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OPINION Regional anesthesia in pain management
Michele Curatolo

Purpose of review
The study focuses on neural blocks with local anesthetics in postoperative and chronic pain. It is prompted
by the recent publication of several systematic reviews and guidelines.
Recent findings
For postoperative pain, the current evidence supports infusions of local anesthetics at the surgical site,
continuous peripheral nerve blocks, and neuraxial analgesia for major thoracic and abdominal procedures.
Ultrasound guidance can improve the performance of the blocks and different patient outcomes, although the
incidence of peripheral nerve damage is not decreased. For chronic pain, the best available evidence is on
nerve blocks for the diagnosis of facet joint pain. Further research is needed to validate diagnostic nerve blocks
for other indications. Therapeutic blocks with only local anesthetics (greater occipital nerve and sphenopalatine
ganglion) are effective in headache. A possible mechanism is modulation of central nociceptive pathways.
Therapeutic nerve blocks for other indications are mostly supported by retrospective studies and case series.
Recent literature strongly supports the use of regional anesthesia for postoperative pain, whereby infusions
at peripheral nerves and surgical site are gaining increasing importance. Local anesthetic blocks are valid
for the diagnosis of facet joint pain and effective in treating headache. There is a need for further research
in diagnostic and therapeutic blocks for chronic pain.
chronic pain, nerve blocks, postoperative pain, regional analgesia, regional anesthesia

INTRODUCTION and the American Society of Anesthesiologists pub-

Regional anesthesia is the only pharmacological lished an evidence-based guideline on the manage-

approach that is able to stop pain. This is because ment of postoperative pain [6 ]. Based on a
of the unique ability of local anesthetics to provide structured systematic review of the available liter-
deep block of sensory input. This study focuses on ature, an interdisciplinary panel developed recom-
the use of neural blocks with local anesthetics for the mendations to guide clinical practice. In the field of
management of acute and chronic pain. Injections regional anesthesia, the panel recommended to:
of steroid, as well as injection of any medication at consider surgical site-specific local anesthetic infil-
joints, ligaments, or tendons are not discussed. In tration (weak recommendation, moderate-quality
line with this journal policy, the study is not a evidence); consider surgical site-specific peripheral
comprehensive review of the practice of regional regional anesthetic techniques in adults and chil-
anesthesia for pain management; it rather discusses dren (strong recommendation, high-quality evi-
topics of current interest in this field and focuses on dence); use continuous, local anesthetic-based
research published in the last 12–18 months, based peripheral regional analgesic techniques when the
on my selection and appraisal of the literature. need for analgesia is likely to exceed the duration of
effect of a single injection (strong recommendation,
The main rationale for using regional anesthesia in Department of Anesthesiology and Pain Medicine, University of Wash-
acute postoperative pain is its superiority to ington, Seattle, USA
systemic analgesia in terms of pain relief [1–5]. Correspondence to Michele Curatolo, MD, PhD, Department of Anes-
thesiology and Pain Medicine, University of Washington, 1959 NE Pacific
Street, Box 356540, Seattle, WA 98195-6540, USA. Tel: +1 206 543
Recent recommendations 2673; e-mail:
Recently, the American Pain Society, the American Curr Opin Anesthesiol 2016, 29:000–000
Society of Regional Anesthesia and Pain Medicine, DOI:10.1097/ACO.0000000000000353

