Regional Anesthesia and Pain Medicine最新文献

Background: We aimed to investigate whether the mode of anesthesia- neuraxial versus general-used during cesarean delivery is associated with the risk of long-term neurodevelopmental disorders (LNDDs) in offspring.

Methods: We conducted a nationwide, population-based cohort study using data from the South Korean National Health Insurance Service. The study included 735 280 children born via cesarean delivery between January 1, 2010 and December 31, 2014. After applying 1:1 propensity score matching based on maternal receipt of neuraxial anesthesia (NA) versus general anesthesia (GA), 273 266 births were included in the matched cohort. The primary outcome was the diagnosis of LNDDs, including intellectual disabilities and psychological development disorders, through December 31, 2023. Incidence rates per 1000 person-years (PYs) and HRs with 95% CIs were estimated using Cox proportional-hazards models. Sensitivity analyses included multivariable Cox models in the full cohort and a within-family (discordant sibling) design.

Results: In the matched cohort, the incidence rate of LNDDs was 3.53 (95% CI, 3.45 to 3.62) per 1000 PYs in the NA group and 3.99 (95% CI, 3.90 to 4.09) per 1000 PYs in the GA group. NA was associated with a lower hazard of LNDDs (HR 0.87, 95% CI 0.84 to 0.90; p<0.001). This association was consistent for intellectual disabilities (HR 0.83, 95% CI 0.78 to 0.88; p<0.001) and for psychological development disorders (HR 0.88, 95% CI 0.85 to 0.91; p<0.001). These associations remained consistent in both the full cohort analyses and the sibling comparison.

Conclusions: In this nationwide cohort, NA for cesarean delivery was associated with a modestly lower incidence and hazard of LNDDs compared with GA. These findings should be interpreted as exploratory and hypothesis-generating, rather than causal, and highlight the need for further research integrating detailed perinatal and anesthetic data.

Background: Cluster headaches (CHs), including episodic (ECH) and chronic (CCH) forms, are intensely painful and disabling, with limited preventative options. Greater occipital nerve blocks (GONBs) are frequently used in practice; however, the safety and efficacy of steroid-based injections, alone or combined with local anesthetic in CH patients, remain unclear.

Objective: To evaluate the efficacy and safety of corticosteroid-based GONBs, with or without local anesthetic, in patients with CHs, including ECH and CCH. Outcomes included attack frequency, proportion of responders, duration of effect, pain reduction, and adverse events.

Evidence review: We systematically searched Cochrane, Embase, Emcare, PubMed, and PsycInfo from inception to March 24, 2025 for eligible studies involving patients with CHs who received GONBs stratified by corticosteroid use. Data were narratively synthesized, with random-effects meta-analyses performed: a proportional meta-analysis of GONB arms, and a binary meta-analysis of randomized studies comparing GONBs versus control (saline±local anesthetic). Subgroup and risk of bias (RoB) sensitivity analyses were conducted for ECH and CCH. RoB was assessed using the Cochrane RoB 2.0 and ROBINS-I tools. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Protocol registered on OSF (https://doi.org/10.17605/OSF.IO/6EAZN). No funding was received.

Findings: Nineteen studies were included, comprising 758 CHs, 324 ECHs, and 375 CCH patients. All studies suggested improvements in outcomes with particulate steroid-based GONBs. Pooled data showed similar efficacy between single and multiple injections, with mostly minor, transient adverse events and consistent reductions in pain across studies. Mean duration of effect was 43 days (CH), 61.6 days (ECH), and 32.2 days (CCH). Proportional meta-analyses explored probabilities of response: CH=73%, ECH=77%, CCH=69% (I²=86.5%, 47.8%, 89.9%). Sensitivity analyses provided similar estimates: CH=79%, ECH=75%, CCH=70%. Binary meta-analyses showed non-significant reductions in attack frequency for CH (p=0.06) and ECH (p=0.11), and a significant reduction for CCH (p=0.01, relative risk=2.67, 95% CI 1.24 to 5.75). Adverse events did not differ between groups (p=0.43).

Conclusion: Particulate steroid-based GONBs show promise for CH treatment by decreasing attack frequency, while mostly producing short-term adverse events. The evidence quality spans from very low to moderate.

Background: The immediate postoperative period is high-risk for patients with psychiatric comorbidities or substance use disorders, who are prone to prolonged opioid use. Transitional Pain Services (TPSs) support pain control, tapering, and recovery, but predictors of high utilization are unclear.

Methods: We conducted a retrospective cohort study of surgical patients managed by TPS at a Veterans Affairs medical center from February 2024 to February 2025. Outcomes included total postoperative opioid use (morphine milligram equivalents, MME), TPS duration (days), and provider contacts, analyzed using multivariable linear regression (one-sided winsorization at 90th percentile). Predictors included demographics, pain catastrophizing, psychiatric/substance use history, and preoperative opioid use.

Results: Among 345 patients, 94% had chronic pain, 26% used opioids preoperatively, 69% had psychiatric diagnosis, and 79% had substance use history. Of preoperative opioid users (n=88), 68% achieved dose reduction; only 3.2% of the full cohort were discharged on higher doses. Median postoperative use was 218 MME (IQR 165-428), TPS duration 31 days (IQR 12-36), provider contacts 5 (IQR 3-6). Pain catastrophizing was the strongest predictor: each point increase was associated with 31 MME higher opioid use (p=0.023), 3.9 additional TPS days (p<0.001), and increased contacts (p=0.015). Active nicotine use (β=109 MME, p=0.005) and preoperative opioid ≥50 MME/day (β=169 MME, p=0.006) also predicted higher opioid consumption.

