Perineural block is superior to intravenous dexamethasone block during a single injection of scalenus muscle in the shoulder under arthroscopy：a meta- analysis

doi:10.21203/rs.3.rs-1912103/v1

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Research Article

Perineural block is superior to intravenous dexamethasone block during a single injection of scalenus muscle in the shoulder under arthroscopy：a meta- analysis

https://doi.org/10.21203/rs.3.rs-1912103/v1

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Purpose

Both perineural and intravenous dexamethasone prolongs the efficacy of a single interscalene brachial plexus block (ISB). But there is currently debate about the best route of administration. The purpose of this meta-analysis was to compare the efficacy and safety of perineural injection of dexamethasone versus intravenous injection of dexamethasone in the treatment of ISB during arthroscopic shoulder surgery.

Methods

Relevant studies published before May 05, 2021 were retrieved from PubMed, Embase, and Web of Science databases according to the preferred reporting items of the Systematic Evaluation and Meta-analysis (PRISMA) guidelines. The primary outcomes were duration of analgesia, sensory and motor block. The secondary outcomes included postoperative pain, opioid consumption and incidence of adverse events. We performed a meta-analysis to find significant differences between the two modalities.

Results

Seven studies were identified (846 patients). Perineural injection of dexamethasone can significantly prolong the analgesic time (WMD: 1.699 hours; 95% CI: 0.0014, 3.384; P: 0.048) and reduced postoperative pain at 12 hours (WMD: -0.652; 95% CI: -1.129, -0.176; P: 0.007). There was no significant difference between the two groups regarding the duration of sensory and motor block, postoperative pain and opioid consumption at 24 hours, and incidence of adverse events (dyspnea, sleep disturbance, and postoperative glucose change).

Conclusions

The current evidence demonstrated the superior effect of dexamethasone is used around the nerve for prolonged analgesia and reducing acute postoperative pain.

perineural

intravenous

dexamethasone

interscalene nerve block

analgesia

Shoulder operation, including an arthroscopic surgery, often results in considerable postoperative pain(1). Untreated or undertreated pain may influence patient’s quality of life, increase the risk of postoperative complication, prevent early rehabilitation and discharge. Despite progress in pain management, optimize pain control after arthroscopic shoulder surgery remains an significant and ambitious mission in clinical practice(2).

Interscalene brachial plexus block (ISB) is the gold standard for acute pain after shoulder surgery (3). However, a single-shot ISB usually dissipates after several hours(4), the duration of analgesia is usually insufficient to adequately control the pain in the majority of patients(3). Therefore, In order to prolong and enhance the analgesic effect of a single injection of ISB, various adjuvants were studied (5). Among all, dexamethasone shows the most promise(6), as Again, studies have shown that adding it to local anesthetics can significantly prolong the duration of analgesia (7, 8).

Although previous studies demonstrated Dexamethasone prolonged analgesia both perineural and intravenous (9). It’s worth noting that the efficacy of dexamethasone may vary depending on the route of administration. Recently, Some researchers intended to compare the analgesic effects of perineural and intravenous dexamethasone for ISB, but the results remained controversial(10). Since more valid and stronger evidences were needed to identify the best administration route, we conducted a meta-analysis to compare the curative effect and safety of perineural versus intravenous dexamethasone for ISB in arthroscopic shoulder surgery.

Search strategy

This meta-analysis was registered at PROSPERO (CRD42021253499) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines (11). We conducted a comprehensive search through PubMed, Embase, and Web of Science databases to identify relevant studies, with final search being conducted on May 05, 2021. The searching terms used are as follows: ((‘intravenous’ OR ‘systemic’) AND ‘perineural’); and ‘dexamethasone’ OR ‘glucocorticoids’ OR ‘corticosteroids’ OR ‘steroids’; and ‘brachial plexus block’ OR ‘interscalene block’ OR ‘infraclavicular block’ OR ‘supraclavicular block’ OR ‘axillary block’ OR ‘nerve block’; and ((‘arthroscopy’ OR ‘arthroscopic’ OR ‘surgery’) AND ‘shoulder’). The search was limited to clinical studies published in English. References to the review and eligible studies were also retrieved for use in other studies. .

