Psychological Distress in Hip Arthroscopy Patients Affects Postoperative Pain Control Michael Q. Potter, M.D., Grant S. Sun, B.S., Jennifer A. Fraser, M.D., James T. Beckmann, M.D., Jeffrey D. Swenson, M.D., Travis G. Maak, M.D., and Stephen K. Aoki, M.D.

Purpose: To determine whether patients with higher levels of preoperative psychological distress more frequently use a postoperative fascia iliaca nerve block for pain control after hip arthroscopy, and to determine whether a fascia iliaca nerve block is an effective adjunct to multimodal oral and intravenous analgesia after hip arthroscopy. Methods: One hundred seven patients undergoing hip arthroscopy were prospectively enrolled. Before surgery, patients were administered the Distress Risk Assessment Method questionnaire to quantify their level of preoperative psychological distress. Postoperatively, patients with pain inadequately controlled by multimodal oral and intravenous analgesics could request and receive a fascia iliaca nerve block. Pain scores, opioid consumption, time in the post-anesthesia care unit (PACU), and postoperative complications were recorded for all patients. Results: Patients with normal Distress Risk Assessment Method scores requested fascia iliaca nerve blocks approximately half as frequently (18 of 50 [36%]) as patients in the at-risk category (28 of 47 [60%]) or distressed category (7 of 10 [70%]) (P ¼ .02). Patients with high levels of distress also received 40% more intraoperative opioid than patients with normal scores (P ¼ .04). In the study population as a whole, patients who received a fascia iliaca nerve block (n ¼ 53) had a higher initial visual analog scale (VAS) pain score in the PACU (7.2  0.3 v 5.5  0.4, P ¼ .001) and showed greater improvement in the VAS pain score by PACU discharge (4.3  0.2 v 2.1  0.3, P  .0001) compared with patients who did not receive a block (n ¼ 54). Conclusions: Patients with higher levels of preoperative psychological distress more frequently requested a postoperative nerve block to achieve adequate pain control after hip arthroscopy. Patients receiving a block had greater improvement in VAS pain scores compared with patients managed with oral and intravenous analgesics alone. Level of Evidence: Level IV, case series.

H

ip arthroscopy is performed with increasing frequency for a range of indications, including femoroacetabular impingement, labral tears, removal of loose bodies, chondral injuries, synovitis, and septic arthritis.1 The increased prevalence of the procedure has increased interest in ensuring adequate analgesia postoperatively.2,3 Multiple authors have suggested that

From the Departments of Orthopaedics (M.Q.P., J.T.B., T.G.M., S.K.A.) and Anesthesia (J.A.F., J.D.S.) and School of Medicine (G.S.S.), University of Utah, Salt Lake City, Utah, U.S.A. The authors report the following potential conflict of interest or source of funding: S.K.A. is an educational consultant for Pivot Medical and ArthroCare. Received April 18, 2013; accepted November 13, 2013. Address correspondence to Stephen K. Aoki, M.D., Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13258/$36.00 http://dx.doi.org/10.1016/j.arthro.2013.11.010

femoral nerve or lumbar plexus blockade with a local anesthetic may improve postoperative pain control when compared with oral and intravenous analgesia alone.4-7 Two of these studies have used prospective randomization schemes to compare the intervention under consideration.5,6 However, in clinical practice, most hip arthroscopy patients are not randomized to receive or not receive a nerve block; more typically, a block is offered if a patient’s pain exceeds a certain threshold postoperatively. Alternatively, a block may be performed preoperatively, although not all patients have enough pain after surgery to warrant a block. In this context, it is important to understand the factors, including psychological distress, that may lead hip arthroscopy patients to select a nerve block postoperatively. Patients with higher levels of psychological distress commonly report greater pain scores and inferior clinical outcomes compared with patients with normal levels of distress. In particular, increased psychological

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 2 (February), 2014: pp 195-201