Conclusions: Pain catastrophizing and substance use markers predicted higher TPS utilization and opioid use, highlighting the value of preoperative psychosocial screening. Limiting dose escalation to 3.2%, despite increased baseline risks, demonstrates the effectiveness of well-resourced TPS programs.

Introduction: Amputation in patients with complex regional pain syndrome (CRPS) remains controversial, with variable outcomes in quality of life (QoL), disability, pain reduction, and complications. This study aims to evaluate long-term outcomes in CRPS patients who underwent amputation.

Methods: We conducted a single-center retrospective observational study combined with a cross-sectional survey of all CRPS patients who underwent limb amputation between 2003 and 2023 at the Erasmus MC University Medical Center. Preamputation and short-term postamputation outcomes were extracted from medical records, with short-term pain scores reflecting measurements within the first year after amputation. Long-term outcomes, including QoL, disability, pain, and satisfaction, were assessed through patient-reported questionnaires. Subgroup analyses were performed based on the presence of a neurostimulator implant.

Results: A total of 39 patients with a median CRPS Severity Score of 12 (IQR 11-13) were included. 34 patients (87%) completed the survey a median of 6.4 years (IQR 3.0-11.7) after amputation. The 36-Item Short Form Health Survey yielded mean physical and mental health summary scores of 45.4 (±26.1) and 67.7 (±22.3), respectively. The mean Pain Disability Index score was 29.3 (±15.1). Pain decreased by a mean of 3.54 points (95% CI: 2.46 to 4.62) at short-term follow-up (median 5 months, IQR 2-6) and 2.71 points (95% CI: 1.76 to 3.65) at long-term follow-up. Residual limb pain occurred in 77%, phantom limb pain in 85%, and CRPS recurrence in the stump in 10%. Overall, 94% of respondents were satisfied and would choose amputation again. Neurostimulator status did not influence measured outcomes.

Conclusions: In this cohort of severe, therapy-resistant CRPS, amputation was associated with meaningful improvements in QoL, disability, and pain in carefully selected cases, although complications remained common. Amputation should, therefore, be reserved as a last-resort intervention, offered only in specialized multidisciplinary centers.

Introduction: The safety of operating room extubation (ORE) immediately following cardiac surgery via median sternotomy remains unclear. However, reported outcomes in the setting of parasternal regional analgesia are limited. This study examined the safety of ORE for patients who received postoperative superficial parasternal intercostal plane (SPIP) blocks following median sternotomy for cardiac surgery.

Methods: Single-center retrospective cohort study from January 2020 to September 2023 compared the outcomes of adult cardiac surgical patients who were either extubated in the operating room immediately after surgery with SPIP blocks (ORE-B), received SPIP blocks and were extubated in the intensive care unit within 6 hours (FTE-B) or did not receive SPIP blocks and were extubated in the intensive care unit within 6 hours (FTE). Assessed outcomes were reintubation, use of non-invasive positive pressure ventilation (NIPPV), intensive care unit (ICU) readmission, return to OR, postoperative transfusion, ICU and hospital length of stay.

Results: 2294 patients were studied, which included 256 ORE-B patients, 729 FTE-B patients and 1,309 FTE patients. Differences in reintubation rates (1.2% vs 0.7% vs 1.2%, all p≥0.26) and use of NIPPV (4.8% vs 4.8% vs 5.1%, all p≥0.743) did not differ between ORE-B, FTE-B, and FTE groups, respectively. Time to extubation differed between FTE-B and FTE groups (2.5 hours vs 3.8 hours, p=<0.001), respectively. Additionally, hospital length of stay was significantly shorter for groups ORE-B and FTE-B compared with group FTE (5 days vs 5 days vs 6 days), respectively.

Conclusions: Selective ORE after median sternotomy for cardiac surgery was not associated with an increased risk of reintubation and NIPPV use in the setting of parasternal regional analgesia.

Introduction: Certain specialized hand surgery procedures benefit from intraoperative motor testing and patient-demonstrated active range of motion. This requires motor-sparing regional anesthesia of the hand using targeted ultrasound-guided nerve blocks in the forearm.

Objective: We present a joint surgical and anesthetic perspective covering the utility and indications for motor-sparing forearm blocks. We describe the anatomical principles and technical details of their performance and discuss other considerations for surgical and anesthetic success.

Findings: Patient selection and expectation setting are critical for success. Four terminal nerves must be blocked: median nerve, ulnar nerve, superficial radial nerve, and lateral antebrachial cutaneous nerve. These must be targeted distal to origin of motor branches to extrinsic muscles of the hand, with precise deposition of limited volumes of local anesthetic. The nerves can be readily identified with ultrasound imaging by their predictable anatomical relationship to specific muscles and blood vessels.

Conclusion: Intraoperative motor testing in complex surgical repair of the hand is associated with improved surgical outcomes, as well as greater patient satisfaction. Ultrasound-guided motor-sparing forearm blocks are a safe and effective method for achieving surgical anesthesia and optimal operating conditions in this context.