Inclusion/Exclusion criteria

We collected studies that met the required criteria below: (1) Participants: sick people underwent single-shot ISB for arthroscopic shoulder surgery; (2) Intervention:

dexamethasone was given to the peripheral nerve as an adjunct to local anesthetics; (3) Comparator:Same dose of dexamethasone i.V. (4) Outcomes: duration of analgesia, duration of sensory and motor block, postoperative pain at 12 hours and 24 hours, opioid consumption within 24 hours and incidence of adverse events.

The exclusive criteria were as follows: (1) studies evaluating local anesthetics plus dexamethasone versus local anesthetic alone; (2) studies comparing perineural versus intravenous dexamethasone in other types of surgery. (3) Case studies, letters, abstracts, reviews, reviews and in vivo or in vitro studies; ; (4) The study did not have enough data to extract or calculate results; (5) Repeated studies..

Data extraction and quality assessment

All searched studies were independently verified and extracted by two reviewers. Any disagreement is resolved by consulting a third author. The main outcomes were block-related outcomes (duration of analgesia, sensory and motor block). Secondary outcomes included postoperative pain at 12 hours and 24 hours, opioid consumption within 24 hours and incidence of adverse events (dyspnea, sleep disturbance and postoperative glucose change). In addition, the following data were extracted: first author, published year, country, sample size, age, gender, type of local anesthetic, dose of dexamethasone and quality of each study. The quality of included randomized studies were assessed by the Jadad Scale(12), studies with Jadad score greater than 3 were defined as high quality study.

Statistical analysis

Meta-analysis was performed using STATA 12.0 software, with P-value＜0.05 considered statistically significant.. Heterogeneity between studies was assessed by I² statistic and Chi squared test. If the heterogeneity test was not statistically significant (I²＜50%, P＞0.1), the fixed-effect model was adopted. Otherwise, random effect model was used. We calculated risk rations (RR) with 95% confidence interval (95% CI) for dichotomous outcomes, and weighted mean difference (WMD) or standard mean difference (SMD) with 95% CI for continuous outcomes.

Literature retrieval results

Figure 1 shows the screening and selection processes. The primary literature search initially identified 91 studies. After 28 duplicates were deleted, 63 potential eligible studies were screened on titles and abstracts. Of these studies, 55 were excluded because they were not able to meet the inclusion criteria. Subsequently, the remained 8 studies were assessed for full-text eligibility. Finally, 7 studies satisfied the inclusion criteria(6, 13-18).

Research characteristics and quality assessment

The characteristics of included studies were summarized in Table 1. In total, 846 Eligible patients were included, including 426 patients in perineural dexamethasone group and 420 patients in intravenous dexamethasone group. The population ranged from 47 to 59.2 years old. The type, concentration, and dose of local anesthetics used for nerve block varied from studies. The studies also varied in the dose of dexamethasone used, ranged from 1 mg to 10 mg, and the most commonly used dose was 4mg. One study compared low-dose (4mg) dexamethasone with high-dose (8mg) dexamethasone administered by either perineural or intravenous routes, and data for both doses were included in our study (6). All included studies were considered as high quality.

Primary outcomes

Duration of analgesia: This variable was reported in five studies, with pooled results showing that perineural dexamethasone significantly prolonged analgesia compared to intravenous dexamethasone (WMD: 1.699 hours; 95% CI: 0.0014, 3.384; I²: 64.3%; P: 0.048, random model) (Figure 2a).

Duration of sensory block: Two included studies investigated this outcome, and the result showed no significant difference between perineural and intravenous dexamethasone (WMD: 264.579 minutes; 95% CI: -490.767, 1019.924; I²: 86.7%, P: 0.492, random model) (Figure 2b).

Duration of motor block: This variable was assessed in two studies. Overall, there was no significant difference between the two groups (WMD: 110.48 minutes; 95% CI: -284.379, 505.339; I²: 74.2%, P: 0.583, random model) (Figure 2c).

Secondary outcomes

Postoperative pain at 12 hours: In view of this variable, the pooled result showed perineural dexamethasone was associated with a significant lower postoperative pain score at 12 hours (three studies, WMD: -0.652; 95% CI: -1.129, -0.176; I²: 43.1%, P: 0.007, fixed model) (Figure 3a).

