Colombian Journal of Anesthesiology · Data selection and data mining Two authors (FACO, AAMO) independently selected the trials following the Cochrane methodology for SRs. The ﬁrst

Effectiveness and safety of exclusive spinalanesthesia with bupivacaine versus femoralsciatic block during the postoperative period ofpatients having undergone knee arthroscopysystematic review

Efectividad y seguridad de la anestesia espinalexclusiva con bupivacaiacutena vs el bloqueo ciaacuteticofemoral en el postoperatorio de pacientes llevadosa artroscopia de rodilla revisioacuten sistemaacutetica

Fernando Calderoacuten-Ochoaa Anderson Mesa OliverosaGustavo Rincoacuten Platabc Isaiacuteas Pinto Quintildeonesde

a School of Medicine Fundacioacuten Universitaria de Ciencias de la Salud (FUCS) Bogotaacute Colombiab Department of Orthopedics and Traumatology School of Medicine Fundacioacuten Universitaria

de Ciencias de la Salud (FUCS) Bogotaacute Colombiac Unit of Orthopedics Hospital de San Joseacute Bogotaacute Colombiad Department of Anesthesiology School of Medicine Fundacioacuten Universitaria de Ciencias de la

Salud (FUCS) Bogotaacute Colombiae Unit of Anesthesiology Hospital de San Joseacute Bogotaacute Colombia

Keywords Arthroscopy KneeAnesthesia Spinal Nerve Block

Bupivacaine

Palabras clave ArtroscopiacuteaRodilla Anestesia Raquiacutedea

Bloqueo Nervioso Bupivacaiacutena

Abstract

Introduction Spinal anesthesia (SA) and sciaticndashfemoral nerve

block are the most widely used anesthesia techniques for knee

arthroscopy however there is still some controversy with regard

to which anesthetic procedure offers improved safety better pain

control and higher patient satisfaction

Objective To assess the effectiveness of exclusive SA with

bupivacaine versus sciaticndashfemoral nerve block regardless of the

drug during the postoperative period of patients having under-

gone knee arthroscopy through a systematic review of the

scientific literature

Methods A search of Randomized Clinical Trials was

conducted in a number of databases including Ovid Cochrane

Embase Lilacs Open Grey ClinicalTrialsgov and academic

Google The snowball technique was also used to identify

additional trials The design of the search strategy included

Boolean operators and considered studies in English Spanish

How to cite this article Calderoacuten-Ochoa F Mesa Oliveros A Rincoacuten Plata G Pinto Quintildeones I Effectiveness and safety of exclusive spinal anesthesiawith bupivacaine versus femoral sciatic block during the postoperative period of patients having undergone knee arthroscopy systematic reviewColombian Journal of Anesthesiology 20194757ndash68

Read the Spanish version of this article at httplinkslwwcomRCAA843

Copyright copy 2018 Sociedad Colombiana de Anestesiologiacutea y Reanimacioacuten (SCARE) Published by Wolters Kluwer This is an open access articleunder the CC BY-NC-ND license (httpcreativecommonsorglicensesby-nc-nd40)

Correspondence Transversal 21 Bis 60-65 Bogotaacute Colombia E-mail calderonfernandohotmailcom

