Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery.
BACKGROUND
Regional anaesthesia may reduce the rate of persistent (chronic) pain after surgery, a frequent and debilitating condition.


OBJECTIVE
To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent pain six or 12 months after surgery.


METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), PubMed (1966 to April 2012), EMBASE (1966 to May 2012) and CINAHL (1966 to May 2012) without any language restriction. We used a combination of free text search and controlled vocabulary search. The results were limited to randomized controlled clinical trials (RCTs). We conducted a handsearch in reference lists of included trials, review articles and conference abstracts.


METHODS
We included RCTs comparing local anaesthetics or regional anaesthesia versus conventional analgesia with a pain outcome at six or 12 months after surgery.


METHODS
Two authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. Results are presented as pooled odds ratios (OR) with 95% confidence intervals (CI), based on random-effects models (inverse variance method). We grouped studies according to surgical interventions. We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity.


RESULTS
We identified 23 RCTs studying local anaesthetics or regional anaesthesia for the prevention of persistent (chronic) pain after surgery. Data from a total of 1090 patients with outcomes at six months and of 441 patients with outcomes at 12 months were presented. No study included children. We pooled data from 250 participants after thoracotomy, with outcomes at six months. Data favoured regional anaesthesia for the prevention of chronic pain at six months after thoracotomy with an OR of 0.33 (95% CI 0.20 to 0.56). We pooled two studies on paravertebral block for breast cancer surgery; the pooled data of 89 participants with outcomes at five to six months favoured paravertebral block with an OR of 0.37 (95% CI 0.14 to 0.94).The methodological quality of the included studies was intermediate. Adverse effects were not studied systematically and were reported sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered the assessment of effects, especially at 12 months.


CONCLUSIONS
Epidural anaesthesia may reduce the risk of developing chronic pain after thoracotomy in about one patient out of every four patients treated. Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about one out of every five women treated. Our conclusions are significantly weakened by performance bias, shortcomings in allocation concealment, considerable attrition and incomplete outcome data. We caution that our evidence synthesis is based on only a few, small studies. More studies with high methodological quality, addressing various types of surgery and different age groups, including children, are needed.
Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA.mhandreae@gmail.com.
Michael H
MH
Andreae
Doerthe A
DA
Andreae
D000671:Amputation, Surgical / Q000009:adverse effects; D000698:Analgesia / Q000379:methods*; D000765:Anesthesia, Conduction; D000779:Anesthetics, Local; D001943:Breast Neoplasms / Q000601:surgery; D002585:Cesarean Section / Q000009:adverse effects; D059350:Chronic Pain / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects; D008297:Male; D009407:Nerve Block / Q000379:methods; D010149:Postoperative Pain / Q000517:prevention & control*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D013908:Thoracotomy / Q000009:adverse effects
D000779:Anesthetics, Local