Postoperative pain at 24 hours: This outcome was reported in three studies, the pooled analysis demonstrated no significant difference between the groups (WMD: -0. 309; 95% CI: -1.275, 0.658; I²: 72%, P: 0.531, random model) (Figure 3b).

Opioid consumption within 24 hours: Two studies measured this outcome. In this analysis, no significant difference was observed between the two groups (SMD: -0.019; 95% CI: -0.244, 0.206; I²: 0%, P: 0.866, fixed model) (Figure 3c).

Adverse events: In view of the incidence of adverse events, the pooled results showed no statistical difference for either outcome. Dyspnea (three studies, RR: 0.936; 95% CI: 0.27, 3.24; I²: 0%, P: 0.916, fixed model), sleep disturbance (two studies, RR: 1.028; 95% CI: 0.526, 2.01; I²: 28.7%, P: 0.935, fixed model), and postoperative glucose change (two studies, WMD: -1.5; 95% CI: -4.723, 1.722; I²: 0%, P: 0.361, fixed model).

ISB is widely and increasingly performed for better postoperative pain control, but it is often insufficient because of the relatively short duration of analgesia. Efforts to enhance and prolong the analgesic effect of local anesthetics include the use of adjuvants such as dexamethasone(18). However, several studies have reported contradictory findings concerning the safety and administration route of dexamethasone for ISB in arthroscopic shoulder surgery. Therefore, we conducted a meta-analysis to evaluate the comparative efficacy and safety of perineural and intravenous dexamethasone for ISB. Our results indicated Perineural dexamethasone was more effective in increasing the duration of analgesia and reducing pain up to 12 hours after surgery, which might improve the recovery and outcome of patients after surgery.

When dexamethasone was combined with medium or long-acting local anesthetics, postoperative analgesia time was approximately doubled (17). In regard to the optimal administration route, the results varied across studies. Whereas Abdallah and Desmet reported the analgesic duration was independent of the administration route as both perineural and intravenous dexamethasone produced similar results(10, 13). Several investigators supported perineural over intravenous dexamethasone for improving analgesic duration. Ryosuke and colleagues demonstrated that the duration of effective postoperative analgesia induced by a single ISB was significantly prolonged by perineural rather than intravenous dexamethasone injection (16). Richard et al concluded that perineural dexamethasone prolonged the analgesic duration in the range of 2.5 to 5 hours (19). It was evident that because of the conflicting results, there was pressing need to identify the most effective route of administration. Our meta-analysis confirmed a significantly longer analgesic duration in perineural dexamethasone. This was concordant with a Cochrane review, which suggested that perineural dexamethasone provided superior analgesic duration in both upper and lower extremity peripheral nerve block(20).

Literature search suggested that the superior function of perineural dexamethasone for ISB might have contributions from both systemic absorption and direct local effects(21). In a word, Dexamethasone, which was used locally, was thought to suppress ectopic neural discharge, decrease nociceptive C-fibre activity and reduce neuropeptide immune response to injury(10, 22). Furthermore, it also induced vasoconstriction with concomitant slower anesthetic absorption, thus extended the analgesic duration of local anesthetic(23).

Since most studies only focus on the analgesic duration, the research in the duration of sensory and motor block is relatively limited. Theoretically, perineural administration should also prolong the sensory and motor block duration, but several studies demonstrated conflicting results. Thiago and colleagues observed that sensory and motor blocks in the perineural group lasted longer than those in the intravenous group (17). Results of a meta-analysis showed that perineural injection of dexamethasone significantly prolonged sensory block duration, but had no statistical significance in motor block duration (21). These findings were, however, contrary to the results found by Paul and Faraj, which showed similar sensory and motor block duration between the two modalities(18, 24). Their studies arrived at the same conclusion as ours, the pooled results revealed that the two routes of administration exert an equivalent effect on sensory and motor block. However, due to the limited studies included in our meta-analysis, further investigation is needed to verify this finding.

Optimization of postoperative pain control and opioid consumption play an important role in the outcomes of arthroscopic shoulder surgery. Previous studies proved that both perineural and intravenous administration of dexamethasone could reduce postoperative pain and opioid consumption, but the superior route remained a topic of debate. Some studies found no difference between the two modalities(10, 19), whereas other studies supported perineural dexamethasone for relieving pain(17) and reducing opioid consumption(16). The results of our meta-analysis showed that, perineural dexamethasone provided a great benefit in terms of pain control within 12 hours, but there was no significant difference in postoperative pain and opioid consumption at 24 hours. Recent evidence suggests that local interactions between dexamethasone and nerves are one of the pain regulatory mechanisms by which perineural dexamethasone controls acute postoperative pain (21).

