Nerve Block Rationale

WHY I DON’T USE NERVE BLOCKS FOR SHOULDER (OR KNEE) SURGERY – NEW STUDY AGAIN SHOWS INCREASED PAIN THE DAY AFTER SURGERY WITH BLOCK COMPARED TO NO BLOCK!

Many patients ask me why I don’t use nerve blocks for outpatient arthroscopic shoulder (eg rotator cuff or labrum repair) and knee (eg acl reconstruction or meniscectomy) surgery which form the bulk of my surgical practice. There are 4 reasons.

• First, these are minimally invasive procedures for which nerve blocks are not necessary. We have found that the use of motorized ice machines combined with a short period of narcotic use are satisfactory. Indeed some patients hardly even need the narcotics because of the benefits of the cold therapy.
• Second, numerous studies and meta-analyses, including a new just published such study have shown that there is a “rebound effect” that results in greater pain the day after surgery than if no block were used. Years ago I tried using blocks and noticed that my day-after surgery patients were often miserable, worse on average than patients who had no block, and I stopped using them
• Third, the blocks do provide better pain relief for 6-8 hours after surgery facilitating patients being discharged. However when the block wears off late at night the pain can be difficult to control. I took care of patient a few years ago who had failed prior surgery in Chicago at a respected major medical center. His pain was so severe when the block wore off the night of surgery that he passed out and had to be taken by ambulance to the hospital. He was quite unhappy. If he had not had a block this excess pain would been recognized before he left and could have been properly controlled, perhaps he would have been admitted. As it stands the block benefits the hospital or surgicenter by allowing them to discharge patients on time but is not always in the patient’s best interest.
• Fourth, although rare, complications from blocks, such as nerve damage do occur – and I have seen such patients referred in. For knee surgery femoral blocks, formerly very commonly used, have now been associated with long term perhaps permanent quadriceps muscle weakness and an increased risk of falls – sometimes resulting in fracture - after surgery. In my view there is no reason to take even small risks for a procedure that offers no compensatory benefit, and, as described above, is in fact undesirable in my opinion for the other reasons described above.

I wish to add that the use of nerve blocks for those surgeons who choose to use them is perfectly appropriate and I respect their judgement, but the above evidence based discussion explains why I believe it is in my patient’s best interest not to use them in general. I would add that in special circumstances, such as medication allergies, I will use them. And I will also use them if the patient wishes me to, although in my experience most patients are relieved at not having to have one. My goal is to have an informed evidenced based discussion with the patient so that we can make the best decision for that individual together.