Advances in Easing Joint Surgery Pain

In the past, having a joint replaced usually meant general anesthesia for surgery followed by grogginess and the need for strong narcotic pain relievers. To reduce side effects and, in some cases, post-surgical pain, many surgeons now use regional and local anesthesia. 

Regional vs. General Anesthesia

Unlike general anesthesia, which knocks you out during surgery, regional anesthesia allows you to remain awake and blocks pain sensations to a particular area of the body. 

Joint replacement surgery is typically done with one of two types of regional anesthesia: 

• Spinal block is the injection of a pain reliever into the fluid surrounding the spinal cord in the lower back. It can last for several hours. 
• Epidural block is where the pain medicine is delivered to the epidural space (the outermost part of the spinal canal) through a thin tube (catheter) inserted near the spine, which is left in place until the surgery is complete.

Regional nerve blocks – applying an anesthetic directly to the nerves that supply the joint and its soft tissues – are often used along with spinal or epidural blocks. If longer relief is needed, the surgeon may place a tiny catheter next to the nerve and connect it to a pump to administer medicine for up to three days after surgery. 

Medical Advances and Research

Although nerve blocks have been available for some time, ultrasound technology is making them more precise, says Howard Konowitz, MD, medical director of Comprehensive Pain Management Group in Morton Grove, Illinois. “With ultrasound we [can locate] the arteries, veins, nerves, muscle and tissue under the skin,” he says. “This gives you a much higher success rate.”   

Some research suggests that people who have regional and local anesthesia experience less pain than those who have only general anesthesia. Literature shows pain control is better if the nerves are blocked and the brain doesn’t get the message that surgery going on.

In addition, evidence suggests people who have nerve blocks are less likely to experience complex regional pain syndrome. This trauma to the nerve, which can occur with surgery, leads to long-term pain that may be worse than what they started with.

Other Benefits

Regional and local analgesia may offer these other direct or indirect benefits: 

• Less need for opioids. The use of opioids for post-surgical pain relief can cause unwanted side effects and a risk of addiction. In a review of 10 studies of femoral nerve blocks for total knee replacement, use of the blocks was found to reduce opioid use at 24 hours and 48 hours after surgery. “Because numbing the nerves keeps people more comfortable the first few days after surgery, when pain is typically at its worst, some are able to avoid [opioids] completely,” says Dr. Konowitz. “Some patients tell me they never get their [painkiller] prescriptions filled.” When the analgesia wears off, the pain may be manageable with milder painkillers and nonsteroidal anti-inflammatory drugs (NSAIDs). 
   
• Less blood loss during surgery. General anesthetics can cause veins to dilate, which increases bleeding risk during surgery. Studies of people having total hip replacement have shown that those receiving regional anesthesia have approximately 30% less blood loss compared to those who have general anesthesia.  

• Reduced risks from immobility. Regional and local anesthetics may help patients be active sooner after surgery. “Any time people can use their limbs earlier, that reduces lung problems and breathing issues and the development of other problems,” says William J. Hopkinson, MD, orthopedic surgeon and professor at Loyola University Medical Center in Illinois. “The quicker you walk, the less likely you are to get a blood clot.”  

• Quicker recovery time. Blocking pain in the first days after surgery with regional nerve blocks and local anesthetics can help people move their joints and better tolerate physical therapy, says Dr. Konowitz. For knees, femoral nerve blocks can relieve pain while allowing enough sensation to begin exercise. 

Discuss Your Options

Regional and local anesthesia are not without risks, however, including potential cardiac problems resulting from too much analgesia.

Furthermore, spinal and epidural anesthesia are not appropriate for everyone, including those with spinal fusion or bleeding disorders. In these cases, regional nerve blocks and local analgesia can still be useful for pain relief after surgery.

Talk to your surgeon before surgery to discuss pain-relief options during and after surgery. The goal is not only to improve the outcome of joint surgery, but also to make the process of getting there easier.