Colombian Journal of Anesthesiology (2019) 471

httpdxdoiorg101097CJ90000000000000092

REVIEW COLOMBIAN JOURNAL OF ANESTHESIOLOGY 201947(1)57-68

Colombian Journal of AnesthesiologyRevista Colombiana de Anestesiologiacutea

wwwrevcolanest comco

OPENOOPENOPENOPEN

57

and Portuguese with no date restrictions The information is

presented in narrative form

Results The search identified 478 studies of which 3 met the

eligibility criteria The effectiveness was evaluated based on total

anesthesia time and rescue analgesia Safety was evaluated with

heart rate monitoring and time to first micturition Patient

satisfaction was identified through surveys to measure the

acceptance of the anesthetic technique

Conclusion SA is effective as assessed based on the motor-

sensory blockade effect and pain control but its adverse events

shall be taken into consideration when making a decision The

anesthetic techniques of the peripheral sciaticndashfemoral nerve

block present less undesirable side effects than spinal analgesia

and provide better postoperative pain control

Resumen

Introduccioacuten La anestesia espinal y el bloqueo de nervios ciaacutetico-

femoral son las teacutecnicas de anestesia regionalmaacutes utilizadas para

la artroscopia de rodilla sin embargo existe controversia en

relacioacuten a queacute procedimiento anesteacutesico ofrece mayor seguridad

mejor control del dolor y satisfaccioacuten del paciente

Objetivo Evaluar la efectividad de la anestesia espinal

exclusiva con bupivacaiacutena vs el bloqueo de nervio ciaacutetico ndash

femoral sin distincioacuten de faacutermaco en el postoperatorio de

pacientes intervenidos con artroscopia de rodilla a traveacutes de

una revisioacuten sistemaacutetica de la literatura cientiacutefica

Meacutetodos se realizoacute una busqueda de Ensayos Cliacutenicos

Aleatorizados en las bases de datos Ovid Cochrane Embase

Lilacs al igual que en Open Grey ClinicalTrialsgov y Google

acadeacutemico tambieacuten se utilizoacute la teacutecnica bola de nieve para

encontrar estudios adicionales El disentildeo de la estrategia de

busqueda incluyoacute operadores boleanos y consideroacute estudios en

ingleacutes espantildeol y portugueacutes sin restriccioacuten de fecha La

informacioacuten se presenta de forma narrativa

Resultados la busqueda identificoacute 478 estudios de los cuales

tres cumplieron los criterios de elegibilidad La efectividad fue

valorada con el tiempo total de anestesia y analgesia de rescate

La seguridad fue evaluada conmonitoreo de frecuencia cardiaca y

tiempo de primeramiccioacuten La satisfaccioacuten del paciente se indagoacute

a traveacutes de encuestas de aceptacioacuten de la teacutecnica anesteacutesica

Conclusiones la anestesia espinal resulta efectiva valorada

por el efecto de bloqueo motor-sensitivo y control del dolor pero

sus eventos adversos deben ser considerados en la seleccioacuten Las

teacutecnicas anesteacutesicas de bloqueo perifeacuterico del nervio ciaacutetico-

femoral presentan menos efectos indeseables que la analgesia

espinal y ofrecen un mejor control del dolor postoperatorio

Introduction

Arthroscopy is an ambulatory minimally invasive anduseful technique for managing most pathological andtrauma lesions of the knee1ndash3 Through 2 or 3 ports orincisions the injured tissue is repairedThisproceduremaybe conducted under general regional or local anesthesia4

Postoperative pain control is a crucial clinical factor forthe recovery of the patient since pain limits adequaterehabilitation and resuming of daily activities56 withsubsequent social and economic impact not just for thepatient but also for the healthcare system7

There are different techniques for regional anesthesiabased on the site of administration of the local anesthetic(LA) agents and 2 of these are sciaticndashfemoral peripheralnerve block (SFNB) and spinal anesthesia (SA) adminis-tered with bupivacaine as the only LA These techniqueshave been used in daily practice of anesthesiology andorthopedics for the last decades specially due to the lowerincidence of complications greater convenience andusefulness8

SA is considered to be safe though not risk-free9 One ofits advantages is easier administration and patientcomfort however some disadvantages have been de-scribed such as puncture site pain post-punctureheadache urinary retention and a high level of nerveblock that compromises the heart rate (HR) This tech-nique requires longer patient isolation time and delays thestart of the surgical procedure10

The sciaticndashfemoral nerve block technique requires thelocalization of the site of needle insertion using anatomi-cal landmarks and neurostimulation or ultrasound-guided support1112 as indicated in some studies13 TheSFNB is effective for controlling postoperative pain14 andsome of its advantages include lesser hemodynamicchanges and preserved intestinal and bladder functionwith a lower risk of neuro-infectious complications15

