Efficacy of Lumbar Erector Spinae Plane Block for Postoperative Analgesia in Hip Arthroplasty Patients– A Prospective Case Series

Vol 3 | Issue 2 | July-December 2022 | Page 98-101 | Bharati A. Adhye, Sandeep M. Diwan, Rajeev Joshi, Parag K. Sancheti

DOI: 10.13107/ijra.2022.v03i02.062

Authors: Bharati A. Adhye [1], Sandeep M. Diwan [1], Rajeev Joshi [1], Parag K. Sancheti [2]

[1] Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Bharati A. Adhye,
Chief Anaesthesiologist, Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
E-mail: bharatiadhye@gmail.com


The Thoracic Erector spinae plane block (ESPB) has been incorporated in multimodal analgesia protocols since 2016. In a series of 20 Total Hip Arthroplasty (THA) patients, done under spinal anaesthesia, we studied the efficacy of Lumbar Erector spinae plane block (L-ESPB) for post operative analgesia. L-ESPB was administered at L4 with Ropivacaine 0.2% (0.4 mg/kg). Time to first analgesia (TTFA) request (mean 15.03 hours) and total opioid consumption in first 24 hours (mean 27.5 mg Tramadol) was noted. A median NRS at TTFA was 3.5. Our study demonstrates L-ESPB as an effective alternate technique for postoperative analgesia in THA patients.
Keywords: Lumber ESP block, Hip Arthroplasty


1. Singh R, Bajaj JK, Singh D. Comparison of psoas compartment block and epidural block for postoperative analgesia in hip surgeries. Astrocyte 2018;4(4):221.
2. Capdevila X, Macaire P, Dadure C, Choquet O, Biboulet P, Ryckwaert Y, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002;94(6):1606-1613.
3. Grant CR, Checketts MR. Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia. Contin Educ Anaesthesia, Crit Care Pain. 2008;8(2):56-61.
4. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627.
5. Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 2019;53:29-34.
6. Chin KJ, Adhikary S Das, Forero M. Erector spinae plane (ESP) block: A new paradigm in regional anesthesia and analgesia. Curr Anesthesiol Rep. 2019;9(3):271-280.
7. Tulgar S, Ermis MN, Ozer Z. Combination of lumbar erector spinae plane block and transmuscular quadratus lumborum block for surgical anaesthesia in hemiarthroplasty for femoral neck fracture. Indian J Anaesth. 2018;62(10):802.
8. Tulgar S, Senturk O. Ultrasound guided Erector Spinae Plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. J Clin Anesth. 2017;44:68.
9. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med. 2020;52(1):16.
10. Tulgar S, Aydin ME, Ahiskalioglu A, De Cassai A, Gurkan Y. Anesthetic techniques: focus on lumbar erector spinae plane block. Local Reg Anesth. 2020;13:121.
11. González SJDL, Pomés J, Prats-Galino A, Gracia J, Martínez-Camacho A, SalaBlanch X. Estudio anatómico de la distribución del volumen administrado tras bloqueo en el plano profundo del erector espinal a nivel lumbar. Rev Esp Anestesiol Reanim. 2019;66(8):409-416.
12. R. Shane T, Matthew R, Levin B.S., Marios Loukas, Eric A. Potts, Aaron A. Cohen-Gadol. Anatomy and landmarks for the superior and middle cluneal nerves: application to posterior iliac crest harvest and entrapment syndromes. J. Neurosurg: Spine/ Volume13/ September 2010
13. Diwan S, Nair A. Lumbar erector spinae plane block obtunding knee and ankle reflexes. Saudi J Anaesth. 2021;15(2):222.

How to Cite this Article: Adhye BA, Diwan SM, Joshi R, Sancheti PK | Efficacy of Lumbar Erector Spinae Plane Block for Postoperative Analgesia in Hip Arthroplasty Patients– A Prospective Case Series | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 98-101.

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Ischiorectal Abscess Under Bilateral Pudendal Nerve Block for Perioperative Analgesia in a Patient with Severe Ischaemic Heart Disease- A Case Report

Vol 3 | Issue 2 | July-December 2022 | Page 102-104 | Kartik Sonawane, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.063

Authors: Nitin Gawai [1], Sandeep Diwan [1], Abhishek Lonikar [1], Ganesh Bhong [1], Parag Sancheti [2]

[1] Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Nitin Gawai,
Department of Anesthesiology, Sancheti Hospital, Pune, Maharashtra, India
E-mail: drnitingawai@yahoo.com


Anorectal abscess, an infection in the anal area is a potentially debilitating and painful condition requiring urgent drainage to prevent septicemia. Commonly performed under neuraxial anaesthesia, we report surgical drainage of bilateral ischiorectal abscess under bilateral pudendal nerve blocks and general anaesthesia in a patient with severe ischaemic heart disease. Through our case we add to the existing literature, the importance of administrating peripheral nerve block in highly co-morbid patients.
Keywords: Anorectal abscess, Bilateral pudendal block, Severe ischaemic heart disease.


1. Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011;54(12):1465-74. https://doi.org/10.1097/DCR.0b013e31823122b3 [ Links ]
2. Chahal HS, Garg K, Bose A, Kaur S. Anorectal Surgeries under Local Anaesthesia: A Single Center Experience. MGM J Med Sci 2017;4(2):75-7
3. Hedge J, Balajibabu PR, Sivaraman T. The patient with ischaemic heart disease undergoing non cardiac surgery. Indian J Anaesth. 2017;61(9):705-711. doi:10.4103/ija.IJA_384_17.
4. Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer T, Rauck R, Huntoon MA. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anaesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018 Apr;43(3):225-262. doi: 10.1097/AAP.0000000000000700. PMID: 29278603.
5. Gruber H, Kovacs P, Piegger J, Brenner E. New, simple, ultrasound-guided infiltration of the pudendal nerve: topographic basics. Dis Colon Rectum. 2001;44:1376–1380.
6. Bellingham GA, Bhatia A, Chan CW, Peng PW. Randomized controlled trial comparing pudendal nerve block under ultrasound and fluoroscopic guidance. Reg Anesth Pain Med. 2012;37:262–266.

How to Cite this Article: Gawai N, Diwan S, Lonikar A, Bhong G, Sancheti P | Ischiorectal Abscess Under Bilateral Pudendal Nerve Block for Perioperative Analgesia in a Patient with Severe Ischaemic Heart Disease- A Case Report | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 102-104.

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Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

Vol 3 | Issue 2 | July-December 2022 | Page 105-106 | Pratibha Jain, A. Sashank, Divyanand Mishra

DOI: 10.13107/ijra.2022.v03i02.064

Authors: Pratibha Jain [1], A. Sashank [1], Divyanand Mishra [1]

[1] Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Address of Correspondence
Dr. Divyanand Mishra,
Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.
E-mail: itsdnmishra09@gmail.com

Letter to Editor

Dear Editor,
Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air.
For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital.
Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4]
Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.


1. Uysal I, Sekar M, Karabulut AK, Buyukmumcu M, Ziylan T. Brachial plexus variations in human foetuses. Neurosurgery 2003;53(3):676-684.
2. Gadsden JC, Tsai T, Iwata T, Somsundarum L, Robards C, Hadzic A. Low interscalene block provides reliable anesthesia for surgery at or about the elbow. Journal of Clinical Anesth 2009;21:98-102.
3. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006;15:686-90.
4. Brown AR, Parker GC. The use of a reverse axis (axillary interscalene) block in a patient presenting with fractures of the left shoulder and elbow. Anesth Analg 2001;93:1618-20.

How to Cite this Article: Jain P, Sashank A, Mishra D | Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 105-106.

