Caldwell George L, Selepec Michael A
Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA.
HSS J. 2020 Dec;16(Suppl 2):349-357. doi: 10.1007/s11420-019-09745-4. Epub 2020 Jan 22.
The use of opioid analgesia is common in both the acute and extended post-operative periods after rotator cuff repair. The current opioid crisis has prompted surgeons to seek alternatives that minimize or even eliminate the need for oral opioids after surgery.
QUESTIONS/PURPOSES: We sought to investigate the effects on post-operative opioid use of a surgeon-administered block of the suprascapular and axillary nerves in arthroscopic rotator cuff repair (ARCR), in particular to quantify outpatient opioid consumption and duration.
In this prospective observational study, all patients undergoing primary ARCR performed under general anesthesia by a single surgeon were studied over a 15-month period. Of 91 ARCRs performed, 87 patients were enrolled and followed prospectively. At the conclusion of the procedure, the surgeon performed "local-regional" nerve blockade with injections to the sensory branches of the suprascapular nerve and the axillary nerve, as well as local infiltration about the shoulder. Use of medications in the post-anesthesia care unit was left up to the anesthesiologist. Patients were prescribed oral opioids (hydrocodone/acetaminophen 5/325 mg) for analgesia after discharge. The quantity and duration of opioid use and pain scores were recorded for 4 months. Statistical analysis was performed to evaluate factors that could account for greater opioid use.
Total opioid consumption ranged from 0 to 30 opioid tablets (average, 4.2 tablets) over the 4-month period. Post-operatively, 91% of patients took between ten or fewer tablets, and 39% took no opioids. The average duration of opioid use was 2.4 days. No patients were taking opioids at the 4- to 6-week or 4-month follow-up visits, none required refills, and none received prescriptions from outside prescribers. No statistically significant differences were seen in opioids taken or duration of use in regard to tear size, sex, body mass index, surgery location, or procedure time. There was a significant inverse correlation between opioid use and age. In addition, the cost of the surgeon-performed procedure was substantially lower than that associated with pre-operative nerve blockade performed by an anesthesiologist. All patients were satisfied with the post-operative pain management protocol. Average reported post-operative pain scores were low and decreased at each visit.
With this local-regional nerve-blocking protocol, opioid use after ARCR was unexpectedly low, and a large proportion of patients recovered without any post-surgical opioids. The correlation seen between opioid use and age may not be clinically significant, given the low use of post-operative opioids overall. These results may be useful in guiding post-operative opioid prescribing after ARCR, as well as in lowering costs associated with ARCR.
阿片类镇痛药在肩袖修复术后的急性期和延长恢复期都很常用。当前的阿片类药物危机促使外科医生寻求替代方案，以尽量减少甚至消除术后口服阿片类药物的需求。
问题/目的：我们试图研究在关节镜下肩袖修复术（ARCR）中，由外科医生实施的肩胛上神经和腋神经阻滞对术后阿片类药物使用的影响，特别是要量化门诊患者阿片类药物的消耗量和使用时长。
在这项前瞻性观察研究中，对在15个月期间由单一外科医生在全身麻醉下进行初次ARCR的所有患者进行了研究。在实施的91例ARCR手术中，87例患者被纳入并进行前瞻性随访。手术结束时，外科医生对肩胛上神经和腋神经的感觉支进行注射，实施“局部区域”神经阻滞，并对肩部进行局部浸润麻醉。麻醉后护理单元的用药由麻醉医生决定。患者出院后被开了口服阿片类药物（氢可酮/对乙酰氨基酚5/325毫克）用于镇痛。记录阿片类药物的使用量、使用时长和疼痛评分，为期4个月。进行统计分析以评估可能导致阿片类药物使用量增加的因素。
在4个月期间，阿片类药物的总消耗量在0至30片之间（平均4.2片）。术后，91%的患者服用了10片或更少的药片，39%的患者未服用阿片类药物。阿片类药物的平均使用时长为2.4天。在4至6周或4个月的随访中，没有患者服用阿片类药物，没有人需要续方，也没有人从外部开方者处获得处方。在撕裂大小、性别、体重指数、手术部位或手术时间方面，阿片类药物的服用量或使用时长没有统计学上的显著差异。阿片类药物的使用与年龄之间存在显著的负相关。此外，由外科医生实施的手术成本大大低于麻醉医生实施的术前神经阻滞的成本。所有患者对术后疼痛管理方案都很满意。报告的术后平均疼痛评分较低，且每次随访时都有所下降。
采用这种局部区域神经阻滞方案后，ARCR术后阿片类药物的使用量出人意料地低，并且很大一部分患者在术后未使用任何阿片类药物的情况下康复。鉴于术后阿片类药物的总体使用量较低，阿片类药物使用与年龄之间的相关性可能在临床上并不显著。这些结果可能有助于指导ARCR术后的阿片类药物处方，以及降低与ARCR相关的成本。