195

196

M. Q. POTTER ET AL.

distress predicts a poor response to therapy, increased self-perceived pain, and decreased self-perceived function in patients with chronic low-back pain,8 upper-extremity musculoskeletal pain,9 and surgical spine conditions.10-12 On the basis of these findings, we believe it likely that distressed patients might report increased pain after hip arthroscopy and might more frequently require nerve blocks to achieve adequate analgesia postoperatively. The primary purpose of this study was to determine whether patients with higher levels of preoperative psychological distress more frequently use a fascia iliaca nerve block after hip arthroscopy. The secondary purpose was to evaluate whether a postoperative fascia iliaca nerve block is an effective adjunct to multimodal oral and intravenous analgesia after hip arthroscopy. We hypothesized that patients with higher levels of preoperative distress would more frequently request a nerve block to achieve adequate pain control postoperatively and that patients who received nerve blocks would show greater improvement in visual analog scale (VAS) pain scores than patients who did not receive blocks.

Methods Approval from our institutional review board was obtained before this study began. The inclusion criteria were patients aged 18 years or older who underwent hip arthroscopy for a primary complaint of hip pain. The exclusion criterion was an inability to complete the Distress Risk Assessment Method (DRAM) questionnaire or chronic use of opioid medications. One hundred fourteen consecutive patients scheduled for hip arthroscopy by a single orthopaedic surgeon were approached to participate in the study. Of these, 107 (94%) consented to participate and completed the DRAM questionnaire before the surgical procedure. The DRAM questionnaire is a 45-item patient questionnaire that combines the modified Zung Depression Scale and the Modified Somatic Perception Questionnaire. The modified Zung Depression Scale assesses depressive symptoms using statements such as “I feel hopeful about the future” or “I feel downhearted and sad,” with patients indicating how often they feel the statement to be true. The Modified Somatic Perception Questionnaire asks patients to score how often they have somatic symptoms such as “feeling hot all over” or “muscles twitching or jumping.” The scores on these 2 questionnaires are combined and used to stratify patients into normal, at-risk, and distressed groups, which represent increasing levels of depressive and somatic symptomatology.13 The DRAM has been validated and shown to correlate with worsening psychological distress as measured by the more comprehensive Minnesota Multiphasic Personality Inventory.13,14 It is presently used as a parsimonious method to stratify patients into groups of low, moderate, and high

psychological distress, which correspond to the normal, at-risk, and distressed designations, respectively. Patients completed a pen-and-paper questionnaire, which was then collected and sequestered by a study coordinator. The tests were scored by the same study coordinator. The treating surgeon and all others involved in providing patient care were blinded to the DRAM results. Patient enrollment began in October 2011 and concluded in November 2012. One hour before surgery, patients received 1-time oral doses of pregabalin, 150 mg; celecoxib, 400 mg; and tapentadol, 100 mg. The possibility of a fascia iliaca nerve block was discussed, and patients gave informed consent to receive a block postoperatively if their pain control was inadequate. Hip arthroscopy was performed under a total intravenous general anesthetic using remifentanil and propofol, with intravenous fentanyl administered during the procedure at the discretion of the anesthesiologist. The fentanyl dose was titrated to maintain a respiratory rate greater than 10 breaths per minute. Patients were admitted to the postanesthesia care unit (PACU) postoperatively, and their pain levels were assessed with the VAS pain score. Patients who believed that their pain was inadequately controlled in the PACU had the option to request and receive a fascia iliaca nerve block. All patients, independent of block status, continued to receive oral and intravenous analgesics and were discharged from the PACU based on standard criteria. Three patients required admission overnight, in all cases for inadequate pain control. Fascia iliaca nerve blocks were performed with a variable-frequency linear ultrasound transducer (GE Medical, Milwaukee, WI) under the supervision of specialty-trained regional anesthesiologists. By use of ultrasound guidance and an out-of-plane approach, a 22-gauge needle was positioned 1 cm lateral to the femoral nerve and deep to the fascia iliaca. Thirty milliliters of 0.25% preservative-free bupivacaine with 5 mg/mL of epinephrine was injected deep to the fascia iliaca and lateral to the femoral nerve. Expansion of the tissue plane and local anesthetic spread around the femoral nerve were visualized with ultrasound to confirm appropriate placement of the block (Fig 1). Demographic data were collected for all patients and are reported in Tables 1 and 2. All surgical procedures were performed by a single surgeon, and the groups were similar with respect to surgical time and procedures performed. We recorded data on intraoperative opioid administration (morphine equivalents [MEQ] in milligrams), PACU opioid administration, admission and discharge VAS scores in the PACU, total time in the PACU, and admission status. Any postoperative cutaneous numbness was assessed and recorded at regularly scheduled clinic follow-up visits.