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Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

Vol 3 | Issue 2 | July-December 2022 | Page 107-109 | Chetana V Bhalerao, Tuhin Mistry, Stephan Jebaraj, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.065

Authors: Chetana V Bhalerao [1], Tuhin Mistry [1], Stephan Jebaraj [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Tuhin Mistry,
Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.
E-mail: tm.tuhin87@gmail.com

Letter to Editor

Dear Editor,
Clavipectoral fascial plane block (CFPB) is an attractive alternative to traditional regional anaesthesia (RA) techniques for clavicle surgery. It was reported to provide motor-sparing, diaphragm-sparing stand-alone surgical anaesthesia, or perioperative analgesia [1]. We want to highlight the application of CFPB as the sole RA technique in a polytrauma patient with brachial plexus injury for surgical management of clavicle fracture. Consent was obtained for the publication of this letter.
A 30-year-old American Society of Anesthesiologist physical grade I male (weight 75 kg, height 170 cm) patient was admitted with an alleged history of a fall from a two-wheeler. He had displaced comminuted right clavicle fracture (Allman type I) (Figure 1a), displaced fracture of right transverse processes of C6-T1, and right brachial plexus injury. He had undergone emergency left fronto-temporo-parietal craniotomy and evacuation of an acute subdural hematoma under general anaesthesia. The patient was transferred to the intensive care unit following surgery and weaned off from ventilatory support after three days. A Follow-up computed tomography (CT) scan revealed a significant reduction of cerebral edema and a thin rim of residual left frontal, bilateral tentorial, and interhemispheric subdural hematoma. Magnetic resonance imaging of the right brachial plexus revealed C5-C8 complete nerve root avulsion with hematoma and soft tissue edema in the adjacent area. After ten days of craniotomy, the patient was scheduled for right clavicle open reduction and internal fixation with plating (Figure 1b). The plan was to provide motor-sparing, phrenic nerve-sparing surgical anaesthesia without brachial plexus block (BPB). The anaesthesia plan was explained to the patient and relatives, and informed written high-risk consent was obtained.
Standard monitors were attached inside the operating room, and an infusion of ringer lactate was started. Oxygen supplementation using a Hudson mask at 5 L/min flow was provided. The patient was placed supine with the head turned towards the contralateral side. Ultrasound-guided modified right CFPB was performed as described by Sonawane et al.[2] A high-frequency linear probe (Sonosite HFL 38xp/13–6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) was placed on the skin over the anterior surface of the clavicle. The local anesthetic (LA) was deposited on the medial (10 ml) and lateral (10 ml) third of the clavicle between the clavipectoral fascia and periosteal collar using an in-plane technique (Figure 1c,d). In addition, the probe was kept over the fracture site, and LA (5 ml) was deposited around it under vision. Also, the skin over the incision site was covered by an additional subcutaneous infiltration (5 ml). The total volume of the LA was 30 ml (1:1 of 0.25% Bupivacaine and 1% Lignocaine-adrenaline, 8 mg Dexamethasone). The patient’s vitals remained stable, and the procedure was completed without complications.
Clavicle innervation is complex and controversial. The pain-generating elements in clavicle surgeries include the skin and the richly innervated periosteum. The brachial plexus roots involved in complete innervation (dermatome, myotome, and osteotome) of the clavicle are C3-C7. Proximal BPB has been a standard practice for anaesthesia or analgesia for clavicle fracture surgeries. Hemidiaphragmatic paresis due to blockade of the phrenic nerve can be detrimental in polytrauma patients with lung injury or pneumothorax. Recently, the C5 ventral ramus block and selective supraclavicular nerve and upper trunk (SCUT block) with a low volume of LA have been described as site-specific and phrenic-sparing RA techniques for clavicle surgeries [3, 4]. However, BPB is contraindicated in patients with ipsilateral brachial plexus injury. Bhat et al. reported an incident of apnoea and cardiac arrest following paraesthesia-guided subclavian perivascular BPB in a polytrauma patient with undiagnosed brachial plexus injury [5]. The spread of injected LA to the subarachnoid space through the dural tear around the ruptured nerve roots resulted in total spinal anaesthesia and cardio-respiratory arrest. A CT myelogram after the resuscitation revealed a traumatic meningocele of the C8 nerve root. We avoided BPB in our patient, considering such dreaded consequences.
In 2017, Dr. Luis Valdes described CFPB as an RA technique for clavicle surgeries targeting the sensory nerves that traverse the clavipectoral fascia [1]. CFPB creates a field block by depositing the LA at the medial and lateral third of the clavicle between the clavipectoral fascia and the periosteum of the clavicle involving all the nerves piercing the fascia to enter the clavicle. Rosale et al. managed a case where CFPB with intravenous Dexmedetomidine sedation provided intraoperative surgical anaesthesia and postoperative analgesia up to 16 hours after the block [6]. However, the skin incision may not be covered with the CFPB alone. So, an additional supraclavicular nerve block, cervical plexus block, or skin infiltration is required. The spread of LA in CFPB depends on the integrity of the clavipectoral fascia, which is lost in displaced or comminuted fractures due to a breach in the continuity of the fascia around the fractured site. Hence, an additional injection or hematoma block at the fracture site may improve the quality of the RA. We opted for the modified CFPB, which covered all the innervations and provided optimal surgical anaesthesia or analgesia.
To conclude, the modified CFPB can be a better alternative to general anaesthesia or other available RA techniques in providing incision congruent surgical anaesthesia or postoperative analgesia for awake clavicle fracture surgery, especially in polytrauma patients with brachial plexus injury. However, randomized controlled trials are warranted for further validation.


1. Sonawane K, Dixit H, Balavenkatasubramanian J, Gurumoorthi P. Uncovering secrets of the beauty bone: a comprehensive review of anatomy and regional anaesthesia techniques of clavicle surgeries. Open J Orthop Rheumatol. 2021(6):19-29.
2. Sonawane K, Dharmapuri S, Saxena S, et al. Awake Single-Stage Bilateral Clavicle Surgeries Under Bilateral Clavipectoral Fascial Plane Blocks: A Case Report and Review of Literature. Cureus 13(12): e20537.
3. Diwan S, Feigl G, Nair A. C5 ventral ramus block for clavicle surgery: How low concerning the volume can we go? J Anaesthesiol Clin Pharmacol. 2021 Oct-Dec;37(4):561-564.
4. Sivashanmugam T, Areti A, Selvum E, Diwan S, Pandian A. Selective blockade of supraclavicular nerves and upper trunk of brachial plexus “The SCUT block” towards a site-specific regional anaesthesia strategy for clavicle surgeries – A descriptive study. Indian J Anaesth. 2021;65(9):656–61.
5. Bhat VR, Kumar M, Sabapathy SR. Cardiac Arrest Following Brachial Plexus Block in a Patient with Missed Brachial Plexus Injury. Ind. J. Trauma. Anaesth. Crit. Care. 2003; 4(1): 177-178.
6. Rosales AL, Aypa NS. Clavipectoral plane block as a sole anesthetics technique for clavicle surgery – A case report. Anesth Pain Med. 2022;17(1):93-97.

How to Cite this Article: Bhalerao CV, Mistry T, Jebaraj S, Balavenkatasubramanian J | Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 107-109.

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Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review

Vol 3 | Issue 2 | July-December 2022 | Page 42-48 | Prasanna Khare, Rijuta Kashyapi, Manjiri Ranade

DOI: 10.13107/ijra.2022.v03i02.055

Authors: Prasanna Khare [1], Rijuta Kashyapi [1], Manjiri Ranade [1]

[1] Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.

Address of Correspondence
Dr. Manjiri Ranade
Department of Anaesthesiology, Deenanath Mangeshkar Hospital & Research Centre, Pune, Maharashtra, India.
E-mail: manjirir47@gmail.com


Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Interscalene brachial plexus block, which is administered either as since injection (ssISB) or with continuous catheter (ccISB) technique, is the gold standard. Ultrasonography (USG) guidance facilitates a faster, more accurate block with a lower local anaesthetic volume in ssISB. USG also helps for accurate catheter placement in ccISB. Hemi-diaphragmatic palsy is a common complication of ISB. This can be a major concern for patients with a respiratory compromise so it necessitates the administration of diaphragm-sparing nerve blocks. Phrenic nerve sparing block like suprascapular nerve block (SSNB) singly or along with axillary nerve block, subomohyoid anterior suprascapular block, superior trunk block, erector spinae plane block, individually, provide perioperative analgesia non-inferior to ISB. Subacromial or intraarticular infiltration of local anaesthesia (SAIA) is not recommended due to its limited clinical efficacy. Extended analgesic effects have been observed with liposomal bupivacaine when used as a field block. This article provides an overview of regional anaesthesia techniques for postoperative analgesia following Total shoulder arthroplasty (TSA)
Keywords: Shoulder arthroplasty, Pain management, Regional anaesthesia, Interscalene brachial plexus block