Some of the disadvantages described are the time requiredfor administration and the need of technologies to guidethe placement of the LA agent the development ofhematomas and potential HR alterations1617

There is currently a controversy around the selection ofthe anesthetic technique for knee arthroscopy1819 insearch of effectiveness safety patient satisfaction andpractitioner comfort However in clinical practice there isa preference for bupivacaine as the LA of choice for thesetechniques20 but over the last few decades the combina-tion between LAs and the peripheral nerve block tech-nique has emerged in the quest for postoperativemanagement that favors early rehabilitation21 and lessadverse events such as bladder globus and postoperativejoint pain that requires rescue analgesia

Due to the rapid administration and thereforeshorter time to start surgery some anesthesiologistsprefer SA with bupivacaine22 which is a long-lastingLA agent that provides up to 6hours range for thesurgical procedure No instances of decreased levels ofhemoglobin in blood have been described and allergicreactions are minor as compared against other LAagents However the presence of other adverse eventsand limitations such as anatomical alterations of thelumbosacral spine mostly in elderly patients increasesthe use of peripheral nerve blocks20 that have anatomical

COLOMBIAN JOURNAL OF ANESTHESIOLOGY

58

REV

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landmarks for ease of administration and better post-operative pain control

In view of the clinical practice heterogeneity theauthors conducted this systematic review (SR) with aview to establishing the effectiveness and the safetyduring the postoperative period of adult patients under-going arthroscopic knee surgery using exclusive spinalanalgesia with bupivacaine as compared with sciaticndashfemoral nerve block

Method

Eligibility criteria

The Randomized Clinical Trials (RTC) considered includedadult population having undergone knee arthroscopyusing SA or sciaticndashfemoral nerve block as the comparatorexcluding any trials using an anesthetic agent other thanbupivacaine in SA and nerve block other than sciaticndashfemoral nerve block simultaneously

The primary outcomes evaluated were effectivenesssafety of anesthesia and patient satisfaction

Search methods to identify the trials

The keywords selected to design a search strategy usingsynonyms indexed terms truncation and proximityoperators were ldquospinal anesthesiardquo ldquobupivacainerdquoldquonerve blockrdquo and ldquoknee arthroscopyrdquo The search wasconducted in the following databases Ovid CochraneEmbase Lilacs Open Grey ClinicalTrialsgov and aca-demic Google in English Spanish and Portuguese withno date restrictions The snowball technique was alsoused See Annex 1

Data selection and data mining

Two authors (FACO AAMO) independently selected thetrials following the Cochrane methodology for SRs Thefirst step is the review and selection of titles andabstracts the second step is the selection of potentialarticles for reading of the full text and a final step ofreview and selection of the articles based on compliancewith all the inclusion criteria The authors settled theirdiscrepancies consulting a third and a fourth reviewer(IP and GR)

One of the inclusion criteria considered for this SR wasthe selection of RCTs since the expectation was to avoidtrials with design limitations that could bias theestimates of the impact of the intervention SimilarlyRCTs provide better-quality evidence in studies compar-ing techniques due to less bias in the design and in theprocedures

Data mining was independently conducted by theauthors (FACO AAMO) using an extraction matrix thatincluded variables such as nameof thefirst author year of

the intervention type of surgery number of patients ageof patients sample size by group and sub-group LA agentused time of total analgesia length of time of theprocedure adverse events time of the first spontaneousmicturition (minutes) need for rescue analgesia length ofthe recovery for discharge (minutes) and patient satisfac-tion as information related to effectiveness safety andsatisfaction

Evaluation of risk of bias in the trials included

The evaluation of the methodological quality of the trialswas done with the Risk of Bias Assessment Tool proposedby the Cochrane collaboration for randomized trialsadapted from Higgins et al23