DISTRESS AND NERVE BLOCK AFTER ARTHROSCOPY

197

Fig 1. (A) An ultrasound image of the inguinal region shows the femoral artery (FA) and the femoral nerve (FN) before injection of local anesthetic. The FN is immediately lateral to the FA and deep to the fascia iliaca. The nerve lies on the surface of the iliopsoas (IS) muscle. The arrow indicates the point of injection lateral to the FN. (B) Ultrasound image of inguinal region after injection of 30 mL of local anesthetic deep to fascia iliaca. The arrows indicate the deep surface of the fascia iliaca, which has been displaced superiorly, confirming placement of the injection in the appropriate tissue plane. In this view the FN is still adherent to the surface of the IS muscle but has been displaced inferiorly by the volume of local anesthetic.

A power analysis was performed before patient enrollment began. Using a b of 20%, an a of 20%, and an SD of 30%, we estimated that we would require 35 patients per group (normal, at risk, and distressed), or 105 patients in total, to have 80% power to show a 20% difference in nerve block utilization rates. Age at surgery, body mass index (BMI), intraoperative opioid administration, PACU opioid administration, initial PACU VAS score, discharge PACU VAS score, change in VAS score, and time in the PACU were treated as continuous variables and compared by use of the Student t test. Gender, procedures performed, procedure laterality, smoking status, percentage receiving a block, percentage admitted, and percentage with postoperative cutaneous numbness were treated as categorical variables and analyzed with the c2 test. P  .05 is reported as significant. A simple Bonferroni correction was used for the 2 primary study hypotheses, and the threshold for significance was set at P  .025.

Results One hundred seven patients enrolled in the study. Of these patients, 50 (47%) had DRAM scores within the

normal range, 47 (44%) fell into the at-risk group, and 10 (9%) fell into the distressed group. Demographic data among all groups were similar, with no significant differences seen in gender, laterality of the affected hip, procedures performed, BMI, or smoking status. The distressed group was significantly older (mean age, 46.2  2.9 years) than either the normal group (mean age, 34.4  1.7 years) or at-risk group (mean age, 35.5  1.7 years) (P ¼ .04), but the clinical significance of this is uncertain (Table 1). Patients in the normal group received a fascia iliaca nerve block in 36% of cases, as compared with 60% in the at-risk group and 70% in the distressed group (P ¼ .02). Patients in the distressed group received significantly more intraoperative opioid (9.5  2.1 MEQ) than those in the at-risk group (6.7  0.5 MEQ) or normal group (6.8  0.4 MEQ) (P ¼ .04) and showed nonsignificant trends toward greater opioid utilization in the PACU (P ¼ .19), a higher VAS pain score on PACU admission (P ¼ .07), and a greater likelihood of overnight admission for pain control (P ¼ .07). Time in the PACU (P ¼ .94) and the VAS score at PACU discharge (P ¼ .93) were similar across groups (Table 3).

Table 1. Demographic Characteristics by DRAM Group Age (yr) Gender Laterality Femoral osteoplasty Labral repair Capsular repair Additional procedure BMI Smoking status

Normal (n ¼ 50) 34.4  1.7 (95% CI, 31.1-37.6) 29 female and 21 male 27 left and 23 right 50 of 50 (100%) 30 of 50 (60%) 47 of 50 (94%) 18 of 50 (36%) 25.4  0.7 (95% CI, 24.2-26.7) 10 of 50 (20%)

At Risk (n ¼ 47) 35.5  1.7 (95% CI, 32.2-38.9) 30 female and 17 male 24 left and 23 right 45 of 47 (96%) 22 of 47 (47%) 41 of 47 (87%) 13 of 47 (28%) 26.2  0.8 (95% CI, 24.6-27.8) 14 of 47 (30%)