1. Chillemi C, Franceschini V. Shoulder osteoarthritis. Arthritis. 2013; 2013:370231.
2. Dillon MT, Chan PH, Inacio MCS, Singh A, Yian EH, Navarro RA. Yearly Trends in Elective Shoulder Arthroplasty, 2005-2013. Arthritis Care Res (Hoboken). 2017 Oct;69(10):1574-1581.
3. Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am. 2014 Feb 5;96(3):198-205.
4. Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Physician. 2008 Mar;11(2 Suppl):S105-20.
5. Grosh T, Elkassabany NM. Enhanced Recovery After Shoulder Arthroplasty. Anesthesiol Clin. 2018 Sep;36(3):417-430.
6 Aszmann OC, Dellon AL, Birely BT, McFarland EG. Innervation of the human shoulder joint and its implications for surgery. Clin Orthop Relat Res. 1996 Sep;(330):202-7.
7. Ricchetti ET, Williams Jr GR. Total shoulder arthroplasty—indications, technique, and results. Operative Techniques in Orthopaedics. 2011 Mar 1;21(1):28-38
8. Gabriel RA, Nagrebetsky A, Kaye AD, Dutton RP, Urman RD. The Patterns of Utilization of Interscalene Nerve Blocks for Total Shoulder Arthroplasty. Anesth Analg. 2016 Sep;123(3):758-61.
9.Winnie AP. Interscalene brachial plexus block. Anesth Analg. 1970 May-Jun;49(3):455-66. PMID: 5534420.
10. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009 Mar;102(3):408-17.
11. Gautier P, Vandepitte C, Ramquet C, DeCoopman M, Xu D, Hadzic A. The minimum effective anesthetic volume of 0.75% ropivacaine in ultrasound-guided interscalene brachial plexus block. Anesth Analg. 2011 Oct;113(4):951-5.
12. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg. 2015 May;120(5):1114-1129.
13. Krishna Prasad GV, Khanna S, Jaishree SV. Review of adjuvants to local anesthetics in peripheral nerve blocks: Current and future trends. Saudi J Anaesth. 2020 Jan-Mar;14(1):77-84.
14. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017 Nov 9;11(11):CD011770.
15. Brummett CM, Williams BA. Additives to local anesthetics for peripheral nerve blockade. Int Anesthesiol Clin. 2011 Fall;49(4):104-16.
16. Vorobeichik L, Brull R, Bowry R, Laffey JG, Abdallah FW. Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth. 2018 Apr;120(4):679-692.
17. Fredrickson MJ, Leightley P, Wong A, Chaddock M, Abeysekera A, Frampton C. An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study. Anaesthesia. 2016 Apr;71(4):373-9.
18. Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ. 2019 Apr;19(4):98-104.
19. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001 Oct;95(4):875-80.
20. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008 Oct;101(4):549-56.
21. Hasan SS, Rolf RH, Sympson AN, Eten K, Elsass TR. Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Am Acad Orthop Surg Glob Res Rev. 2019 Jun 11;3(6):e014.
22. Vorster W, Lange CP, Briët RJ, Labuschagne BC, du Toit DF, Muller CJ, de Beer JF. The sensory branch distribution of the suprascapular nerve: an anatomic study. J Shoulder Elbow Surg. 2008 May-Jun;17(3):500-2.
23. Tran J, Peng PWH, Agur AMR. Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention. Reg Anesth Pain Med. 2019 Jan 11:rapm-2018-100152.
24. Jezierski H, Podgórski M, Stefańczyk L, Kachlik D, Polguj M. The Influence of Suprascapular Notch Shape on the Visualization of Structures in the Suprascapular Notch Region: Studies Based on a New Four-Stage Ultrasonographic Protocol. Biomed Res Int. 2017;2017:5323628.
25. Price DJ. The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesth Intensive Care. 2007 Aug;35(4):575-81.
26. Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology. 2017 Dec;127(6):998-1013.
27. Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Reg Anesth Pain Med. 2012 May-Jun;37(3):325-8.
28. Abdallah FW, Wijeysundera DN, Laupacis A, Brull R, Mocon A, Hussain N, Thorpe KE, Chan VWS. Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial. Anesthesiology. 2020 Apr;132(4):839-853.
29. Tran DQ, Elgueta MF, Aliste J, Finlayson RJ. Diaphragm-Sparing Nerve Blocks for Shoulder Surgery. Reg Anesth Pain Med. 2017 Jan/Feb;42(1):32-38.
30. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations. Anesthesiology. 2017 Jul;127(1):173-191.
31. Kim DH, Lin Y, Beathe JC, Liu J, Oxendine JA, Haskins SC, Ho MC, Wetmore DS, Allen AA, Wilson L, Garnett C, Memtsoudis SG. Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial. Anesthesiology. 2019 Sep;131(3):521-533.
32. Kang R, Jeong JS, Chin KJ, Yoo JC, Lee JH, Choi SJ, Gwak MS, Hahm TS, Ko JS. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology. 2019 Dec;131(6):1316-1326.
33. Forero M, Rajarathinam M, Adhikary SD, Chin KJ. Erector spinae plane block for the management of chronic shoulder pain: a case report. Can J Anaesth. 2018 Mar;65(3):288-293. English.
34. Diwan S, Nair A. Erector Spinae Plane Block for Proximal Shoulder Surgery: A Phrenic Nerve Sparing Block! Turk J Anaesthesiol Reanim. 2020 Aug;48(4):331-333.
35. Ciftci B, Ekinci M, Gölboyu BE, Kapukaya F, Atalay YO, Kuyucu E, Demiraran Y. High Thoracic Erector Spinae Plane Block for Arthroscopic Shoulder Surgery: A Randomized Prospective Double-Blind Study. Pain Med. 2021 Apr 20;22(4):776-783.
36. Sandeep Diwan; Xavier Sala Blanch; Abhijit Nair; Dipal Shah. Anatomic and radiological correlation of injectate spread from first thoracic costotransverse junction in cervical erector spinae plane. Autopsy and Case Reports, vol 11, e2021275, 2021. Hospital Universitario da Universidade de Sao Paulo.
37. Bjørnholdt KT, Jensen JM, Bendtsen TF, Søballe K, Nikolajsen L. Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial. Eur J Orthop Surg Traumatol. 2015 Dec;25(8):1245-52.
38. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010 Jun;65(6):608-624.
39. Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009 Sep-Oct;18(5):742-7.
40. Kolade O, Patel K, Ihejirika R, Press D, Friedlander S, Roberts T, Rokito AS, Virk MS. Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2019 Sep;28(9):1824-1834.
41. Dinges HC, Wiesmann T, Otremba B, Wulf H, Eberhart LH, Schubert AK. The analgesic efficacy of liposomal bupivacaine compared with bupivacaine hydrochloride for the prevention of postoperative pain: a systematic review and meta-analysis with trial sequential analysis. Reg Anesth Pain Med. 2021 Jun;46(6):490-498.
42. Vandepitte C, Kuroda M, Witvrouw R, Anne L, Bellemans J, Corten K, Vanelderen P, Mesotten D, Leunen I, Heylen M, Van Boxstael S, Golebiewski M, Van de Velde M, Knezevic NN, Hadzic A. Addition of Liposome Bupivacaine to Bupivacaine HCl Versus Bupivacaine HCl Alone for Interscalene Brachial Plexus Block in Patients Having Major Shoulder Surgery. Reg Anesth Pain Med. 2017 May/Jun;42(3):334-341.
43. Panchamia JK, Amundson AW, Jacob AK, Sviggum HP, Nguyen NTV, Sanchez-Sotelo J, Sperling JW, Schroeder DR, Kopp SL, Johnson RL. A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty. J Shoulder Elbow Surg. 2019 Oct;28(10):e325-e338.
44. Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology. 2018 Jul;129(1):47-57.
45. Auyong DB, Yuan SC, Choi DS, Pahang JA, Slee AE, Hanson NA. A Double-Blind Randomized Comparison of Continuous Interscalene, Supraclavicular, and Suprascapular Blocks for Total Shoulder Arthroplasty. Reg Anesth Pain Med. 2017 May/Jun;42(3):302-309.

How to Cite this Article: Khare P, Kashyapi R, Ranade M | Current Concepts in Regional Analgesia Techniques for Postoperative Pain Management after Total Shoulder Arthroplasty: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 42-48.