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Regional anesthesia

However, a wide application of this practice has

KEY POINTS been challenged in recent years. Some surgical tech-
 For postoperative pain, the current evidence supports niques have become less invasive, requiring less
infusions of local anesthetics at the surgical site, aggressive analgesic regimens. Improved periopera-
continuous peripheral nerve blocks, and neuraxial tive care has reduced the risk of postoperative com-
analgesia for major thoracic and abdominal plications, reducing the effect of epidural analgesia
procedures. on postoperative morbidity over time [8]. Severe
 Ultrasound guidance can improve the performance of neurological complications, although very rare,
the blocks and different patient outcomes, although the remain a concern.
incidence of peripheral nerve damage is not decreased. The above considerations led to a progressively
lesser use of neuraxial blocks, in favor of peripheral
 For chronic pain, the best available evidence is on
nerve blocks. These procedures, when performed
nerve blocks for the diagnosis of facet joint pain, and
further research is needed to validate diagnostic nerve either as single shot or as continuous infusion, are
blocks for other indications. particularly suited for surgery on the upper and
lower limb, and for some procedures on the trunk.
 Therapeutic blocks with only local anesthetics (greater The main advantages over neuraxial analgesia are
occipital nerve and sphenopalatine ganglion) are
the avoidance of potentially catastrophic neurologic
effective in headache, whereas their efficacy for other
chronic pain conditions has not been adequately complications associated with spinal procedures,
studied. the higher hemodynamic stability and the lesser
impairment of motor function. A recent narrative
review based on a systematic literature search and
prospectively defined appraisal criteria came to the
moderate-quality evidence); and offer neuraxial conclusion that the majority of peripheral regional
analgesia for major thoracic and abdominal pro- anesthetic techniques produce benefits for patients
cedures, particularly in patients at risk for cardiac and hospital efficiency: they reduce postoperative
complications, pulmonary complications, or pro- pain and opioid consumption and/or increase
longed ileus (strong recommendation, high-quality patient satisfaction; for selected surgical procedures,
evidence). the use of blocks can avoid general anesthesia and is
The same panel identified several research gaps in associated with increased efficiency of the surgical
postoperative pain management and published an pathway [9]. An exception is the transversus abdom-
additional study highlighting areas where future inis plane block, where the evidence for efficacy was
research is needed [7 ]. In the field of regional anes- conflicting. This is confirmed by a recent meta-
thesia, the review found that most trials were not analysis, which found marginal postoperative anal-
designed to assess the risk of uncommon compli- gesic efficacy of transversus abdominis plane block
cations. Because the sample size would be prohibitive after abdominal laparotomy/laparoscopy and cesar-
for a randomized controlled trial (RCT), the review ean delivery [10]. Consistent with the aforemen-
highlighted the need for databases or registries that &&
tioned study by the multisociety panel [7 ], the
capture data of large patient populations to address review [9] found that the evidence for the impact
occurrence and risk factors for uncommon, but of peripheral nerve blocks on longer-term outcomes
potentially disastrous, complications. Although was inadequate to inform clinical decision-making.
there is a reasonable amount of evidence suggesting Ultrasound guidance has gained enormous pop-
that the use of epidural analgesia is associated with a ularity in the last decade. Multiple recently pub-
decrease in perioperative morbidity, the review lished systematic reviews found ultrasound
found a lack of similar data for continuous peripheral guidance to improve the performance of the blocks
regional analgesia. In addition, there are few data on and different patient outcomes [11–14]. Impor-
the efficacy of regional analgesia on patient-reported tantly, the expectation that direct visualization of
outcomes (e.g., satisfaction, quality of recovery, qual- the neural structures would reduce the incidence of
ity of life, and sleep). The use of perioperative regional neurologic complications has not been confirmed,
anesthesia/analgesia may decrease the incidence or but ultrasound guidance has been found to reduce
severity of chronic postsurgical pain, but there is a the risk of local anesthetic systemic toxicity and
need for further research in this field. possibly pneumothorax [15 ].

An alternative to neuraxial and peripheral

blocks is infiltration of local anesthetics at the sur-
Alternatives to neuraxial analgesia gical site, which has been the focus of several inves-
The use of neuraxial analgesia undoubtedly led to tigations in the last decade. A recent meta-analysis
dramatic improvements in perioperative pain care. found continuous local anesthetic infusion to be

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Regional anesthesia in pain management Curatolo