Although dexamethasone has demonstrated excellent efficacy in prolonging analgesic duration and reducing acute postoperative pain, concerns exist regarding possible adverse events. Of most concern is the steroid-induced hyperglycemia. Several studies have observed increased blood glucose concentration in patients receiving dexamethasone intravenously or by the perineural route(13, 14). In our meta-analysis, pooled results indicated no apparent differences in the changes of blood glucose concentration between the two administration routes. Beside this, dyspnea and sleep disturbance both have a considerable impact on overall patient satisfaction. Our results are consistent with previous study, which suggested no marked difference in the incidence of dyspnea and sleep disturbance between the two modalities(6). Thus, it could be presumed that perineural dexamethasone offered a significant benefit to analgesic duration and acute postoperative pain control, without any associated increase of complications.

Limitation

There were some limitations to our study that need to be noted. Firstly, only a small number of studies were included and some studies reported only part of outcomes. This limitation prevented us from achieving a robust conclusion. Secondly, the type, concentration and dosage of local anesthetic in various trials were inconsistent, which might contribute to the observed heterogeneity. Moreover, there was a possibility that dexamethasone might be dose-dependent effects on duration of analgesia. However, due to the limited number of studies included, we could not conduct a subgroup analysis to evaluate this effect in the two modalities.

In conclusion, this study demonstrated that perineural dexamethasone significantly prolonged analgesic duration and reduced postoperative pain at 12 hours compared with intravenous dexamethasone for ISB. However, due to the uncertainty about its mechanism of action, optimal dose and neurotoxicity, more consideration and research is required before perineural dexamethasone can be routinely used to treat ISB in arthroscopic shoulder surgery. .

Benefit Conflict: There are no conflict of interest that the authors declare

PROSPERO: CRD42021253499

Implication statement:The optimal route of dexamethasone for single-shot interscalene block remains a subject of debate. Our meta-analysis demonstrate perineural dexamethasone can provide superior analgesic effects for interscalene block.

Author’s contribution: RW wrote the manuscript, ZC, RW, JS collected and analyzed the data, WL designed this study and revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We sincerely thank all the authors of the original studies for providing published data in our meta-analysis.

Ethics approval and consent to participate: Not applicable.

Consent to publication: Not applicable.

Availability of data and material: The data are available from the corresponding author on reasonable request.

Competing interests: There was no conflicts of interest.

Funding: There was no funding information to declare.

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Table 1. Characteristics of included studies

Author

Year

Country

Study

Patients

Age

Sex(M/F)

Dose

Local anesthetic

Quality

McHardy PG^[18]

2020

Canada

RET

52.8

67/25

69/21

4mg

1% ropivacaine 3ml

Kahn RL^[15]

2018

USA

RCT

37/26

39/23

1mg

0.5% bupivacaine 30ml

Holland D(a)^[6]

2018

Canada

RCT

49/21

53/17

4mg

0.5% bupivacaine 30ml

Holland D(b)^[6]

2018

Canada

RCT

45/25

53/17

8mg

0.5% bupivacaine 30ml

Sakae TM^[17]

2017

Brazil

RCT

52.1

12/8

14/6

4mg

0.75% bupivacaine 20ml

Chun EH^[14]

2016

Korea

RCT

33/17

34/15

5mg

0.75% ropivacaine 60mg

Kawanishi R^[16]

2014

Japan

RCT

59.2

9/3

7/3

4mg

0.75% ropivacaine 20ml

Desmet L^[13]

2013

Belgium

RCT

51.6

21/28

23/26

10mg

0.5% ropivacaine 30ml

PN: peripheral group, IV: intravenous group, RET: randomized equivalence trial, RCT: randomized controlled trial.

No competing interests reported.

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Editor assigned by journal
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Submission checks completed at journal
02 Aug, 2022
First submitted to journal
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Perineural block is superior to intravenous dexamethasone block during a single injection of scalenus muscle in the shoulder under arthroscopy：a meta- analysis

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