This tool was used to assess the following biasesselection performance detection abandonment reportetc with a view to making a comprehensive qualifiedjudgment such as low unclear or high Both authors(FACO AAMO) independently evaluated each domain anda shared a joint was reached on the risk of bias for eachtrial

Treatment effect and analysis measures

Based on the selected outcomes 5 statistical parameterswere chosen for evaluation total anesthesia time rescueanalgesia HR time to first micturition (TFM) andacceptance of the anesthetic technique

Statistical analyses such as meta-analyses are notapplicable for the selected trials which is considered alimitation for this review For the evaluation of biasesthe Review Manager (RevMan) [Programa informaacutetico]Versioacuten 53 Copenhague The Nordic Cochrane CenterThe Cochrane Collaboration 2014 was used24

Heterogeneity may not be assessed through statisticaltests due to the inability to group the numerical data foroutcomes since these are estimated differently in eachtrial If the golden rule criterion is used for I2 value thismay be low because it is lt4025 For this reason anarrative studywas conducted to consider the clinical andmethodological heterogeneity among the trials

Likewise the publication bias could not be statisticallyidentified because the review included only 3 articles25

with a small sample size

Results

Trial identification

A total of 478 references were analyzed of which 12 werereviewed as full text and 3 that complied with theeligibility criteria were selected the 9 trials not includedwere ruled out because the SAwas administeredwith a LAagent other than bupivacaine and the lower limb blockadewas not consistent with knee arthroscopy (Fig 1) Of the

COLOMBIAN JOURNAL OF ANESTHESIOLOGY 201947(1)57-68

59

REV

IEW

trials selected 2 were conducted in Italy1626 and 1 inColombia27

Characteristics of the trials

The population in the 3 RCTs corresponds to 100 ofpatients undergoing elective knee arthroscopy whichmakes the populations comparable However the use ofthe various tools for monitoring of the times in each of thetrials limits the comparison of the results

The total population was 132 patients with a distribu-tion of 50 for each anesthetic technique Table 1 depictsthe characteristics of the trials included

In the SA groups the studies used the single injectiontechnique for the administration of LA at low doses ofbupivacaine28 According to the literature low doses rangebetween 5 and 8mg29 For the SFNB groups the studiesreport a technique using electro-stimulation to identifythe peripheral nerves with variations in the procedure foradministering the LA agent Table 2 illustrates thecharacteristics of both techniques

The results reported correspond to the sample of 131patients because of a technical anesthetic failure in theSFNB in the Montes et al27 trial the patient requiredgeneral anesthesia and therefore was excluded from theanalysis

Effectiveness of anesthesia

The effectiveness was evaluated in terms of quality ofanesthesia during the postoperative period of the 3 trialsfrom the time of the anesthetic injection until patientdischarge This assessment included both the sensory andmotor blockade using various techniques and scales

The 3 trials evaluated the sensitivity block before thestart of surgery using the prick test with total loss ofsensation for both anesthetic techniques The trial bySpasiano et al26 used a numerical frequency scale (NFS)during the application of the tourniquet to complementthe sensitivity blockade evaluation

The motor blockade was evaluated using the Bromagescalewith a score of 3 as the optimumvalue for Casati et al16

Figure 1 Selection process flowchart for inclusion of trials PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)Source Authors


60

REV

IEW

andMontes et al27while Spasiano et al26 usedanorthopedicevaluation of freedom of knee movement during SA with94ratedasexcellent 6assufficientWithregards toSFNB81 rated excellent and 19 rated as sufficient

Quality of anesthesia The 3 trials evaluate the quality ofanesthesia for the 2 techniques with different tools Thesufficiency of anesthesia over the postoperative period israted as inadequate in the presence of pain and need for

Table 2 Characteristics of the anesthetic technique

SA SFNB

Trial LA type Dose Procedure LA type Dose Electro-stimulator

Casatiet al16

05 HyperbaricBupivacaine

8mg 25-ga Whitacreneedle L3ndashL4space lateralposition

2 Mepivacaine 25mL distributed10mL for thesciatic nerve

15mL for thefemoral nerve

Frequency ofstimulation 2Hz

Intensity of thestimulating currentinitial 1mA andgradual tapering toless than 05mA

