Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
J Shoulder Elbow Surg. 2021 Nov;30(11):2638-2647. doi: 10.1016/j.jse.2021.06.008. Epub 2021 Jul 17.
Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use.
A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the I statistic. Treatments were ranked using the P score, and statistical significance was set at P < .05.
The initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P < .001 for 4 and 8 hours) or local ropivacaine injection (P < .001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot interscalene block (ssISB). No differences in opioid use (at P < .05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points < 24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection.
Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot interscalene blocks are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.
全肩关节置换术后（TSA）的疼痛管理具有挑战性。鉴于现有的各种疼痛管理选择，本研究旨在系统地回顾文献，以找到关于肩部置换术后疼痛控制的随机对照试验。我们旨在确定哪些方式最有效地控制术后疼痛并减少术后阿片类药物的使用。
使用 PRISMA（系统评价和荟萃分析的首选报告项目）指南进行系统评价。在 PubMed、Scopus 和 Cochrane 对照试验中心注册库中搜索比较 TSA 后术后疼痛控制干预的 I 级-II 级随机对照试验。疼痛控制措施包括神经阻滞和神经阻滞辅助、局部注射、患者自控镇痛、口服药物和其他方式。主要的 2 个结果指标是术后 0-10 视觉模拟量表上的疼痛水平和阿片类药物的使用。使用 Cochrane 协作的风险偏倚 2（RoB 2）工具分析研究偏倚和方法学质量的风险。使用似然法和随机效应模型对术后时间点的视觉模拟量表疼痛评分和阿片类药物使用进行网络荟萃分析，使用 I 统计量来量化异质性。使用 P 评分对治疗方法进行排名，并将统计学意义设定为 P <.05。
最初的搜索产生了 2391 篇文章（695 篇重复，1696 篇筛选，53 篇进行全文审查）。纳入并分析了 18 篇文章（1358 个肩部；51%女性患者；平均年龄范围为 65-73.7 岁；4 项研究的偏倚风险低，12 项有一定风险，2 项风险高）。术后 4 小时和 8 小时，接受局部包载布比卡因（LB）注射的患者（4 小时和 8 小时时 P <.001）或局部罗哌卡因注射的患者（4 小时时 P <.001，8 小时时 P =.019）与接受连续颈浅丛阻滞（cISB）或单次颈浅丛阻滞（ssISB）的患者相比，疼痛更明显。各治疗方法之间在阿片类药物使用（P <.05）方面没有差异。治疗方法的 P 评分表明，ssISB 在 24 小时内最有利于缓解疼痛，而 24 小时和 48 小时后的疼痛最好通过 cISB 或 ssISB 与局部 LB 注射联合治疗来管理。
颈浅丛阻滞在 TSA 后管理疼痛方面优于单纯局部注射。单次颈浅丛阻滞最适合于减轻术后早期疼痛（< 24 小时），而术后 24-48 小时的疼痛可能通过 cISB 或 ssISB 与局部 LB 注射联合治疗来最佳控制。
