Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review

Abstract

Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.

The effect of perineural dexamethasone on rebound pain after ropivacaine single-injection nerve block: A randomized controlled trial

“…Rebound pain following single-shot nerve block is a clinically relevant but less valued phenomenon that even diminishes the real bene t of peripheral nerve block in some surgeries [7,8,17]. Patients undergoing surgical repair of distal radius fractures experienced different pain pro les after general anesthesia compared with a peripheral nerve block.…”

“…For patients receiving ambulatory surgery, rebound pain is challenging to prevent or control, especially when it happens at home, which is a common cause of unplanned readmission to the hospital [5]. Initially focused on by orthopedic surgeons, rebound pain after nerve block is gaining increasing attention from anesthesiologists [6][7][8]. It has been reported after different kinds of surgeries, such as ankle fracture surgery under popliteal sciatic nerve block [9], distal radius fracture xation under brachial plexus block [10] and shoulder arthroscopy surgery under interscalene brachial plexus block [11].…”

The effect of perineural dexamethasone on rebound pain after ropivacaine single-injection nerve block: A randomized controlled trial

“…Rebound pain following single-shot nerve block is a clinically relevant but less valued phenomenon which even diminishes the real bene t of peripheral nerve block in some surgeries [7,8,17].Patients undergoing surgical repair of distal radius fractures experienced different pain pro le after general anaesthesia compared with a peripheral nerve block. Although patients with brachial plexus block had less pain immediately after the procedure, 12 h to 24 h later when the block wore off, their pain was higher than those in the general anaesthetic group [10].…”

“…For patients receiving ambulatory surgery, the rebound pain is challenging to prevent or control, especially when it happens at home, which is a common cause of unplanned readmission to hospital [5]. Initially brought out by orthopaedic surgeons, rebound pain after nerve block are gaining more and more attention from anesthesiologists [6][7][8]. It has been reported after different kinds of surgeries, such as ankle fracture surgery under popliteal sciatic nerve block [9], distal radius fracture xation under brachial plexus block [10] and shoulder arthroscopy surgery under interscalene brachial plexus block [11].Understanding the mechanism and searching for strategies to prevent rebound pain is integral to the effective utilization of regional anaesthesia.…”

Local Anesthetics

“…It is a relevant complication since it hinders the postoperative evolution, disturbing sleep, increasing the opioid requirement and delaying hospital discharge. Preventive analgesia before the blockage subsides, intra-articular or intravenous anti-inflammatory drugs, and the use of adjuvants added to nerveblock or systemic solutions can reduce rebound pain [65][66][67].…”