Pain management and reduction of opioid consumption after
shoulder surgery remains a concern. The association between postoperative
exposure to opioids and long-term dependence has been described. Liposomal
bupivacaine (LB) has been utilized as a soft tissue infiltration during
shoulder surgery with mixed results and unclear efficacy compared to
interscalene brachial plexus blockade. Recently, LB has become FDA approved for
use in an interscalene brachial plexus block.
Patel and colleagues performed a randomized,
double-blinded controlled trial comparing an interscalene brachial plexus block
using LB to saline (placebo) for shoulder surgery. In this industry-funded phase
3 trial, the authors found that the LB group demonstrated substantially
improved pain scores and decreased narcotic consumption during the first 48
hours after surgery without an increase in adverse events. Additionally, it
appeared that a smaller dosage of LB (133 mg) was sufficient to generate a
sustained pain-relieving effect and rebound pain was minimal.
Based on this study, LB is clearly superior to placebo.
Given that saline blocks are not used clinically, the lack of a clinically
relevant control group represents the study’s most striking weakness. Further
research will be necessary to compare the efficacy, safety and cost-analysis of
LB to bupivacaine HCl blocks with and without catheters.
Surena Namdari , MD, MSc
Shoulder and elbow surgery
Associate professor of orthopedic surgery
Director of Shoulder & Elbow Research
Rothman Institute - Thomas Jefferson University
Disclosures: Namdari reports no relevant financial disclosures.