Warrender William J, Syed Usman Ali M, Hammoud Sommer, Emper William, Ciccotti Michael G, Abboud Joseph A, Freedman Kevin B
Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Am J Sports Med. 2017 Jun;45(7):1676-1686. doi: 10.1177/0363546516667906. Epub 2016 Oct 13.
Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction.
This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery.
Systematic review.
We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures.
A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction.
On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.
肩关节镜检查术后有效的疼痛管理是恢复、康复及患者满意度的关键组成部分。
本系统评价全面概述了关于门诊关节镜下肩关节手术术后疼痛管理的一级和二级证据。
系统评价。
我们对文献中报道的门诊肩关节镜检查术后疼痛控制的各种方式进行了系统评价，并分析了其结果。所审查的镇痛方案包括区域神经阻滞/输注、肩峰下/关节内注射或输注、冷冻疗法及口服药物。仅纳入具有一级或二级证据且比较了两种或更多疼痛管理方式或安慰剂的随机对照试验。我们排除了未采用客观测量方法来量化术后第一个月内的疼痛、主观疼痛量表测量或麻醉药物消耗量作为结局指标的研究。
共有40项随机对照试验符合我们的纳入标准。在这40项纳入研究中，15项研究了神经阻滞，4项研究了口服药物方案，12项研究了肩峰下输注，8项比较了多种方式，1项评估了冷冻疗法。发现肌间沟神经阻滞（ISB）是控制肩关节镜检查术后疼痛最有效的方法。增加浓度、持续输注及患者自控方法可更有效地积极控制疼痛。地塞米松、可乐定、滑囊内羟考酮及镁作为辅助药物使用时，均已证明可成功改善ISB的持续时间和充分性。术前口服普瑞巴林和依托考昔有证据支持可减轻术后疼痛并提高患者满意度。
基于本评价中的证据，我们推荐将ISB用作门诊关节镜下肩关节手术最有效的镇痛药。
