative period. Pain scores were also collected during three different postoperative periods: the early (0-6 h), middle (6-18 h), and late (18-24 h) periods.

RESULTS

A total of 21 RCTs (1391 patients) were included. TPVB showed the greatest effect on opioid consumption compared with the control (mean difference [MD] = -13.2 mg; 95% CI [-16.2, -10.1]). In terms of pain scores in the early period, ESPB had the greatest effect compared to control (MD = -1.6; 95% CI [-2.3, -0.9]). In the middle and late periods, pain scores showed that TPVB, ESPB and INB had superior analgesic effects compared to controls, while SPB did not.

CONCLUSIONS

TPVB had the best analgesic efficacy following VATS, though the analgesic efficacy of ESPBs was comparable. However, further studies are needed to determine the optimal regional analgesia technique to improve postoperative pain control following VATS.

Use of ultrasound guided single shot costotransverse block (intertransverse process) in breast cancer surgery: a prospective, randomized, assessor blinded, controlled clinical trial

BACKGROUND

Ultrasound guided costotransverse block (CTB) is a relatively new "peri-paravertebral" block that has been described recently. It has been previously reported that CTB, administered with a single high-volume injection, provides effective analgesia in breast conserving surgery. In this study we evaluated the effect of CTB when used in breast cancer surgery.

METHODS

Seventy patients due to undergo breast cancer surgery were included in this blinded, prospective, randomized, efficiency study. Patients were randomized into two equal groups (CTB group and control group) using the closed envelope technique. All patients underwent general anesthesia. In addition to standard analgesia methods, patients in group CTB also received CTB block while the remaining (control group) did not. Numeric rating (pain) scores and opioid consumption was compared between the two groups.

RESULTS

Opioid consumption in all time frames and pain scores at 1st and 3rd hours only were found to be significantly lower in Group CTB when compared to the control group.

CONCLUSIONS

Ultrasound guided CTB improves analgesia quality in breast cancer surgery.

TRIAL REGISTRATION

Clinicaltrials Registration ID: NCT04197206 , Registration Date: 13/12/2019.

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Erector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.

DESIGN

A meta-analysis of randomized controlled trials.

SETTING

Perioperative setting.

PATIENTS

Patients undergoing lumbar spine surgery under general anesthesia.

INTERVENTIONS

We searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.

MEASUREMENTS

The primary outcome was opioid consumption in the first 24 h after surgery.

MAIN RESULTS

Twelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = -14.55; 95% confidence interval (CI), -21.03 to -8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0-10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = -1.24 days; 95% CI, -2.31 to -0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.

CONCLUSIONS

ESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required. PROSPERO registration number: CRD42021233362.

Impact of ultrasound-guided erector spinae plane block on outcomes after lumbar spinal fusion: a retrospective propensity score matched study of 242 patients

BACKGROUND

We evaluated the impact of bilateral ultrasound-guided erector spinae plane blocks on pain and opioid-related outcomes within a standardized care pathway for lumbar fusion.

METHODS

A retrospective propensity score matched cohort study. Clinical data were extracted from the electronic medical records of patients who underwent lumbar fusion (January 2019-July 2020). Propensity score matching based on common confounders was used to match patients who received or did not receive blocks in a 1:1 ratio. Primary outcomes were Numeric Rating Scale pain scores (0-10) and opioid consumption (morphine equivalent dose) in the first 24 hours after surgery (median (IQR)). Secondary outcomes included length of stay and opioid-related side effects.

RESULTS

Of 1846 patients identified, 242 were matched and analyzed. Total 24-hour opioid consumption was significantly lower in the erector spinae plane block group (30 mg (0, 144); without-blocks: 45 mg (0, 225); p=0.03). There were no significant differences in pain scores in the postanesthesia care unit (with blocks: 4 (0, 9); without blocks: 4 (0,8); p=0.984) or on the nursing floor (with blocks: 4 (0,8); without blocks: 4 (0,8); p=0.134). Total length of stay was 5 hours shorter in the block group (76 hours (21, 411); without blocks: 81 (25, 268); p=0.001). Fewer patients who received blocks required postoperative antiemetic administration (with blocks: n=77 (64%); without blocks: n=97 (80%); p=0.006).

CONCLUSIONS

Erector spinae plane blocks were associated with clinically irrelevant reductions in 24-hour opioid consumption and no improvement in pain scores after lumbar fusion. The routine use of these blocks in the setting of a comprehensive care pathway for lumbar fusion may not be warranted.