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Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review

Vol 3 | Issue 2 | July-December 2022 | Page 56-75 | Kartik Sonawane, Jagannathan Balavenkatasubramanian

DOI: 10.13107/ijra.2022.v03i02.057

Authors: Kartik Sonawane [1], Jagannathan Balavenkatasubramanian [2]

[1] Department of Anaesthesia, Ganga Medical Centre & Hospitals Pvt. Ltd. , Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Jagannathan Balavenkatasubramanian,
Department of Anaesthesia, Ganga Medical Centre & Hospital, Coimbatore, Tamil Nadu, India.
E-mail: drbalavenkat@gmail.com


Total knee replacement/arthroplasty (TKR/TKA) is considered a life-changing surgery as it not only corrects the pathology and associated joint deformity but also renders the patient pain-free allowing them to perform activities of daily living as before. Such favorable outcomes depend entirely on the perioperative pain management strategies. Structuring such strategies requires background knowledge of the goals set, the process of pain generation before and after the surgery, and innervations of the pain-generating components involved in each surgical step.
The multifactorial origin of TKR pain requires a multidimensional pain management strategy such as multimodal analgesia (MMA). It should incorporate all the essential ingredients that target each step of the pain generation process. Apart from pharmacological agents and nonpharmacological techniques, regional analgesia (RA) plays a very important role as an adjunct to MMA to provide quality analgesia that promotes enhanced recovery and mobility. However, the choice of RA technique remains dependent on its motor-sparing effect, procedure-specific analgesic coverage, opioid-sparing effect, and suitability for enhanced recovery after surgery (ERAS). Psychological analgesia is also an important aspect of MMA, aiding in resolving psychological concerns and postoperative pain management and empowering patients in their own pain management process by encouraging active participation. In addition to providing appropriate pain management services, assessing expected outcomes in the postoperative period is also important to close loopholes and provide rescue analgesics when needed.
This narrative review article highlights important aspects of pain management strategies and the essential requirements for implementing them to achieve desired outcomes. We believe this article will help readers design or modify their pain management strategy to meet all of their goals.
Keywords: Total knee replacement, Total knee arthroplasty, Pain management, Motor-sparing regional anesthetic technique, Multimodal analgesia, Procedure-specific analgesia.


[1] Filos KS, Lehmann KA. Current concepts and practice in postoperative pain management: need for a change? Eur Surg Res. 1999;31:97-107.
[2] Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467:1418-23.
[3] Parvataneni HK, Ranawat AS, Ranawat CS. The use of local periarticular injections in the management of postoperative pain after total hip and knee replacement: a multimodal approach. Instr Course Lect. 2007;56:125-31.
[4] Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg. 2002;10:117-29.
[5] Sonawane, K. , Dixit, H. . Regional Analgesia for Knee Surgeries: Thinking beyond Borders. In: Whizar-Lugo, V. M. , Saucillo-Osuna, J. R. , Castorena-Arellano, G. , editors. Topics in Regional Anesthesia [Internet]. London: IntechOpen; 2021 [cited 2022 Jul 12]. Available from: https://www.intechopen.com/chapters/77934.
[6] Campbell JN. APS 1995 Presidential address. Pain Forum.1996;5:85–8.
[7] Morone NE, Weiner DK. Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 1016; 2013;35(11):1728-1732:001.
[8] Lippe PM. The decade of pain control and research. Pain Med. 2000;1 (4):286.
[9] Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011; 5(5):342–8.
[10] Moningi S, Patki A, Padhy N, Ramachandran G. Enhanced recovery after surgery: An anesthesiologist’s perspective. J Anaesthesiol Clin Pharmacol. 2019;35(Suppl 1):S5–13.
[11] Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95.
[12] Johnson RL, Kopp SL. Optimizing perioperative management of total joint arthroplasty. Anesthesiol Clin. 2014;32 (4):865–80.
[13] Chan E-Y, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;(5):CD009941.
[14] Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10(6):329–35.
[15] Hirasawa Y, Okajima S, Ohta M, Tokioka T. Nerve distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop. 2000;24(1):1–4.
[16] Haus J, Halata Z. Innervation of the anterior cruciate ligament. Int Orthop. 1990;14(3):293–6.
[17] Krauspe R, Schmitz F, Zöller G, Drenckhahn D. Distribution of neurofilament-positive nerve fibres and sensory endings in the human anterior cruciate ligament. Arch Orthop Trauma Surg. 1995;114(4):194–8.
[18] Ikeuchi M, Wang Q, Izumi M, Tani T. Nociceptive sensory innervation of the posterior cruciate ligament in osteoarthritic knees. Arch Orthop Trauma Surg. 2012;132(6):891–5.
[19] Day B, Mackenzie WG, Shim SS, Leung G. The vascular and nerve supply of the human meniscus. Arthroscopy. 1985;1(1):58–62.
[20] Mine T, Kimura M, Sakka A, Kawai S. Innervation of nociceptors in the menisci of the knee joint: an immunohistochemical study. Arch Orthop Trauma Surg. 2000;120(3–4): 201–4.
[21] Institute of Medicine (US) Committee on Pain, Disability, and Chronic Illness Behavior. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Osterweis M, Kleinman A, Mechanic D, editors. Washington (DC): National Academies Press (US); 1987. PMID: 25032476.
[22] Bourne S, Machado AG, Nagel SJ. Basic anatomy and physiology of pain pathways. Neurosurg Clin N Am. 2014; 25(4):629–38.
[23] Felson DT. The sources of pain in knee osteoarthritis. Curr Opin Rheumatol. 2005 Sep;17(5):624-8.
[24] Eitner A, Hofmann GO and Schaible H-G (2017) Mechanisms of Osteoarthritic Pain. Studies in Humans and Experimental Models. Front. Mol. Neurosci. 10:349. doi: 10.3389/fnmol.2017.00349
[25] Schaible HG. (2013) Articular Nociceptors. In: Gebhart G.F., Schmidt R.F. (eds) Encyclopedia of Pain. Springer, Berlin, Heidelberg.
[26] Cummins TR, Sheets PL, Waxman SG. The roles of sodium channels in nociception: Implications for mechanisms of pain. Pain. 2007 Oct;131(3):243-257.
[27] McEntire DM, Kirkpatrick DR, Dueck NP, Kerfeld MJ, Smith TA, Nelson TJ, Reisbig MD, Agrawal DK. Pain transduction: a pharmacologic perspective. Expert Rev Clin Pharmacol. 2016 Aug;9(8):1069-80.
[28] Yam MF, Loh YC, Tan CS, Khadijah Adam S, Abdul Manan N, Basir R. General Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation. Int J Mol Sci. 2018 Jul 24;19(8):2164.
[29] Kirkpatrick DR, McEntire DM, Hambsch ZJ, Kerfeld MJ, Smith TA, Reisbig MD, Youngblood CF, Agrawal DK. Therapeutic Basis of Clinical Pain Modulation. Clin Transl Sci. 2015 Dec;8(6):848-56.
[30] Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 1993;77:1048-56.
[31] Buvanendran A., Kroin J. S. Multimodal analgesia for controlling acute postoperative pain. Current Opinions in Anaesthesiology. 2009;22(5):588–593.
[32] Young A., Buvanendran A. Recent advances in multimodal analgesia. Anesthesiology Clinics. 2012;30(1):91–100.
[33] Novello-Siegenthaler A, Hamdani M, Iselin-Chaves I, Fournier R. Ultrasoundguided continuous femoral nerve block: a randomized trial on the influence of femoral nerve catheter orifice configuration (six-hole versus end-hole) on postoperative analgesia after total knee arthroplasty. BMC Anesthesiol, 2018, 18: 191.
[34] Kim DH, Beathe JC, Lin Y, et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection
enhances postoperative pain control in total knee arthroplasty: a randomized controlled trial. Anesth Analg, 2019, 129: 526–535.
[35] Walder B, Schafer M, Henzi I, Tramèr MR. Efficacy and safety of patientcontrolled opioid analgesia for acute postoperative pain. A quantitative systematic review. Acta Anaesthesiol Scand, 2001, 45: 795–804.
[36] Dias AS, Rinaldi T, Barbosa LG. The impact of patients controlled analgesia undergoing orthopedic surgery. Braz J Anesthesiol, 2016, 66: 265–271.
[37] Song MH, Kim BH, Ahn SJ, et al. Peri-articular injections of local anaesthesia can replace patient-controlled analgesia after total knee arthroplasty: a randomised controlled study. Int Orthop, 2016, 40: 295–299.
[38] Rantasalo MT, Palanne R, Juutilainen K, et al. Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol. BMJ Open, 2018, 8: e025546.
[39] Yik JH, Tham WYW, Tay KH, Shen L, Krishna L. Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2019, 27: 2104–2110.
[40] Ryu JH, Jeon YT, Min B, Hwang JY, Sohn HM. Effects of palonosetron for prophylaxis of postoperative nausea and vomiting in high-risk patients undergoing total knee arthroplasty: a prospective, randomized, double-blind, placebocontrolled study. PLoS One, 2018, 13: e0196388.
[41] Borckardt JJ, Reeves ST, Milliken C, et al. Prefrontal versus motor cortex transcranial direct current stimulation (tDCS) effects on post-surgical opioid use. Brain Stimul, 2017, 10: 1096–1101.
[42] Pogatzki-Zahn EM, Zahn PK. From preemptive to preventive analgesia. Curr Opin Anaesthesiol, 2006, 19: 551–555.
[43] Grape S, Tramèr MR. Do we need preemptive analgesia for the treatment of postoperative pain? Best Pract Res Clin Anaesthesiol, 2007, 21: 51–63.
[44] Korean Knee Society. Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surg Relat Res. 2012;24(4):201-207.
[45] Sonawane K, Dixit H, Balavenkatasubramanian J. Regional analgesia technique for postoperative analgesia in total knee arthroplasty: have we hit the bull’s eye yet? Braz J
Anesthesiol. 2021 May-Jun;71(3):307-309.
[46] Momoli A, Giarretta S, Modena M, Micheloni GM. The painful knee after total knee arthroplasty: evaluation and management. Acta Biomed. 2017;88 (2S):60–7.
[47] Bannister K, Sachau J, Baron R, Dickenson AH. Neuropathic Pain: Mechanism-Based Therapeutics. Annu Rev Pharmacol Toxicol. 2020 Jan 6;60:257-274.
[48] Finnerup NB, Kuner R, Jensen TS. Neuropathic Pain: From Mechanisms to Treatment. Physiol Rev. 2021 Jan 1;101(1):259-301.
[49] St John Smith E. Advances in understanding nociception and neuropathic pain. J Neurol. 2018 Feb;265(2):231-238.
[50] Macario A, Weinger M, Carney S, Kim A Anesth Analg. 1999 Sep; 89(3): 652-8.
[51] Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC Anesthesiology. 2005 May; 102(5): 1001-7.
[52] lfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW Anesthesiology. 2006 Nov; 105(5): 999- 1007.
[53] Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and combined neuraxial/ general anesthesia compared to general anesthesia for major truncal and lower limb surgery: A systematic review and meta-analysis. Anesth Analg. 2017;125 (6):1931– 45.
[54] Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK. Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):102–5.
[55] Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK. Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64–101.
[56] Sonawane K, Balavenkatasubramanian J, Dixit H, Tayi H, Goel VK. Regional anesthesia for scapular fracture surgery: an educational review of anatomy and techniques. Reg Anesth Pain Med. 2021; 46(4):344–9.
[57] Sonawane K, Dixit H, Balavenkatasubramanian J, Gurumoorthi P (2021) Uncovering secrets of the beauty bone: A comprehensive review of anatomy and regional anesthesia techniques of clavicle surgeries. Open J Orthop Rheumatol 6(1): 019-029.
[58] Vas L, Pai R, Khandagale N, Pattnaik M. Pulsed radiofrequency of the composite nerve supply to the knee joint as a new technique for relieving osteoarthritic pain: a preliminary report. Pain Physician. 2014;17(6): 493–506.
[59] Priest , B.T. , B.A. Murphy , J.A. Lindia , C. Diaz , C. Abbadie , A.M. Ritter , P. Liberator
, L.M. Iyer , S.F. Kash , M.G. Kohler , et al . 2005 . Contribution of the tetrodotoxin- resistant voltage-gated sodium channel NaV1.9 to sensory transmission and nociceptive behavior. Proc. Natl. Acad. Sci. USA. 102 : 9382 – 9387 .
[60] Amaya , F. , H. Wang , M. Costigan , A.J. Allchorne , J.P. Hatcher , J. Egerton , T. Stean ,
V. Morisset , D. Grose , M.J. Gunthorpe , et al . 2006 . The voltage-gated sodium channel Na(v)1.9 is an effector of peripheral infl ammatory pain hypersensitivity. J. Neurosci. 26 : 12852 – 12860 .
[61] Gorczyca R, Filip R, Walczak E. Psychological aspects of pain. Ann Agric Environ Med. 2013;Spec no. 1:23-7. PMID: 25000837.
[62] McGrath PA. Psychological aspects of pain perception. Arch Oral Biol. 1994;39 Suppl:55S-62S.
[63] Weissman DE, Dahl JL, Beasley JW. The cancer pain role model program of the Wisconsin cancer pain initiative. J Pain Symptom Manage. 1993;8(1):29–35.
[64] Brown JK, Singh K, Dumitru R, Chan E, Kim MP. The benefits of enhanced Recovery After Surgery programs and their application in cardiothoracic surgery. Methodist Debakey Cardiovasc J. 2018;14(2):77–88.
[65] Tennant F. The physiologic effects of pain on the endocrine system. pain Ther. 2013;2(2):75-86.
[66] Sonawane K, Dixit H, Mistry T, Balavenkatasubramanian J. Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial. Cureus. 2021 Dec 17;13(12):e20488.