more effective than placebo in controlling pain after instance, they cannot tell us whether pain stem-
total knee arthroplasty, but the incidence of infection ming from a facet joint has an inflammatory origin,
was increased [16]. However, a previous meta- is the result of a joint capsule tear, a microfracture,
analysis on heterogeneous types of surgery had found or other lesions. However, they can provide infor-
efficacy of continuous local anesthetic infusion, mation on the anatomical structure that is the
without an increase in the incidence of infections primary source of nociception; specifically, medial
[17]. Another systematic review and meta-analysis on branch blocks can tell us with a reasonable degree of
wound infiltration of bupivacaine or ropivacaine in confidence whether the pain stems primarily from a
breast cancer surgery found no difference from facet joint or not. This conclusion cannot be made
placebo in postoperative pain scores; of notice, the for a block of nerves that supply multiple structures
medication was injected perioperatively, with no that are potential sources of nociception. For
following continuous infusion via a catheter [18]. instance, pain relief after a block of the ilioinguinal
It seems that a continuous local anesthetic infusion and iliohypogastric nerves in a patient with groin
at the site of surgery may be a valuable alternative to pain cannot differentiate between neuropathy of
neuraxial or peripheral nerve blocks. Although this those nerves and pain arising from damaged tissues
treatment seems to be more effective than placebo, supplied by the nerves. Block of nerves supplying
the relevant question is whether it produces superior multiple structures that are potential sources of
or at least an equivalent effect on patient outcomes nociception should not be called diagnostic. A
compared with continuous epidural or peripheral possible better term is test block, as the aim is testing
nerve infusions. Clinical trials will unlikely have the possible involvement of nerves in the trans-
enough power to detect differences in rare compli- mission of pain [19,25].
cations, but it would be desirable to have more data
on how infusions at surgical sites compare with
traditional analgesic techniques in terms of analgesia Therapeutic blocks
and common side-effects. The use of therapeutic nerve blocks with local anes-
thetics has a long tradition but a weak literature. The
term therapeutic is used when a long-term effect is
CHRONIC PAIN expected by the procedure. On a first glance, it
Blocks with local anesthetics are offered to chronic seems irrational to expect a therapeutic effect by
pain patients for either diagnostic or therapeutic the injection of a local anesthetic, as the effect on
purposes. nerve conduction is short lasting. However, a sys-
tematic review found consistent evidence for an
effect of local anesthetic injections that exceeds
Diagnostic blocks the duration of the conduction blockade [26]. No
Many chronic pain conditions have no morphologi- study included in the review had negative results,
cal correlate that can be detected by clinical exam- but all reviewed articles were single case reports or
ination or medical imaging. For some such case series, preventing reliable conclusions.
conditions, nerve blocks can be used to identify The best available literature on therapeutic
the source of pain [19]. The rationale is that if a nerve blocks is on the use of greater occipital nerve
structure is the source of pain, then anesthetizing it (GON) blocks in headache. Different studies using
or its nerve supply should relieve the pain. If the local anesthetics alone or in combination with a
suspected structure is not the source of pain, anaes- steroid have been performed. They have mostly
thetizing it should not relieve the pain. shown efficacy in reducing pain intensity and/or
Nerve blocks of the facet joints have shown face frequency of pain attacks in different forms of head-
validity and construct validity for the diagnosis of ache. Most of the studies were prospective case series
cervical and lumbar facet joint pain (medial branch or audits, either using single injections or a series of
blocks) [20–24]. The validity of medial branch procedures at variable intervals [27–29]. An obser-
blocks has been thoroughly studied in the 90s, open- vational study evaluated the effect of repeated GON
ing a new era in the evidence-based practice of and supraorbital nerve blocks on migraine patients,
interventional pain medicine. Regrettably, research performed a maximum 10 times on alternate days:
on validation of diagnostic nerve blocks has almost 85% of patients had a positive response during a
stopped since then. This leaves us with only specu- 6-month observation period [30]. Of notice, only
lation on the possible validity of blocks performed bupivacaine without a steroid was injected. The
for indications other than facet joint pain. efficacy of GON blocks has been evaluated also by
Nerve blocks cannot identify the specific patho- RCTs. One RCT on cervicogenic headache found
logical process underlying a pain condition. For occipital nerve blocks to be superior to placebo at

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2-week follow-up; a mixture of local anesthetic, sphenopalatine ganglion blocks may be useful for the
opioid, and clonidine was injected [31]. A GON acute management of headache. The literature on
steroid injection without local anesthetic was different approaches to block the sphenopalatine
superior to placebo in preventing cluster headache ganglion was recently reviewed [36 ]: it was found
attacks [32]. Another RCT compared a local anes- that the published data support efficacy of the block
thetic alone with a mixture of a local anesthetic and for cluster headache and migraine in both the short
a steroid in chronic daily headache: pain was sig- and long term, although the data are not very robust.
nificantly reduced, with no difference between the Different mechanisms may underlie a possible
two groups up to 4 weeks after the injection [33]. therapeutic effect of local anesthetic nerve blocks in
The most recent placebo-controlled trial was con- chronic pain conditions. The literature on headache
ducted on chronic headache using a series of GON is important in this respect. The GON supplies the
injections and showed superiority of local anes- skin of the occipital region, which is not a primary
thetic injections to placebo at 4-week follow-up source of nociception in headache. So why should
[34 ]. A limitation of placebo-controlled trials is anesthesia of this nerve reduce headache? Further-
the limited ability to blind patients to the group more, why should the effect be long-lasting, given
allocation, as the GON block produces cutaneous the fact that the conduction blockade is of short
numbness. duration? The most widely accepted explanation for
A recent placebo-controlled study evaluated a possible effect of GON block on headache is the
transnasal sphenopalatine ganglion blocks with presence of anatomical and functional connections
0.5% bupivacaine, performed 12 times during 6 between cervical and trigeminal pathways involved
weeks in patients with chronic migraine [35]. The in headache [37,38]. Block of sensory input from the
bupivacaine group had statistically significant lower tissues supplied by the GON may lead to reduced
pain scores up to 24 h after the block, with an activity of central neural pathways responsible for
improvement during the overall treatment period. headache, ultimately producing pain relief (Fig. 1).
The patients were re-evaluated at 1 and 6 months Two studies on healthy volunteers and cluster head-
after procedure, but no data on pain were ache patients analyzed the effect of unilateral GON
provided. This study shows that a series of transnasal block on the nociceptive blink reflex [39,40]. The