Distressed (n ¼ 10) 46.2  2.9 (95% CI, 40.6-51.8) 7 female and 3 male 4 left and 6 right 10 of 10 (100%) 5 of 10 (50%) 10 of 10 (100%) 4 of 10 (40%) 25.7  1.9 (95% CI, 22.0-29.4) 2 of 10 (20%)

P Value P ¼ .004 P ¼ .71 P ¼ .72 P ¼ .27 P ¼ .53 P ¼ .29 P ¼ .60 P ¼ .37 P ¼ .50

NOTE. The baseline demographic characteristics and nature of procedures performed in patients are stratified by DRAM group. Age and BMI are reported as mean  standard error of the mean (95% confidence interval [CI]).

198

M. Q. POTTER ET AL.

Table 2. Demographic Characteristics by Block Group Age (yr) Gender Laterality Femoral osteoplasty Labral repair Capsular repair Additional procedure BMI Smoking status

Block (n ¼ 53) 37.1  1.6 (95% CI, 34.0-40.1) 38 female and 15 male 29 left and 24 right 53 of 53 (100%) 25 of 53 (47%) 50 of 53 (94%) 17 of 53 (32%) 25.8  0.7 (95% CI, 24.5-27.1) 13 of 53 (25%)

No Block (n ¼ 54) 34.9  1.7 (95% CI, 31.6-38.2) 28 female and 26 male 22 left and 32 right 52 of 54 (96%) 32 of 54 (59%) 48 of 57 (89%) 18 of 54 (33%) 25.8  0.7 (95% CI, 24.3-27.2) 13 of 54 (24%)

P Value P ¼ .35 P ¼ .03 P ¼ .15 P ¼ .16 P ¼ .21 P ¼ .31 P ¼ .89 P ¼ .96 P ¼ .96

NOTE. The baseline demographic characteristics and nature of procedures performed in patients are compared between patients receiving a block and those not receiving a block. Age and BMI are reported as mean  standard error of the mean (95% confidence interval [CI]).

In total, 53 of 107 patients (50%) received a fascia iliaca nerve block. The demographic data in patients receiving a block and those not receiving a block were similar, with no significant differences seen in age, laterality of the affected hip, procedures performed, BMI, or smoking status. The block group contained a higher percentage of female patients (38 of 53 [72%]) than the non-block group (26 of 54 [52%]) (P ¼ .03) (Table 2). Patients who requested a fascia iliaca nerve block had significantly higher VAS scores on PACU admission (7.2  0.3) than patients who did not request a block (5.5  0.4) (P ¼ .001). When PACU admission and discharge VAS scores were compared, block patients reported significantly greater improvement in their postoperative pain (4.3  0.2) than did non-block patients (2.1  0.3) (P  .0001). There were no significant differences between the block and non-block groups in intraoperative or PACU opioid utilization (P ¼ .98), VAS score at PACU discharge (P ¼ .15), time spent in the PACU (P ¼ .08), or likelihood of admission (P ¼ .08). Patients who received a nerve block were significantly more likely to report cutaneous numbness at clinic follow-up (26%) than patients who did not receive a block (11%) (P ¼ .04) (Table 4). Of 20 patients with numbness at the initial postoperative visit, 12 (60%) had complete resolution of their symptoms at most recent follow-up (mean, 8 months; range, 3 to 18 months).

Discussion The primary aim of this investigation was to determine whether patients with higher levels of preoperative psychological distress more frequently request a fascia iliaca nerve block for pain control after hip arthroscopy. This appears to be the case by a nearly 2-to-1 margin, with patients in the at-risk and distressed DRAM groups selecting a nerve block in 60% and 70% of cases, respectively, compared with 36% of patients with normal DRAM scores (P ¼ .02). Our study was not specifically powered to address the secondary variables that we collected, but we saw nonsignificant trends toward greater opioid consumption, higher selfreported pain scores, and a greater likelihood of admission for pain control among distressed patients. These trends accord with data from the surgical spine population, in which increased preoperative anxiety and depression were the greatest independent predictors of failure to report improved pain or function after lumbar fusion surgery.10-12 Unfortunately, our study is of insufficient size to draw firm conclusions about opioid consumption or the likelihood of admission for pain control based on DRAM grouping because it was powered to address the primary outcome of receiving or not receiving a block rather than these secondary outcome measures. Investigation of a larger, appropriately powered population is still required. Furthermore, documenting pain and functional scores at later clinical time pointsdas has been

