Peripheral nerve blocks compared to other types of pain relief for people having total hip joint replacement surgery

Background

Controlling pain after hip replacement surgery improves comfort and improves participation in rehabilitation. These aspects help people to return home sooner and limit treatment costs.

Peripheral nerve block is a treatment for pain control that involves injecting local anaesthetic around nerves to block or stop the sensation of pain reaching the brain. A neuraxial block is an injection of local anaesthetic in the spine through a needle or catheter (very thin, small tube) to block pain transmission from the spine to the brain.

We evaluated the benefits and harms of nerve blocks compared to no nerve blocks or other forms of pain relief to following hip replacement in adults.

Search dates

We searched to December 2016.

Study characteristics

We included 51 studies (2793 participants) in the review and analysed results from 45 studies (2491 participants). There are 11 ongoing studies and three awaiting classification.

Study funding sources

Funding sources included governments, charities, institutions, industry (in part, n = 1); over half were unspecified (n = 29).

Key results

Compared to systemic analgesia, we found that peripheral nerve blocks reduce pain, reduce the risk of becoming confused (e.g. not knowing the date, time, or location) (for every 12 people treated one fewer will become confused), reduce itching (for every 4 people treated one fewer will develop itch), hospital length of stay (equivalent to 0.75 day) and increase patient satisfaction for pain treatment (equivalent to 2.4 points more on a 0 to 10 scale). We did not find a difference in time to first walk after surgery.

Two people had complications: one local haematoma and one delayed persistent muscle weakness.

Quality of evidence

The quality of evidence for peripheral nerve blocks compared with systemic pain relievers was rated as moderate to very low.

The quality of evidence for peripheral nerve blocks compared to neuraxial blocks was rated as high for patient satisfaction, moderate for reducing itch, similar pain relief, low for similar block-related complications, hospital length of stay and time to first walk. Evidence for confusion was assessed as very low quality.

Evidence quality was downgraded to low or very low due to flawed study designs and limited numbers of trials and participants.

Authors' conclusions: 

Compared to systemic analgesia alone, there is moderate-quality evidence that peripheral nerve blocks reduce postoperative pain, low-quality evidence that patient satisfaction is increased and very low-quality evidence for reductions in acute confusional status, pruritus and hospital length of stay .

We found moderate-quality evidence that peripheral nerve blocks reduce pruritus compared with neuraxial blocks.

The 11 ongoing studies, once completed, and the three studies awaiting classification may alter the conclusions of the review once assessed

Read the full abstract...
Background: 

It is estimated that over 300,000 total hip replacements are performed each year in the USA. For European countries, the number of hip replacement procedures per 100,000 people performed in 2007 varied from less than 50 to over 250. To facilitate postoperative rehabilitation, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia.

Objectives: 

We aimed to compare the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2016), MEDLINE (Ovid SP) (1946 to December Week 49, 2016), Embase (Ovid SP) (1980 to December week 49, 2016), CINAHL (EBSCO host) (1982 to 6 December 2016), ISI Web of Science (1973 to 6 December 2016), Scopus (from inception to December 2016), trials registers, and relevant web sites.

Selection criteria: 

We included all randomized controlled trials (RCTs) performed in adults undergoing elective primary hip replacement and comparing peripheral nerve blocks to any other pain treatment modality. We applied no language or publication status restrictions.

Data collection and analysis: 

Data were extracted independently by two review authors. We contacted study authors.

Main results: 

We included 51 RCTs with 2793 participants; of these 45 RCTs (2491 participants: peripheral nerve block = 1288; comparators = 1203) were included in meta-analyses. There are 11 ongoing studies and three awaiting classification.

Compared to systemic analgesia alone, peripheral nerve blocks reduced: pain at rest on arrival in the postoperative care unit (SMD -1.12, 95% CI -1.67 to -0.56; 9 trials, 429 participants; equivalent to 3.2 on 0 to 10 scale; moderate-quality evidence); risk of acute confusional status: risk ratio (RR) 0.10 95% CI 0.02 to 0.54; 1 trial, 225 participants; number needed to treat for additional benefit (NNTB) 12, 95% CI 11 to 22; very low-quality evidence); pruritus (RR 0.16, 95% CI 0.04 to 0.70; 2 trials, 259 participants for continuous peripheral nerve blocks; NNTB 4 (95% CI 4 to 8); very low-quality evidence); hospital length of stay (SMD -0.75, 95% CI -1.02 to -0.48; very low-quality evidence; 2 trials, 249 participants; equivalent to 0.75 day). Participant satisfaction increased (SMD 0.67, 95% CI 0.45 to 0.89; low-quality evidence; 5 trials, 363 participants; equivalent to 2.4 on 0 to 10 scale). We did not find a difference for the number of participants walking on postoperative day one (very low-quality evidence). Two nerve block-related complications were reported: one local haematoma and one delayed persistent paresis.

Compared to neuraxial blocks, peripheral nerve blocks reduced the risk of pruritus (RR 0.33, 95% CI 0.19 to 0.58; 6 trials, 299 participants; moderate-quality evidence; NNTB 6 (95% CI 5 to 9). We did not find a difference for pain at rest on arrival in the postoperative care unit (moderate-quality evidence); number of nerve block-related complications (low-quality evidence); acute confusional status (very low-quality evidence); hospital length of stay (low quality-evidence); time to first walk (low-quality evidence); or participant satisfaction (high-quality evidence).

We found that peripheral nerve blocks provide better pain control compared to systemic analgesia with no major differences between peripheral nerve blocks and neuraxial blocks. We also found that peripheral nerve blocks may be associated with reduced risk of postoperative acute confusional state and a modest reduction in hospital length of stay that could be meaningful in terms of cost reduction considering the increasing numbers of procedures performed annually.

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