Functional Possible mechanism for

connections greater occipital nerve block

Headache Reduced headache

Trigeminal Reduced nociceptive

pathways trigeminal transmission
Reduced nociceptive


C1–2–3 Nerve
pathways block

FIGURE 1. Possible mechanisms of action of greater occipital nerve blocks in headache. Left: functional connection between
trigeminal and cervical pathways. Right: possible modulating effect of blocking neural transmission from the greater occipital
nerve on trigeminocervical pathways involved in headache.

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Regional anesthesia in pain management Curatolo

nociceptive blink reflex is a measure of central scores before at 1 and 3 months after procedure [43].
nociceptive trigeminal transmission. In both studies When compared with fluoroscopy, ultrasound
GON block produced a decrease in the reflex imaging was found to be an accurate technique
responses that was statistically significant only for for performing cervical facet joint nerve blocks,
reflexes measured at the side of the block [39,40], except for the C7 medial branch blocks [44].
supporting a reduction in nociceptive trigeminal In two randomized controlled studies on diagnostic
transmission by block of afferent input from cervical nerve blocks for facet joint pain, fluoroscopy and
pathways. Cutaneous allodynia is common in ultrasound guidance provided similar success
migraine and is the result of central sensitization rates, but ultrasonography was associated with
[41]. GON block reduces cutaneous allodynia in improved efficiency (decreased performance time
trigeminal and cervical areas [42]. This suggests that and fewer needle passes) [45,46 ]. Ultrasound-
a block of afferent input from cervical pathways guided piriformis injections provided similar out-
leads to attenuation of hypersensitivity of both comes to fluoroscopically guided injections with-
trigeminal and cervical nociceptive pathways. These out differences in imaging, needling, or overall
considerations may apply also to nerve blocks per- procedural times [47].
formed for conditions other than headache, but to
my knowledge, no mechanistic studies have been
conducted in this area. CONCLUSION
Another possible mechanism for a long-term Recent literature strongly supports the use of
effect is facilitation of functional and mental health regional anesthesia for postoperative pain, whereby
rehabilitation following the temporary pain infusions at peripheral nerves and surgical site are
reduction induced by the block. Patients who gaining increasing importance. Nerve blocks have
experience pain relief may be encouraged to diagnostic validity in chronic facet joint pain.
increase their level of activity and their mood Blocks of the GON and of the sphenopalatine
may be improved, with following long-term ganglion are effective in headache. More research
reduction in their pain. It is also possible that the is definitely needed to validate diagnostic blocks for
effect of local anesthetic blocks is explained by indications other than facet joint pain and to study
placebo, at least in part: most studies did not include the potential therapeutic value of nerve blocks in
a placebo control group; for those that did, group chronic pain. Ultrasound guidance improves the
allocation is difficult to blind, exposing these studies performance of peripheral nerve blocks and differ-
to the risk of observer bias. ent patient outcomes, but does not increase the
It is clear that the above considerations on incidence of neurologic complications.
mechanisms are largely speculative. More research
on therapeutic nerve blocks in terms of efficacy and Acknowledgements
mechanisms of action is highly desirable to establish None.
their role in the management of chronic pain.
Financial support and sponsorship
Ultrasound guidance
The use of ultrasound as guidance for nerve blocks Conflicts of interest
in chronic pain is increasing. Most of the published
The author has provided occasional consulting for Sono-
studies have focused on techniques, namely, aimed
Site, Bothell, USA.
at describing how to perform blocks under ultra-
sound guidance. Although this is very valuable
research, feasibility of a block under ultrasound REFERENCES AND RECOMMENDED
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