Monteset al27

05Hyperbaric

Bupivacaine

75mg 26-ga Whitacreneedle L2ndashL3 orL3ndashL4 spaces

2 Lidocaine and 05isobaric Bupivacaine

Mix of 40mL 20mL of 2Lidocaine+20mLof 05 isobaricBupivacaine

20mL of the mixinto each nerve

Connected to the 21-ganeedle

100mm de longFrequency of

stimulation 2HzIntensity of the

stimulus between03ndash05mA

Spasianoet al26

05 hyperbaricBupivacaine

7mg 25-ga Sprotteneedle into theL2ndashL3 space

1 Mepivacaine 40mL distributed15mL sciaticnerve block

25mL femoralnerve block

Connected to isolated22-ga needles 120and 35mm

Frequency ofstimulation of 2HzStimulating currentbetween 04 and 06mA

SA=spinal anesthesia SFNB=sciaticndashfemoral nerve blockSource Authors

Table 1 Characteristics of the trials included

Authors YearNumber ofpatients Population Age

Sample sizeby group Outcomes reported

Casati et al16 2000 50 M 54F 46

M 43plusmn11F 39plusmn13

SA Group 25SFNB Group 25

Total anesthesia timeRescue analgesia TFMHR

Montes et al27 2007 50 M 41F 59



Total anesthesia timeRescue analgesia TFMHRAcceptance of the technique

Spasiano et al26 2007 32 H 53M 47

H 392plusmn185M 458plusmn187


Total anesthesia timeRescue Analgesia TFMHRAcceptance of the technique

F= female HR=heart rate M=male SA=spinal anesthesia SFNB=sciaticndashfemoral nerve block TFM= time to first micturitionSource Authors


61

REV

IEW

rescue analgesia and adequate when no additionalanalgesia was required

In the trial by Casati et al16 sufficiency of anesthesiawas evaluated every 30minutes using the modifiedBromage scale during the postsurgical period untildischarge with 84 of the patients in the SA group beingadequate and 92 in the SFNB group FurthermoreMontes et al27 evaluated the sufficiency of anesthesiaduring the postsurgical period in the OR until hospitaldischarge at 15-minute intervals the presence of pain wasevaluated using the visual analog scale (VAS) with 88 ofthe patients reporting adequate results in the SA groupand 92 in the SFNB group Spasiano et al26 evaluated thesufficiency of anesthesia during the postsurgical periodusing the NFS with 94 of the patients rated as adequatein both groups in addition 13 patients (41) stillmaintained the effect after 2hours 3 patients (9) after4hours and the effect resolved in all patients after 6hours

Use of rescue analgesia Postoperative pain was monitoredusing various instruments and at different points in timein each trial Casati et al16 continued monitoring througha telephone survey 24hours later and 1 week after theintervention during the postoperative control visit for bothgroups reporting that 12 (3 patients) required rescueanalgesia in the SA group and 8 (2 patients) in the SFNBgroup

The trial by Montes et al27 used the VAS for inpatientmonitoring every 15minutes and then continued dailyhomemonitoring at 6 12 18 and 24hours for both types ofanesthesia reporting that 16 (4 patients) in the SA grouprequired additional analgesia while none of the patientsin the SFNB group required additional analgesia

Spasiano et al26 used the NFS in both anesthetictechniques 2 4 and 6hours during the postoperativeperiod reporting that 1 patient (62) required rescueanalgesia after 4hours in the SA group and 1 patient (62)after 51hours in the SFNB group

Safety of anesthesia and adverse events (AE)

Time to first micturition The time to the first spontaneousmicturition was observed in each group although Monteset al27 indicates that he does not consider this variable inthe results

According to Casati et al16 the TFM report is 231plusmn93minutes for SA and 145plusmn36 for SFNB On the other handthe trial by Spasiano et al26 reports a TFM of 269plusmn66 for SAfor SFNB The TFM results in these 2 trials show adifference in favor of SFNB

