Regional Anesthesia and Acute Pain Management

The number of patients with osteoarthritis of large joints in the Russian Federation may reach 4 million, with the demand for knee arthroplasty estimated at approximately 300,000 procedures annually. Improved osteoarthritis diagnostics, increased life expectancy, and advancements in prosthetic technologies have driven the rise in knee arthroplasties. However, unresolved challenges related to anesthetic management for such surgeries underscore the importance of effective pain management during total knee arthroplasty (TKA) from both scientific and practical perspectives. Anesthetic techniques for TKA have evolved significantly over time. Advances in medical knowledge and technology have led to the development and refinement of various anesthetic approaches aimed at improving patient outcomes. Historically, general and infiltration anesthesia, along with neuraxial blocks, were used. The introduction of ultrasound-guided (US-guided) techniques has expanded the use of peripheral nerve blocks. Current practices include multimodal general anesthesia, spinal anesthesia, and, less commonly, epidural anesthesia. US-guided techniques encompass obturator nerve block, anterior-medial and posterior-lateral capsule blocks, periarticular infiltration, “four-in-one” block, and selective genicular nerve blocks, among others. Future directions in anesthetic management for TKA include evaluating the clinical efficacy of radiofrequency catheter ablation and cryoablation. Additionally, addressing the significant challenge of rebound pain by identifying its causes and developing effective treatment strategies is essential. The global increase in TKA volumes presents a challenge for anesthesiologists and surgeons, emphasizing the need to further advance regional anesthesia techniques to improve recovery quality following surgery.

Background: The annually increasing number of arthroscopic interventions on cruciate ligaments, especially in outpatient settings, necessitates identifying the most rational methods of anesthetic support for such procedures.

Aim: To evaluate spinal anesthesia (SA) as the method of choice for anesthetic support in arthroscopic cruciate ligament reconstruction.

Materials and methods: This single-center prospective cohort study included 52 patients who underwent arthroscopic cruciate ligament reconstruction under SA. Postoperative outcomes were assessed by measuring pain intensity at rest and during movement at 4, 8, 12, 16, 20, and 24 hours postoperatively using the visual analog scale (VAS). The need for opioid analgesics, their total dose, time to the first analgesic request, motor block recovery time (Bromage scale to Bromage-1), and time to first ambulation were recorded. Intraoperative hemodynamic and pulse oximetry parameters, SA performance time, duration of anesthesia and surgery, total dose of non-steroidal anti-inflammatory drugs (NSAIDs) during hospitalization, complications, adverse anesthesia reactions, and hospital stay duration were also evaluated. Additionally, patient satisfaction with anesthesia and postoperative pain management quality was assessed.

Results: Significant differences in pain levels at rest and during mobilization were observed (p <0.001, R=0.8). A total of 82.6% (n=43) of patients required opioid analgesics postoperatively, with 18% (n=8) needing administration twice or more. The frequency of opioid use was directly proportional to pain severity (p <0.001, R=0.7). The first request for analgesics occurred, on average, at 178 minutes, with motor block recovery at 134 minutes. First ambulation was recorded, on average, more than 3 hours after surgery.

Conclusion: Severe postoperative pain, the inability to achieve early mobilization, adverse anesthesia effects, and the transition of arthroscopic procedures to “day surgery” status emphasize the need for alternative anesthesia techniques that overcome SA shortcomings and provide prolonged postoperative pain relief.

Background: Using regional postoperative analgesia in total hip arthroplasty (THA) minimizes pain and opioid consumption while preserving patient mobility. Quadratus lumborum block (QLB) has demonstrated these effects in abdominal surgery; however, its application in trauma and orthopedics remains understudied.

Aim: To evaluate the efficacy and safety of combining lateral and posterior approaches to QLB as a component of multimodal analgesia for postoperative pain management after THA.

Materials and methods: This single-center prospective randomized study included 153 patients aged 48–65 years undergoing THA. Participants were divided into two groups: Group 1 received preoperative QLB, while Group 2 served as the control. All patients underwent spinal anesthesia with intravenous sedation and received analgesia as part of multimodal pain management. Postoperative outcomes on the first day were assessed by measuring pain intensity using the visual analog scale (VAS) at rest and during mobilization, walking distance, opioid consumption, and the incidence of side effects from opioid use.

Results: VAS pain scores at 6, 12, and 24 hours postoperatively were significantly lower in the QLB group compared to the control group (p <0.001). Walking distance also differed: Group 1 patients walked 10 [5; 20] m within the first 12 hours and 40 [30; 50] m within 24 hours, compared to 5 [0; 10] m and 30 [20; 40] m, respectively, in the control group (p <0.017). In Group 1, 28 (50.67%) patients did not require opioids, and 37 (49.33%) needed them only once. In the control group, all patients required opioids, with 38 (50.67%) requesting repeated doses (p <0.001).

Conclusion: This study demonstrated that QLB effectively reduces pain, opioid consumption, and associated complications while increasing mobility, confirming its efficacy and safety as a postoperative analgesic method for THA.

Background: Pterygopalatine block (PPB) is widely indicated in ophthalmology due to its simultaneous impact on sympathetic, parasympathetic, and nociceptive innervation. Ultrasound (US) guidance enhances block accuracy; however, clinical data on the efficacy of US-assisted PPB using different approaches remain limited.

Aim: To compare the efficacy of US-guided PPB using posterior-to-anterior subzygomatic and suprazygomatic approaches in patients undergoing eye enucleation.

Materials and methods: A prospective randomized study was conducted. For postoperative analgesia, PPB was performed in Group 1 (n=30) using the posterior-to-anterior subzygomatic approach and in Group 2 (n=30) using the suprazygomatic approach. The time required to perform the block, onset of analgesia, changes in arterial blood pressure (BP) and heart rate (HR), and technical aspects of block execution were evaluated.

Results: The interval between block administration and the onset of analgesia was significantly shorter in Group 1 (5.3±1.0 minutes) compared to Group 2 (10.1±1.4 minutes, p=0.041). Significant differences were also observed in the time to decreased skin sensitivity in the infraorbital area and time to pain relief: 8.9±0.9 and 13.5±0.7 minutes in Group 1 versus 14.4±1.2 and 19.6±1.7 minutes in Group 2 (p=0.037 and p=0.034, respectively). Mean arterial pressure and HR were lower in Group 1 (91.2±6.5 mmHg and 88.5±5.2 bpm) compared to Group 2 (101.1±6.6 mmHg and 105.3 ± 8.4 bpm, p=0.001). During the suprazygomatic PPB (Group 2), 53.3% (n=16) of patients reported discomfort, with a mean pain score of 2.3±0.5 on the numeric rating scale.

Conclusion: For managing pain after eye enucleation, ultrasound-assisted PPB using the posterior-to-anterior subzygomatic approach is the method of choice. Compared to the suprazygomatic approach, it provides faster onset of effective analgesia, greater patient comfort, and improved safety.

This peer-reviewed monograph is devoted to caudal epidural anesthesia. The book gives the background to the origin of the method, describes the anatomical basis, the technique and the functional effects of the anesthesia. The author presents his own results of using caudal epidural anesthesia in both surgical and therapeutic practice. Complications and failures that may occur during caudal epidural anesthesia are presented. The monograph is of practical interest for postgraduate students and anesthesiologists.