How to Cite this Article: Sonawane K, Balavenkatasubramanian J | Current Concepts in Pain Management of Total Knee Replacement Surgeries: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 56-75.

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Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review

Vol 3 | Issue 2 | July-December 2022 | Page 49-55 | Anju Gupta, Mallika Kaushal, Amit Malviya, Shalender Kumar, Sandeep Diwan

DOI: 10.13107/ijra.2022.v03i02.056

Authors: Anju Gupta [1], Mallika Kaushal [1], Amit Malviya [1], Shalender Kumar [1], Sandeep Diwan [2]

[1] Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
[2] Department of Anaesthesia, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Anju Gupta,
Assistant Professor, Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.
E-mail: drajugupta09@gmail.com


Hip surgery is a common surgical procedure in the elderly and leads to significant pain postoperatively. The hip joint has a complex innervation which is unlikely to be covered with any single modality of pain relief. Multimodal analgesia has been critical in facilitating early recovery and rehabilitation in these patients. Regional analgesia is an important component of multimodal analgesia regimens and is instrumental in achieving optimal patient outcomes. Single shot or continuous central or peripheral nerve blocks provide effective and safe postoperative analgesia, lower opioid consumption, faster rehabilitation, and a high level of patient satisfaction. An ideal regional anaesthesia technique for hip surgery should be motor sparing while providing effective perioperative pain relief. Regional anaesthesia has seen enormous growth in the recent past due to advances in technology and research. These blocks have shown analgesic efficacy, have an opioid-sparing effect, and enable better patient positioning for central neuraxial blocks. Some of the novel interfascial plane blocks like Pericapsular Nerve Group (PENG) block are now being explored for hip analgesia. Within a few years of being described, these novel nerve blocks have seen tremendous favour in the literature and are being extensively used in the current practice of analgesia for hip surgery. In the present review, we aim to discuss the various modalities of analgesia which have been utilised in the past and would discuss few of the newer blocks for hip surgery.
Keywords: Nerve blocks, Ultrasonography, Analgesics, Total hip arthroplasty, Fascia illiaca block,
Multimodal analgesia, Transmuscular, Quadratus lumborum block