In addition Casatti et al report 12 (3 patients) in the SAgroup who experienced urinary retention and required aurinary catheter There were no reports of urinaryretention and urinary catheter in the SFNB group

Changes in heart rate (HR) and other hemodynamic parametersThe 3 trials conducted a routine HR control with non-

invasive techniques and other hemodynamic parametersThe study by Casati et al16 emphasized vital signsmonitoring and patient awareness during the postopera-tive period and reported 3 patients (12) with bradycardiain the SA group and no reports in the SFNB group Thestudy by Montes et al27 reported ECG conventionalmonitoring HR and blood pressure during the procedurewith measurements every 15minutes during the postsur-gical time with no patient alterations reported

The study by Spasiano et al26 monitored 4 parameterssystolic blood pressure diastolic blood pressure meanarterial pressure and HR which were measured at 5 timepoints (t 0minute t 5minutes t 10minutes t 15minutes t 30min) Changes in blood pressure wereminimal and the HR was lower in the SA group ascompared against the SFNB group

Patient satisfaction

Acceptance of the anesthetic technique Two of the 3 trialsincluded this outcome for the 2 anesthetic techniquesThe study by Casati et al16 did not

The studies by Montes et al27 and Spasiano et al26

evaluated satisfaction using a dichotomous survey askingwhether the patients would undergo a new procedurewith the same anesthetic technique In both trials 100 ofthe patients responded positively The study by Spasianoet al26 also used an ordinal scale in 3 categories to havepatients assess the anesthetic technique with the follow-ing results 93 excellent for SA and 87 for SFNB 6 goodfor SA and 6 for SFNB and 0 sufficient for SA and 6 forSFNB

The consolidated results are illustrated in Table 3

Risk of bias assessment of included studies

Figure 2 shows the quality evaluation of the studiesidentified over the search process

The conclusion is that the trials included in the SR havea low risk of bias for the domains of random sequenceperformance detection attrition reporting and otherbiases due to explicit non-compliance with the processesand procedures A clarification must be made regardingthe study by Montes et al27 where 1 patient had to beoperated under general anesthesia because of block failurein the SFNB group and was excluded from the analysis bythe author27

Two of the studies show an indeterminate risk of biasfor the detection domain The study by Montes et al27

identified a research assistant doing post-operativemonitoring of all patients but does not specify blindingand Spasiano et al26 describes the follow-up and recordingprocess without indicating the observerrsquos conditionsMoreover the study by Casati et al16 assesses the biasof reporting the use of a blind observer for monitoringduring the postoperative period until discharge as low risk


62

REV

IEW

Discussion

The SA technique has been the most widely usedtechnique in knee arthroscopy and the literature reportsthat it provides a complete sensory andmotor blockade ofthe lower extremity when using low single doses30 The 3studies for the SA groups achieved sensory and motorblock in all patients with no reports of intraoperativerescue analgesia using a single dose of 05 bupivacaine(7 75 and 8mg)

Bupivacaine as a LA agent has been widely studied31

and used in regional anesthesia techniques with ahalf-life of 35hours of complete sensory and motorblockade26 The block times achieved in the 3 studies forthe SA group are consistent with the literature32 butdo not allow for an association between the dose andthe block because the results reflect contradictoryanesthesia times

The study by Casati et al16 used the highest dose ofhyperbaric bupivacaine (8mg) which is associated with a