Table 3. Outcome Measures by DRAM Group Received nerve block Intraoperative opioid (MEQ) Opioid in PACU (MEQ) Initial PACU VAS score Discharge PACU VAS score Change in VAS score Time in PACU (min) Admission for pain control Cutaneous numbness

Normal (n ¼ 50) 18 of 50 (36%) 6.8  0.4 (95% CI, 5.9-7.6) 4.4  0.6 (95% CI, 3.2-5.6) 6.0  0.4 (95% CI, 5.3-6.7) 3.1  0.3 (95% CI, 2.6-3.7) 2.9  0.3 (95% CI, 2.3-3.6) 102  4 (95% CI, 94-109) 0 of 50 (0%) 7 of 50 (14%)

At Risk (n ¼ 47) 28 of 47 (60%) 6.7  0.5 (95% CI, 5.8-7.6) 4.0  0.6 (95% CI, 2.7-5.2) 6.4  0.4 (95% CI, 5.7-7.2) 3.2  0.3 (95% CI, 2.5-3.8) 3.3  0.3 (95% CI, 2.6-3.9) 101  4 (95% CI, 93-109) 2 of 47 (4%) 12 of 47 (26%)

Distressed (n ¼ 10) 7 of 10 (70%) 9.5  2.1 (95% CI, 5.5-13.5) 6.5  1.5 (95% CI, 3.5-9.5) 7.6  0.6 (95% CI, 6.5-8.7) 3.1  0.6 (95% CI, 1.9-4.3) 4.5  0.8 (95% CI, 2.9-6.1) 104  4 (95% CI, 95-113) 1 of 10 (10%) 1 of 10 (10%)

P Value P ¼ .02 P ¼ .04 P ¼ .19 P ¼ .07 P ¼ .93 P ¼ .06 P ¼ .94 P ¼ .07 P ¼ .26

NOTE. The outcomes measures of the patients are stratified by DRAM group. Intraoperative and PACU opioid administration is reported as morphine equivalents in milligrams. Opioid utilization, VAS pain scores, and time in the PACU are reported as mean  standard error of the mean (95% confidence interval [CI]).

DISTRESS AND NERVE BLOCK AFTER ARTHROSCOPY

199

Table 4. Outcome Measures by Block Group Intraoperative opioid (MEQ) Opioid in PACU (MEQ) Initial PACU VAS score Discharge PACU VAS score Change in VAS score Time in PACU (min) Admission for pain control Cutaneous numbness

Block (n ¼ 53) 6.8  0.4 (95% CI, 5.9-7.6) 4.4  0.6 (95% CI, 3.3-5.5) 7.2  0.3 (95% CI, 6.7-7.6) 2.8  0.3 (95% CI, 2.3-3.4) 4.3  0.2 (95% CI, 3.8-4.8) 102  4 (95% CI, 94-109) 3 of 53 (6%) 14 of 53 (26%)

No Block (n ¼ 54) 6.9  0.5 (95% CI, 6.0-7.9) 4.4  0.6 (95% CI, 3.1-5.6) 5.5  0.4 (95% CI, 4.7-6.2) 3.4  0.3 (95% CI, 2.9-4.0) 2.1  0.3 (95% CI, 1.5-2.7) 97  4 (95% CI, 89-105) 0 of 54 (0%) 6 of 54 (11%)

P Value P ¼ .98 P ¼ .98 P ¼ .001 P ¼ .15 P  .0001 P ¼ .08 P ¼ .08 P ¼ .04

NOTE. The outcomes measures are compared between patients receiving a block and those not receiving a block. Intraoperative and PACU opioid administration is reported as morphine equivalents in milligrams. Opioid utilization, VAS pain scores, and time in the PACU are reported as mean  standard error of the mean (95% confidence interval [CI]).