1. Diwan S, NairA, Dadke M, Sancheti P. Intricacies of ultrasound guided lumbar plexus block in octogenarians:A retrospective case series. J Med Ultrasound 0;0:0
2. Laumonerie P, Dalmas Y, Tibbo ME, Robert S, Durant T, Caste T et al. Sensory innervation of the hip joint and referred pain: A systematic review of the literature. Pain medicine. 2021;22(5):1149-57
3. Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M et al. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76:1082-97
4. Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta orthopaedica. 2020;91(1):3-19
5. Rothwell MP, Pearson D, Hunter JD, Mitchell PA, Graham-Woollard T, Goodwin L et al. Oral oxycodone offers equivalent analgesia to intravenous patient-controlled analgesia after total hip replacement: a randomized, single-centre, non-blinded, non-inferiority study. Br J Anaesth. 2011;106(6):865-72
6. de Beer J de V, Winemaker MJ, Donnelly GA, Miceli PC, Reiz JL, Harsanyi Z et al. Efficacy and safety of controlled-release oxycodone and standard therapies for postoperative pain after knee or hip replacement. Can J Surg. 2005;48(4):277-83
7. Min BW, Kim Y, Cho HM, Park KS, Yoon PW, Nho JH et al. Perioperative pain management in total hip arthroplasty: Korean Hip Society guidelines. Hip Pelvis. 2016; 28(1):15-23.
8. Bujedo BM. A clinical approach to neuraxial morphine for the treatment of postoperative pain. Pain Res Treat. 2012;2012:612145
9. Gandhi K, Viscusi E. Multimodal pain management techniques in hip and knee arthroplasty. The Journal of New York School of Regional Anaesthesia. 2009;13:1-10
10. Brull R, Macfarlane AJR, Chan VWS. Spinal, epidural and caudal anesthesia. In: Gropper M, Erikson L, Fleisher L, Wiener-Kronish J, Cohen N, Leslie K, eds. Miller’s Anesthesia. 9th ed. Elsevier 2019;1:1413-4
11. Choi P, Bhandari M, Scott J, Douketis JD. Epidural analgesia for pain relief following hip or knee replacement. Cochrane database of systematic reviews. 2003;3:CD003071
12. Mannion S. Psoas compartment block. Continuing education in Anaesthesia, Critical Care & Pain. 2007;7(5):162-6
13. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block”. Anesth Analg. 1973;52(6):989-96
14. Moore CL. Time to abandon the term “3 in 1 block”. Ann Emerg Med. 2015:66(2):215
15. Grant CRK, Checketts MR. Analgesia for primary hip and knee arthroplasty: the role of regional anaesthesia. Continuing education in Anaesthesia, Critical Care & Pain. 2008;8(2):56-61
16. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of patient controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total hip arthroplasty. Reg Anesth Pain Med. 2005;30:452-7
17. Nishio S, Fukunishi S, Fukui T, Fujihara Y, Okahisa S, Takeda Y et al. Comparison of continuous femoral nerve block with and without combined sciatic nerve block after total hip arthroplasty: a prospective randomized study. Orthop Rev (Pavia). 2017;9(2):7063
18. Kuchálik J, Granath B, Ljunggren A, Magnuson A, Lundin A, Gupta A. Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia. Br J Anaesth. 2013;111(5):793-9
19. Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy of intraoperative periarticular injection in total hip arthroplasty: a systematic review and meta-analysis. BioMed Central Musculoskeletal Disorders. 2019;20:269
20. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg. 1989;69:705-13
21. O’Reilly N, Desmet M, Kearns R. Fascia iliaca compartment block. BJA education. 2019;19(6):191-7
22. Zhang X, Ma J. The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis. Journal of orthopaedic surgery and research. 2019;14:33
23. Hong H, Ma Y. The efficacy of fascia iliaca compartment block for pain control after hip fracture: a meta-analysis. Medicine. 2019;98:28(e16157)
24. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-7
25. Tulgar S, Senturk O. Ultrasound guided erector spinae plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. Journal of clinical anaesthesia. 2018;44:68
26. Azevedo AS, Fernandes HS, Júnior WC, Hamaji A, Ashmawi A. Lumbar erector spinae plane block for total hip arthroplasty analgesia. Case report. BrJP. São Paulo. 2021;4(1):91-3
27. Mujahid OM, Dey S, Nagalikar S, Arora P, Dey CK. Ultrasound-guided lumbar ESP block for post-operative analgesia as an alternative mode of analgesia in hip arthroplasty with multiple systemic issues: a case report. Ain-Shams Journal of Anesthesiology. 2021;13:47
28. Singh S, Ranjan R, Lalin D. A new indication of erector spinae plane block for perioperative analgesia is total replacement surgery – A case report. Indian J Anaesth. 2019;63(4):310-1
29. Kinjo S, Schultz A. Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report. Rev Bras Anestesiol. 2019;69(4):420-2
30. Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med. 2020;52(1):16-20
31. Xu L, Leng JC, Elsharkawy H, Hunter OO, Harrison TK, Vokach-Brodsky L et al. Replacement of fascia iliaca catheters with continuous erector spinae plane blocks within a clinical pathway facilitates early ambulation after total hip arthroplasty. Pain Medicine. 2020;21(10):2423-9
32. Blanco R. TAP block under ultrasound guidance: the description of a ‘non pops technique’. Reg Anesth Pain Med. 2007;32:130
33. Gupta A, Sondekoppam R, Kalagara H. Quadratus Lumborum Block: A technical review. Curr Anesthesiol Rep. 2019;9:257-62
34. Tiwari P, Bhatia R, Asthana V, Maheshwari R. Role of ultrasound-guided lumbar “Erector spinae plane block” and ultrasound-guided transmuscular “Quadratus lumborum block” for postoperative analgesia after hip surgeries: A randomized, controlled study. Indian Anaesth Forum. 2021;22:60-6
35. Li J, Wei C, Huang J, Li Y, Liu H, Liu J et al. Efficacy of quadratus lumborum block for pain control in patients undergoing hip surgeries: a systematic review and meta-analysis. Front Med. 2022;8:771859
36. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) block for hip fracture. Regional Anesthesia and Pain Medicine. 2018;43:859-63
37. Pascarella G, Costa F, Del Buono R, Pulitano R, Strumia A, Piliego C et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia. 2022;76:1492-8
38. Teles AS, Altinpulluk EY, Sahoo RK, Galluccio F, Simón DG, İnce İ et al. Beyond the Pericapsular Nerve Group (PENG) block; a narrative review. Turk J Anaesthesiol Reanim. 2022;50(3):167-72.

How to Cite this Article: Gupta A, Kaushal M, Malviya A, Kumar S, Diwan S | Current Concepts in Postoperative Pain Management Surgeries of Hip Joint: A Narrative Review | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 49-55.

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Ultrasound Guided Regional Anaesthesia for Breast Surgery in High Risk Patients- A Retrospective Observational Study

Vol 3 | Issue 2 | July-December 2022 | Page 93-97 | Harshal D Wagh, Shruthi Pendalya, Mandar Nadkarni

DOI: 10.13107/ijra.2022.v03i02.061

Authors: Harshal D Wagh [1], Shruthi Pendalya [1], Mandar Nadkarni [2]

[1] Department of Anaesthesia, Kokilaben Ambani Hospital, Mumbai, Maharashtra, India.
[2] Department of Oncosurgery, Kokilaben Ambani Hospital, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Harshal D Wagh,
Department of Anaesthesia, Kokilaben Ambani Hospital, Mumbai, Maharashtra, India.
E-mail: drhdw2701@gmail.com


Introduction: Modified radical mastectomy (MRM) or breast conservative surgery (BCS) done under general anaesthesia (GA) in high-risk patients may be associated with significant morbidity, Intensive Care Unit stay and increased hospital stay leading to cost issues. In this case-series, we describe our experience with regional anesthesia for MRM or BCS and sentinel / complete axillary clearance in 61 patients with breast carcinoma who were high risk for perioperative complications in view of their co-morbidities. None required ICU or increased hospital stay postoperatively.
Material & Methods: Sixty-one ASA III/IV patients operated under regional anaesthesia for carcinoma of the breast were included. Multiple level USG guided thoracic paravertebral block (PVB), PECS block (1/2), Pecto-intercostal fascial block (PIFB), Serratus-anterior plane block (SAPB), brachial plexus block, Superficial cervical plexus blocks (SCPB), Erector spinae block (ESB) were given in different combinations.
Result: There were 60 female patients (Age: 30-97 years) and 1 male patient (59 years) (Left side -27 patients, right side- 34 patients). Of the total 61 patients, 23 patients underwent BCS with axillary dissection, 36 patients underwent MRM with axillary dissection, 2 patients had MRM with Pectoralis Major muscle resection. Patients received different combinations of blocks PVB or ESB, PECS1/2 and SAPB. 43 patients received the PVB, 61 got the PECS1/2, 12 patients received ESP, 32 patients required SCPB, 1 infra-clavicular block and 35 patients got PIFB. All procedures were completed under regional anaesthesia with 51 patients getting intravenous midazolam (0.01-0.02mg/kg), 59 patients were given IV fentanyl (1-3ug/kg , 43 patients were given IV propofol (1-2mg/kg), These were given in small aliquots during the duration of the procedure. 2 patients had IV ketamine (0.5mg/kg) and 1 patient had IV dexmeditomidine (0.2-0.3ug/kg/hr). IV paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDS) ie. Inj Diclofenac Sodium IV in the dose of 1mg/kg (max 75mg) were given when not contraindicated.
There was single case of axillary hematoma with no other complications. No patient required ICU care postoperatively and were discharged as routine.
Conclusion: A combination of blocks may be an option for surgical anaesthesia for breast surgeries in high risk patients. Careful planning, patient counseling and attention to toxic dose of local anaesthetics must always be considered.
Keywords: Paravertebral block, Thoracic wall blocks, PECS block, Serratus Anterior plane block, Pecto-intercorstal fascial block, Superficial cervical plexus, Modified radical mastectomy, Breast conservative surgery.


