WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management

Abstract

Background: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. Methods: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. Results: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. Conclusion: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients.

Current Evidence Involving WALANT Surgery

“…Additionally, 20 patients underwent carpal tunnel release under WALANT versus 22 under LAWT and 20 under GA. Postoperative pain was statistically lower in the WALANT group in both open cubital tunnel and carpal tunnel surgeries as compared to the other methods of anesthesia, as represented by reduced postoperative opioid usage. Dar et al 25 further demonstrated the reduced lack of need for postoperative opioid usage in WALANT cases in their prospective cohort study, which found that only 2 of 94 patients (2.1%) sought out opioids from outside providers after undergoing WALANT cases, versus 20% of patients who underwent the same procedures under LAWT with sedation. In addition, WALANT patients had significant less pain than LAWT patients with sedation, with or without the use of opioids ( P < .0001).…”

“…Finally, there is possibly an element of demystifying the surgery and encouraging greater patient engagement in their care. 25 …”

“…Postoperative pain is equivalent or better controlled with WALANT surgery than with GA or LAWT with or without sedation. 25 , 26 , 27 , 28 , 29 Chapman et al 26 prospectively evaluated postoperative opioid usage in patients who underwent carpal tunnel release under WALANT versus under LAWT with sedation. They found that there was no statistically significant difference in opioid usage between patients who underwent WALANT surgery (78 cases; 4.9 pills/case) versus LAWT with sedation (198 cases; 3.9pills/case).…”

“…In addition, WALANT patients had significant less pain than LAWT patients with sedation, with or without the use of opioids ( P < .0001). 25 …”

Optimization of Carpal Tunnel Syndrome Using WALANT Method

“…Kang et al did, however, observe that there was less need for supplemental opioid injections in the wide-awake group than in the general anesthesia group (12% versus 35%, respectively), showing that there is a strong possibility that WALANT could be beneficial in reducing the need for opioids [62]. Additionally, Dar et al demonstrated that WALANT patients who were not prescribed opioids following surgery experienced lower pain scores at 14 days post-operation than patients who underwent similar procedures under MAC [63]. This finding suggests that the need for opioid prescriptions post-operatively might be reduced after utilizing the WALANT technique.…”