Table 3 Consolidated results during the postoperative period

Author Casati et al16 Montes et al27 Spasiano et al26

Variables SA Group SFNB Group SA Group SFNB Group SA Group SFNB Group

No of patients 25 25 25 24 16 16

Total anesthesiatime

lowast137plusmn49min 206plusmn51min 217plusmn85min 219plusmn69min NR NR

Rescue analgesia 4 patientsmedicatedduring thefirst 24h

2 patients withadditionalanalgesia

3 patientsexperiencedpostoperativepain after 2h

2 patients experiencedpostoperative painafter 4h

1 patientrequiredanalgesiaafter 4h


Heart rate 3 patientsexperiencedbradycardia

NR NR NR Decreased HR Increased HR

Time to firstmicturition

231plusmn93min 145plusmn36min NR NR 269plusmn66min 200plusmn69min

Satisfaction NR NR 100 Acceptance 100 Acceptance 93 excellent6 good0 sufficient

87 excellent6 good6 sufficient

HR=heart rate NR=Not reported SA=spinal anesthesia SFNB=sciaticndashfemoral nerve blocklowastThe total anesthesia time reported in the studies corresponds to the sum from the time of anesthesia preparation surgical preparation duration of

surgery time in the recovery room until effective discharge in minutesSource Authors

Figure 2 Risk of bias assessment per domainSource Authors


63

REV

IEW

higher risk of transient neurological symptoms moreadverse event reports such as cardiovascular dysfunctionand urinary retention with urinary catheter and theseresults are consistent with the reports of previousresearch studies33 but the findings are not significantbecause of the sample size used According to Monteset al27 and to other researchers the preoperative timeswith SA are shorter and no differences are reported in thetotal OR time and hospital discharge However 12 of thepatients required rescue analgesia after 2hours The studyby Spasiano et al26 used lower doses of bupivacaine (7mg)with lower requirement of rescue analgesia and nosignificant adverse effects

The effectiveness of the SFNB as described in theliterature34 is mostly based on the successful unilateralmotor and sensory blockade and on the postoperativeanesthesia time with a lower risk of hemodynamicchanges preserving the intestinal and bladder func-tion3035 The SFNB technique uses multiple proceduresthat are described in the various approaches36 demandingknowledge and experience in the technique for asuccessful outcome3738 Greater patient safety and stabil-ity is also reported during the perioperative periodreducing the adverse effects and the need for postopera-tive analgesia39

In the study by Casati et al16 the postoperativeanalgesia times were longer and the TFM was shorteras compared with SA 2 patients required rescue analge-sia associated with hip pain subsequent to limb manip-ulation during the procedure The study byMontes et al27

compared the level of analgesia effect during thepostoperative period (6hours) and found a superioreffect in the SFNB group with no significant differencesin other outcomes In this study there was a technicalfailure on the SFNB that required the use of generalanesthesia which evidences the need to strengthen theanesthetic techniquendashpatient relationship Spasianoet al26 showed that it is possible to achieve a successfulSFNB with low LA concentrations using shorter admin-istration times that are associated with minimalhemodynamic changes and significant cardiovascularstability The changes described inHR correspond tomildincreases in theSFNBgroupanddecrease in theSAgroupThe SFNB group experienced longer postoperative anal-gesia and shorter spontaneous micturition times ascompared to the SA group One patient from each grouprequired rescue analgesia but the administration for theSFNB patient was 80minutes later as compared to thepatient in the SA group

When comparing the outcome of rescue analgesiabetween the 2 groups there is a significant difference infavor of SFNB with 3 of the patients requiring rescuetherapy versus 12 in the SA group

In the 3 trials the postoperative analgesia times favorthe SFNB group with 1 additional benefit associated with

the preservation of organic functions that contribute topatient discharge as expected for ambulatory surgery

The 3 studies show evidence of higher patient safetywith SFNB associated with less cardiovascular andneurological function risk and less urinary retentionOther adverse effects described may be due to LA-relatedcomplications and the route of administration of theagent40

Patient satisfaction was evaluated using different toolsin each trial with no differences found in favor of 1 orother technique

The 3 trials are relatively homogeneous with regardsto the SA technique but the results differ in the safetyevaluation and this may be explained based on the doseof LA used by Casati et al16 8mg versus 75 and 7mg inMontes et al27 and Spasiano et al26 respectively Thereare differences in the injection technique and thedrug used for SFNB but the results reported are verysimilar with regard to the quality of the block and thesafety of the patient though there were some differ-ences in the way the outcomes were assessed forinstance when evaluating the quality of the postopera-tive analgesia the trials used VAS modified Bromagescale and NFS