1. Ferlay J1, Autier P, Boniol M, Heanue M, Colombet M, Boyle P. Estimates of the cancer incidence and mortality in Europe in 2006. . Ann Oncol. 2007 Mar;18(3):581-92. Epub 2007 Feb 7.
2. Vadivelu N, Schreck M, Lopez J, Kodumudi G, Narayan D. Pain After Mastectomy And Breast Reconstruction. Am Surg. 2008; 74: 285-96.
3. Voight M, Frohlich Cw, WaschkeKf, Lenz C, Gobel U, Kerger H. Prophylaxis Of Postoperative Nausea And Vomiting In Elective Breast Surgery. J Clin Anaesth. 2011; 23: 461-468.
4. Fujii Y, Tanaka H, Toyooka H. Prophylactic Antiemetic Therapy With Granisetron-Dexamethasone Combination In Women Undergoing Breast Surgery. Acta Anaesthesiol Scand. 1998; 42: 1038-42.
5. Blanco R. The ‘Pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847–848.
6. Pérez MF, Duany O, de la Torre PA. Redefining Pecs blocks for postmastectomy analgesia. Reg Anaesth Pain Med. 2015;40:729–730.
7. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013; 68:1107–1113.
8. De la Torre PA, García PD, Alvarez SL, Miguel FJ, Pérez MF. A novel ultrasound-guided block: a promising alternative for breast analgesia. Aesthet Surg J. 2014;34:198–200.
9. Ueshima H, Kitamura A. Blocking of multiple anterior branches of intercostal nerves (Th2–6) using a transversus thoracic muscle plane block. Reg Anaesth Pain Med. 2015;40:388.
10. Rukewe A1, Afuwape OO2, Ugheoke A3, Fatiregun AA4. Single-shot lamina thoracic paravertebral block with ketofol for modified radical mastectomy. Local Reg Anesth. 2016 Oct 6;9:83-86.
11. Sopena-Zubiria LA, Fernández-Meré LA, Valdés Arias C, Muñoz González F, Sánchez Asheras J, Ibáñez Ernández C. [Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. Rev Esp Anestesiol Reanim. 2012 Jan;59(1):12-7.
12. Pawa A1, Wight J1, Onwochei DN1, Vargulescu R1, Reed I1, Chrisman L1, Pushpanathan E1, Kothari A2, El-Boghdadly K1.Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series. Anaesthesia. 2018 Apr;73(4):438-443.
13. Greengrass R1, O’Brien F, Lyerly K, Hardman D, Gleason D, D’Ercole F, Steele S. Paravertebral block for breast cancer surgery. Can J Anaesth. 1996 Aug;43(8):858-61.
14. Schnabel A1, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK.Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2010 Dec;105(6):842-52.
15. Robert B. Maniker, Rebecca L. Johnson, De Q. Tran. Interfacial Plane Blocks for Breast Surgery: Which Surgery to Block, and Which Block to Choose? www.anesthesia-analgesia.org June 2020 • Volume 130 • Number 6.

How to Cite this Article: Wagh HD, Pendalya S, Nadkarni M | Ultrasound Guided Regional Anaesthesia for Breast Surgery in High Risk Patients- A Retrospective Observational Study | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 93-97.

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Deciding the Better Dose- A Prospective Randomized Double Blind Study of Two Different Doses of Perineural Dexmedetomidine in Axillary Brachial Block

Vol 3 | Issue 2 | July-December 2022 | Page 83-87 | Sheetal Y Chiplonkar, Jalpa A Kate, Dinesh B Vadranapu, Pratibha Toal

DOI: 10.13107/ijra.2022.v03i02.059

Authors: Sheetal Y Chiplonkar [1], Jalpa A Kate [1], Dinesh B Vadranapu [2], Pratibha Toal [1]

[1] Department of Anaesthesiology, BARC Hospital, Anushaktinagar, Mumbai, Maharashtra, India.
[2] Department of Critical Care, P.D. Hinduja Hospital and Research Centre, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Jalpa A Kate,
Consultant, Department of Anaesthesiology, BARC Hospital, Anushaktinagar, Mumbai, Maharashtra, India.
E-mail: dr.japs@gmail.com


Background: Axillary brachial plexus block is generally regarded as the safest and reliable technique for forearm and hand surgeries. Dexmedetomidine, a potent alpha (α)-2-adrenergic receptor agonist when used as an additive in any peripheral nerve block can improve quality of block and postoperative analgesia, though uncertainity prevails regarding the dose in patients undergoing hand and forearm surgeries.
Methods: In this prospective, randomized, comparative, double blind study, 80 patients were included. Each participant fulfilling the inclusion criteria then received axillary brachial plexus block using 15cc 2% lignocaine with adrenaline (1:200000)and 0.5% bupivacaine 5cc mixed with dexmedetomidine either 0.5 µg /kg (group A) or 1 µg /kg ( group B)in 2cc normal saline. Duration of post-operative analgesia was the primary outcome.
Result: Duration of analgesia was significantly prolonged in group B (493.77±115.62 min) compared to group A (434.62±45.18 min, P <0.01).
Conclusion: Between the two doses of dexmedetomidine, block characteristics and analgesia obtained were better with higher dose (1 µg/kg) but chances of side effects like bradycardia increased. Hence 0.5 µg/kg can be a better dose with improved block characteristics yet negligible side effects.
Keywords: Brachial plexus block, Dexmedetomidine Perineural, Peripheral nerve stimulator, Ultrasonography


1. Thakur A, Singh J, Kumar S, Rana S, Sood P, Verma V. Efficacy of Dexmedetomidine in two Different Doses as an Adjuvant to Lignocaine in Patients Scheduled for Surgeries under Axillary Block. J Clin Diagn Res JCDR. 2017; 11(4):UC16–21.
2. Klein SM, Pietrobon R, Nielsen KC, Warner DS, Greengrass RA, Steele SM. Peripheral Nerve Blockade with Long-Acting Local Anesthetics: A Survey of The Society for Ambulatory Anesthesia. Anesth Analg. 2002; 94(1):71–76.
3. Sanghvi KS, Shah VA, Patel KD. Comparative study of bupivacaine alone and bupivacaine along with buprenorphine in axillary brachial plexus block: a prospective, randomized, single blind study. Int J Basic Clin Pharmacol. 2013; 2(5):640–644.
4. Biradar PA, Kaimar P, Gopalakrishna K. Effect of dexamethasone added to lidocaine in supraclavicular brachial plexus block: A prospective, randomised, double-blind study. Indian J Anaesth. 2013; 57(2):180–4.
5. Lee AR, Yi H, Chung IS, Ko JS, Ahn HJ, Gwak MS, et al. Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block. Can J Anesth Can Anesth. 2012; 59(1):21–27.
6. Rojas González A. Dexmedetomidine as an adjuvant to peripheral nerve block. Rev Soc Esp Dolor 2019; 26(2):115-117.
7. Cai, H., Fan, X., Feng, P, et al. Optimal dose of perineural dexmedetomidine to prolong analgesia after brachial plexus blockade: a systematic review and Meta-analysis of 57 randomized clinical trials. BMC Anesthesiol 21, 233 (2021).
8. Jie F, Yuncen S, Fang D et al. The effect of perineural dexamethasone on rebound pain after ropivacaine single injection nerve block: A randomised controlled trial. BMC Anesthesiology 2021; 21(1) doi: 10.1186/s12871-021-01267-z.
9. Agarwal S, Aggarwal R, Gupta P. Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014; 30(1):36–40.
10. Gupta A, Mahobia M, Narang N, Mahendra R. A comparative study of two different doses of dexmedetomidine as adjunct to lignocaine in intravenous regional anaesthesia of upper limb surgeries. Int J Sci Study. 2014; 2(3):53–62.
11. Kaygusuz K, Kol IO, Duger C, Gursoy S, Ozturk H, Kayacan U, et al. Effects of adding dexmedetomidine to levobupivacaine in axillary brachial plexus block. Curr Ther Res Clin Exp. 2012; 73(3):103–11.
12. Brummett CM, Hong EK, Janda AM, Amodeo FS, Lydic R. Perineural Dexmedetomidine Added to Ropivacaine for Sciatic Nerve Block in Rats Prolongs the Duration of Analgesia by Blocking the Hyperpolarization-activated Cation Current. Anesthesiology. 2011; 115(4):836–43.
13. Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine Added to Levobupivacaine Prolongs Axillary Brachial Plexus Block. Anesth Analg. 2010 Dec; 111(6):1548–1551.
14. Bangera A, Manasa M, Krishna P. Comparison of effects of ropivacaine with and without dexmedetomidine in axillary brachial plexus block: A prospective randomized double-blinded clinical trial. Saudi J Anaesth. 2016; 10(1):38–44.
15. Koraki E, Stachtari C, Kapsokalyvas I, Stergiouda Z, Katsanevaki A, Trikoupi A. Dexmedetomidine as an adjuvant to 0.5% ropivacaine in ultrasound-guided axillary brachial plexus block. J Clin Pharm Ther. 2018; 43(3):348–52.
16. Paranjpe JS. Dexmedetomidine: Expanding role in anesthesia. Med J Dr DY Patil Univ. 2013; 6(1):5.
17. Leudi MM, Upadek V, Vogt AP, Steinfeldt T, Eichenberger U, Sauter AR. Swiss nationwide survey shows that dual guidance is the preferred approach for peripheral nerve blocks. SciRep.2019 24:9(1):9178.doi:10.1038/s41598-019-45700-3.