done in the spine literaturedwill give us a more complete understanding of the relation between psychological distress and patient outcomes after hip arthroscopy. The clinical relevance of more frequent nerve block utilization by the distressed population is several-fold. First, the nerve block procedure itself incurs additional material costs and anesthesia professional fees; these costs may not be bundled with the charges for the hip arthroscopy procedure or the anesthetic. Because distressed patients are more likely to request a nerve block, it may be reasonable to counsel them that they are more likely to incur additional costs related to the regional anesthesia procedure. Second, although reported rates of complications are low, nerve block procedures are not totally without risk. In the knee arthroplasty population, quadriceps weakness due to a femoral block has been reported to cause postoperative falls, which in turn risks patient injury.15 Intraneural anesthetic injection may lead to postblock peripheral neuropathy, and intravascular anesthetic injection can cause dysrhythmias or other systemic complications.16,17 In addition, postoperative changes in the anatomy of the inguinal region may make fascia iliaca blocks more challenging, potentially increasing the risk of an adverse event.18 Because of their higher rates of nerve block utilization, distressed patients may in turn run a higher risk of having a block-related complication after hip arthroscopy. Lastly, in a clinical setting in which the preference is to perform a nerve block before surgery, distinguishing between normal and distressed patients preoperatively may help minimize the number of unnecessary procedures. The risks of regional anesthesia may be reduced by using ultrasound guidance to visualize appropriate anesthetic placement, as was performed in our study. We identified no intraneural or intravascular anesthetic injections in our study, although patients receiving a block reported higher rates of cutaneous numbness at initial clinical follow-up (26%) than those not receiving a block (11%) (P ¼ .04). Of 20 patients, 12 (60%) had resolution of their symptoms at most recent follow-up.

Portal placement for hip arthroscopy is known to be associated with cutaneous numbness, particularly in the distribution of the lateral femoral cutaneous nerve.19 However, in light of our data, we suggest that patients should be counseled that a fascia iliaca nerve block may increase the risk of transient cutaneous numbness compared with hip arthroscopy alone. In evaluating our second hypothesis that patients receiving a fascia iliaca nerve block would have greater pain relief than patients not receiving a block, we identified several items of relevance. First, patients selecting a fascia iliaca nerve block reported higher initial VAS scores (7.2  0.3) than those not selecting a block (5.5  0.4) (P ¼ .001). As discussed earlier, regional anesthesia has small but real risks, and it is reassuring that the population that received a block was distinguished from the population that did not receive a block by greater pain scores in the face of similar opioid administration and operative procedures performed. We suggest that using a threshold VAS score of 6 may be an effective way of reserving nerve block procedures for a selected population of patients whose pain cannot be adequately controlled through other means. In our study population, 48 of 53 patients receiving a block (91%) were above this threshold and 31 of 54 patients not receiving a block (57%) were below this threshold on arrival in the PACU. Second, patients receiving a fascia iliaca nerve blockdregardless of DRAM groupdexhibited a greater reduction in postoperative pain (4.3  0.2) than patients managed with oral and intravenous analgesics alone (2.1  0.3) (P  .0001). As a consequence, both the block and non-block groups reported similar VAS scores at PACU discharge. This finding accords with previous reports showing that lumbar plexus blockade4,6 or a femoral nerve block5 is more effective than opioids alone in controlling pain after hip arthroscopy, suggesting that regional anesthetic procedures are an effective analgesic adjunct for postoperative pain control in properly selected hip arthroscopy patients. In the only prior study we identified that evaluated the efficacy of a femoral nerve block for pain control after hip arthroscopy, Ward et al.5 randomized 16

