Background: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. Methods: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. Results: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.

Study Design. A retrospective cohort study of prospectively collected data. Objective. The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. Summary of Background Data. ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. Methods. An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. Results. The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195–398 minutes] overall, 298 minutes (IQR 192–811) for lumbar decompression and 285 minutes (IQR 200–372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). Conclusion. This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. Level of Evidence: 3

OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210–1643 minutes). Eight patients required an extended stay—longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423–1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson’s r = −0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit–administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.

BackgroundEvidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.MethodsA systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.ResultsAnalysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).ConclusionsBased on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Background Hip arthroscopy is associated with moderate to severe postoperative pain. This prospective, randomized, double-blinded study investigates the clinically analgesic effect of anterior quadratus lumborum block with multimodal analgesia compared to multimodal analgesia alone. The authors hypothesized that an anterior quadratus lumborum block with multimodal analgesia would be superior for pain control. Methods Ninety-six adult patients undergoing ambulatory hip arthroscopy were enrolled. Patients were randomized to either a single-shot anterior quadratus lumborum block (30 ml bupivacaine 0.5% with 2 mg preservative-free dexamethasone) or no block. All patients received neuraxial anesthesia, IV sedation, and multimodal analgesia (IV acetaminophen and ketorolac). The primary outcome was numerical rating scale pain scores at rest and movement at 30 min and 1, 2, 3, and 24 h. Results Ninety-six patients were enrolled and included in the analysis. Anterior quadratus lumborum block with multimodal analgesia (overall treatment effect, marginal mean [standard error]: 4.4 [0.3]) was not superior to multimodal analgesia alone (overall treatment effect, marginal mean [standard error]: 3.7 [0.3]) in pain scores over the study period (treatment differences between no block and anterior quadratus lumborum block, 0.7 [95% CI, –0.1 to 1.5]; P = 0.059). Postanesthesia care unit antiemetic use, patient satisfaction, and opioid consumption for 0 to 24 h were not significantly different. There was no difference in quadriceps strength on the operative side between groups (differences in means, 1.9 [95% CI, –1.5 to 5.3]; P = 0.268). Conclusions Anterior quadratus lumborum block may not add to the benefits provided by multimodal analgesia alone after hip arthroscopy. Anterior quadratus lumborum block did not cause a motor deficit. The lack of treatment effect in this study demonstrates a surgical procedure without benefit from this novel block. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery. Methods A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events. Results A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], –1.1 [–1.8, –0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events. Conclusions Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. Methods This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. Results The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. Conclusions Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.