How to Cite this Article: Chiplonkar SY, Kate JA, Vadranapu DB, Toal P| Deciding the Better Dose- A Prospective Randomized Double Blind Study of Two Different Doses of Perineural Dexmedetomidine in Axillary Brachial Block | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 83-87.

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Serratus Anterior Block for Rib Fractures: A Systematic Review and Meta-analysis

Vol 3 | Issue 2 | July-December 2022 | Page 76-82 | Lijiin Zhen, Matthew Bright, Matthew McHugh, Damon Reardon, Leigh White

DOI: 10.13107/ijra.2022.v03i02.058

Authors: Lijiin Zhen [1], Matthew Bright [2], Matthew McHugh [2], Damon Reardon [2], Leigh White [1, 3]

[1] Department of Anaesthesia, Sunshine Coast University Hospital, Queensland, Australia.
[2] Department of Anaesthesia, Princess Alexandra Hospital, Queensland, Australia.
[3] Department of Anaesthesia, Griffith University, Queensland, Australia.

Address of Correspondence
Dr. Lijiin Zhen,
Department of Anaesthetics, Sunshine Coast University Hospital, Birtinya QLD 4575, Australia.
E-mail: lijiin.zhen@health.qld.gov.au


Background: Effective analgesia is the mainstay of the management of traumatic rib fractures. Serratus anterior block is a newer regional anaesthesia technique used in traumatic rib fractures which may have a favourable safety profile compared to other regional techniques. There is currently a lack of evidence for serratus anterior block and its role in the improvement of mortality, pain, duration of stay and pulmonary complications in patients with traumatic rib fractures in comparison to other regional anaesthesia techniques.
Methods: Web of Science and PubMed were searched from inception until April 2022 for studies reporting on the use of a serratus anterior block compared to another therapy for the management of traumatic rib fractures. Primary outcomes were measures of analgesic efficacy. Secondary outcomes were the incidence of intervention related adverse events, hospital length of stay, intensive care unit length of stay and mortality.
Results: Seven studies with 649 patients were included. No significant difference was found between serratus anterior block and intravenous opiates in terms of resting pain scores and achievement of mild or no pain after the chosen intervention(p>0.05). There was a statistically, but not clinically significant difference post block pain scores compared to other regional techniques (WMD= 0.63; 95% CI= 0.45 to 0.80; p< 0.00001). Significant differences were found in favour of blocks, specifically thoracic epidural and paravertebral blocks over serratus anterior block in terms of achieving mild or no pain after the block (OR= 0.54; 95% CI=0.32 to 0.90; I2= 0%; p= 0.02). No significant difference was found for any other outcomes.
Conclusions: Current literature comparing the serratus anterior block to alternative analgesic options is limited by the end points assessing block success. No data was available assessing the effect on pain during deep inspiration and coughing. This meta-analysis demonstrated similar analgesic efficacy to other regional anaesthesia techniques but a lower incidence of mild or no pain post block compared to traditional epidural or paravertebral techniques. Future studies need to be directed towards important outcomes such as dynamic pain scores and respiratory complication rates.
Keywords: Rib fractures, Serratus Anterior, Chest trauma


1. Flagel, B.T.; Luchette, F.A.; Reed, R.L.; Esposito, T.J.; Davis, K.A.; Santaniello, J.M.; Gamelli, R.L. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005 Oct;138(4):717-723; discussion 723-715.
2. Griffiths, R.; Surendra Kumar, D. Major trauma in older people: implications for anaesthesia and intensive care medicine. Anaesthesia. 2017 Nov;72(11):1302-1305.
3. Barry, R.; Thompson, E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg. 2018 Jun;215(6):1020-1023.
4. El-Boghdadly, K.; Wiles, M.D. Regional anaesthesia for rib fractures: too many choices, too little evidence. Anaesthesia. 2019 May;74(5):564-568.
5. Kim, M.; Moore, J.E. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Curr Anesthesiol Rep. 2020;10(1):61-68.
6. Womack, J.; Pearson, J.D.; Walker, I.A.; Stephens, N.M.; Goodman, B.A. Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study. Anaesthesia. 2019 May;74(5):594-601.
7. Adhikary, S.D.; Liu, W.M.; Fuller, E.; Cruz-Eng, H.; Chin, K.J. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia. 2019 May;74(5):585-593.
8. Benyamin, R.; Trescot, A.M.; Datta, S.; Buenaventura, R.; Adlaka, R.; Sehgal, N.; Glaser, S.E.; Vallejo, R. Opioid complications and side effects. Pain Physician. 2008 Mar;11(2 Suppl):S105-120.
9. Kunhabdulla, N.P.; Agarwal, A.; Gaur, A.; Gautam, S.K.; Gupta, R.; Agarwal, A. Serratus anterior plane block for multiple rib fractures. Pain Physician. 2014 Sep-Oct;17(5):E651-653.
10. Rose, P.; Ramlogan, R.; Sullivan, T.; Lui, A. Serratus anterior plane blocks provide opioid-sparing analgesia in patients with isolated posterior rib fractures: a case series. Can J Anaesth. 2019 Oct;66(10):1263-1264
11. Higgins, J.P.; Altman, D.G.; Gotzsche, P.C.; Juni, P.; Moher, D.; Oxman, A.D.; Savovic, J.; Schulz, K.F.; Weeks, L.; Sterne, J.A.; Cochrane Bias Methods, G.; Cochrane Statistical Methods, G. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343:d5928.
12. Sterne, J.A.; Hernan, M.A.; Reeves, B.C.; Savovic, J.; Berkman, N.D.; Viswanathan, M.; Henry, D.; Altman, D.G.; Ansari, M.T.; Boutron, I.; Carpenter, J.R.; Chan, A.W.; Churchill, R.; Deeks, J.J.; Hrobjartsson, A.; Kirkham, J.; Juni, P.; Loke, Y.K.; Pigott, T.D.; Ramsay, C.R.; Regidor, D.; Rothstein, H.R.; Sandhu, L.; Santaguida, P.L.; Schunemann, H.J.; Shea, B.; Shrier, I.; Tugwell, P.; Turner, L.; Valentine, J.C.; Waddington, H.; Waters, E.; Wells, G.A.; Whiting, P.F.; Higgins, J.P. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919.
13. Abu-Elwafa, W.A.E-G.; Ragab, I.A.; Abdelrahman, A.H.; Mahmoud, W.A. Comparative Study between Efficacy of Serratus Anterior Muscle Block as A Regional Analgesia Technique and I.V Morphine Infusion in Patient with Fracture Ribs. The Egyptian Journal of Hospital Medicine. 2021 Jan;82(2):348-353.
14. Beard, L.; Hillermann, C.; Beard, E.; Millerchip, S.; Sachdeva, R.; Gao Smith, F.; Veenith, T. Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures. Reg Anesth Pain Med. 2020 May;45(5):351-356.
15. Bhalla, P.I.; Solomon, S.; Zhang, R.; Witt, C.E.; Dagal, A.; Joffe, A.M. Comparison of serratus anterior plane block with epidural and paravertebral block in critically ill trauma patients with multiple rib fractures. Trauma Surg Acute Care Open. 2021;6(1):e000621.
16. Diwan, S.; Nair, A. A retrospective study comparing analgesic efficacy of ultrasound-guided serratus anterior plane block versus intravenous fentanyl infusion in patients with multiple rib fractures. J Anaesthesiol Clin Pharmacol. 2021 Jul-Sep;37(3):411-415.
17. Riley, B.; Malla, U.; Snels, N.; Mitchell, A.; Abi-Fares, C.; Basson, W.; Anstey, C.; White, L. Erector spinae and serratus anterior blocks for the management of rib fractures: A retrospective exploratory matched study. Am J Emerg Med. 2020 Aug;38(8):1689-1691.
18. Teksen, S.; Oksuz, G.; Oksuz, H.; Sayan, M.; Arslan, M.; Urfalioglu, A.; Gisi, G.; Bilal, B. Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial. Am J Emerg Med. 2021 Mar;41:16-20.
19. El Malla, D.A.; Helal, R.; Zidan, T.A.M.; El Mourad, M.B. The Effect of Erector Spinae Block versus Serratus Plane Block on Pain Scores and Diaphragmatic Excursion in Multiple Rib Fractures.
20. Metelli S, Chaimani A. Challenges in meta-analyses with observational studies. Evidence Based Mental Health. 2020;23(2):83-87.

How to Cite this Article: Zhen L, Bright M, McHugh M, Reardon D, White L | Serratus Anterior Block for Rib Fractures: A Systematic Review and Meta-analysis | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 76-82.

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