200

M. Q. POTTER ET AL.

patients to pain control with morphine and 20 patients to a femoral nerve block without morphine. Patients in the femoral nerve block group had faster times to PACU discharge, greater satisfaction with their pain control regimen, and less nausea than those receiving morphine, leading the authors to conclude that “femoral nerve block is an excellent alternative to routine opioid pain medication in patients undergoing hip arthroscopy.” We are also heartened by our finding that a fascia iliaca nerve block provides excellent analgesia independent of DRAM group and therefore represents an effective treatment modality even in the face of greater psychological distress. Limitations The patients in this study were not randomized to receive or not receive a block postoperatively. This design was necessary to address our primary question of what role psychological distress plays in patient selection of fascia iliaca nerve blocks after hip arthroscopy. When comparing the block and non-block groups, we found similar demographic data, but randomization would have been a more rigorous format to evaluate our secondary question of what effect a fascia iliaca nerve block has on postoperative pain control after hip arthroscopy. Furthermore, our calculation of time spent in the PACU is confounded by the fact that all block procedures were performed in the PACU. If the blocks had been performed in the operating room or after discharge from the PACU, we might expect a more accurate comparison of PACU times between the block and non-block patients. In addition, although our enrollment criteria were broad, all surgeries were performed by a single high-volume arthroscopist at an orthopaedic specialty hospital and all blocks were performed by specialty-trained regional anesthesiologists, so it may be uncertain how generalizable our results are in other clinical settings. Finally, an ideal analysis would have included equal or nearequal numbers in each of the DRAM groups (normal, at risk, and distressed), so our analysis is limited by the small number of enrolled patients who were stratified into the distressed group. Enrollment of unequal numbers of patients in each group was a function of enrolling consecutive patients in a blinded fashion to avoid selection bias.

Conclusions Patients with higher levels of preoperative psychological distress more frequently requested a fascia iliaca nerve block to achieve adequate pain control after hip arthroscopy. Patients receiving a block had greater improvement in VAS pain scores compared with patients managed with oral and intravenous analgesics alone.

References 1. Khanduja V, Villar RN. Arthroscopic surgery of the hip: Current concepts and recent advances. J Bone Joint Surg Br 2006;88:1557-1566. 2. Baker JF, Byrne DP, Hunter K, Mulhall KJ. Postoperative opiate requirements after hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2011;19:1399-1402. 3. Baker JF, McGuire CM, Byrne DP, Hunter K, Eustace N, Mulhall KJ. Analgesic control after hip arthroscopy: A randomised, double-blinded trial comparing portal with intra-articular infiltration of bupivacaine. Hip Int 2011;21: 373-377. 4. Schroeder KM, Donnelly MJ, Anderson BM, Ford MP, Keene JS. The analgesic impact of preoperative lumbar plexus blocks for hip arthroscopy: A retrospective review. Hip Int 2013;23:93-98. 5. Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy 2012;28:1064-1069. 6. YaDeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: A prospective randomized controlled trial. Anesth Analg 2012;115: 968-972. 7. Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: Combined L1 and L2 paravertebral blocks. J Clin Anesth 2008;20:462-465. 8. Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine 1995;20: 2702-2709. 9. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am 2009;91:2014-2018. 10. Trief PM, Ploutz-Snyder R, Fredrickson BE. Emotional health predicts pain and function after fusion: A prospective multicenter study. Spine 2006;31:823-830. 11. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J 2001;1:274-282. 12. Trief PM, Grant W, Fredrickson BE. A prospective study of psychological predictors of lumbar surgery outcome. Spine 2000;25:2616-2621. 13. Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The distress risk assessment method: A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 1992;17:42-52. 14. Deyo RA, Walsh NE, Schoenfel LS, Ramamurthy S. Studies of the modified somatic perceptions questionnaire (MSPQ) in patients with back pain: Psychometric and predictive properties. Spine 1989;14: 507-510. 15. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010;468: 135-140. 16. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional

DISTRESS AND NERVE BLOCK AFTER ARTHROSCOPY Anesthesia Hotline Service. Anesthesiology 2002;97: 1274-1280. 17. Loubert C, Williams SR, Helie F, Arcand G. Complication during ultrasound-guided regional block: Accidental intravascular injection of local anesthetic. Anesthesiology 2008;108:759-760.

201

18. Davis JD, Swenson JD, Kelly S, et al. Anatomic changes in the inguinal region after hip arthroscopy: Implications for femoral nerve block. J Clin Anesth 2012;24: 590-592. 19. Griffen DR, Villar RN. Complications of arthroscopy of the hip. J Bone Joint Surg Br 1999;81:604-606.

Psychological distress in hip arthroscopy patients affects postoperative pain control.

To determine whether patients with higher levels of preoperative psychological distress more frequently use a postoperative fascia iliaca nerve block ...
488KB Sizes 0 Downloads 0 Views