This SR failed to statistically assess the potentialexistence of publication bias however it is presumed tobe low on account of the comprehensive search of thestudies and the reference to additional sources

With the results obtained for the continuous numericalvariable of TFM it is possible to argue in favor of the SFNBtechnique since it does not interfere with voidingUnfortunately the trials do not report separately theanesthesia times limiting the analysis of this SR whichfocuses on postoperative time

Finally the potential occurrence of bias risk in the trialsis overall low which does not compromise the validity ofthe trials

Conclusion

There are not enough studies to definitely compare the 2anesthetic techniques based on the outcomes proposedfor this SR In terms of the effectiveness of anesthesiaboth the SFNB and SA deliver highly satisfactory postop-erative analgesia times and in terms of safety there is alower risk of adverse events and earlier recovery withSFNB However the studies do not allow for conclusivestatements

SA is more widely accepted among the professionalanesthesiologists because of ease and quick administra-tion while SFNB requires technological support trainingand skills for a successful result Considering that kneearthroscopy is an ambulatory procedure further researchis needed to determine which technique should be usedfor each particular case


64

REV

IEW

Ethical responsibility

This is a secondary study and hence it is not governedby the ethical standards for research on human beingsNevertheless from the ethical point of view this system-atic review pulls together current concepts about residualand postoperative analgesia control in knee arthroscopykeeping in mind the benefit for the patients undergoingthis procedure in our daily practice

The privacy of the patients included in the randomizedclinical trials used for this review the authors their rightsand outcomes shared shall be respected

Acknowledgments

The authors are particularly grateful to Dr Lina MariacuteaGonzaacutelez for her methodological counselling of thesystematic review and for reviewing the final version ofthe document contributing with valuable recommenda-tions We also extend our gratitude to FundacioacutenUniversitaria de Ciencias de la Salud for the comprehen-sive support received along the process

Financing

This project was funded by the authors with no externalfinancial contributions

Conflicts of interest

There is no conflicts of interest to disclose in this researchproject

References

1 Pacheco Diacuteaz EA Garciacutea Arango G Jimeacutenez Paneque R et al Theintraarticular knee injuries evaluated by arthroscopy its relation-ship with clinic and imaging Rev Cubana Ortop Traumatol2007211ndash11

2 Garciacutea M Cugat R History of Arthroscopy Rev Esp Artroscopia199419ndash15

3 Ruiz Valverde WE Hidalgo Cisneros FM Valoracioacuten del dolorpostoperatorio en pacientes de 18 antildeos y 45 antildeos de edadcon artroscopia de rodilla con anestesia local atendidos enel servicio de Ortopedia y Traumatologiacutea del Hospital Metropol-itano de Quito en el periodo agosto 2012ndashagosto 2015 [Cited 2017Oct 06] Available at httpwwwdspaceuceeduechandle2500010864

4 Reyes Fierro A de la Gala Garciacutea F Local anaesthesia as electivetechnique for arthroscopic knee surgery Patol Ap Locomotor2004287ndash89

5 Miranda-Rangel A Martiacutenez-Segura RT Multimodal anesthesia avision of modern anesthesia Rev Mex Anestesiol 201538 (suppl1)S300ndashS301

6 Choquet O Zetlaoui PJ Peripheral regional anesthesia techniqueslower limb EMC Anest Reanim 2015411ndash24

7 Saacutenchez Contreras MD Evaluacioacuten de la eficacia de tres teacutecnicasanalgeacutesicas analgesia epidural bloqueo femoral continuo y doblebloqueo femoral y ciaacutetico continuo en la artroplastia total derodilla [Internet] Valencia Facultad de Medicina y OdontologiacuteaDepartamento de Cirugiacutea 2015 [Cited 2017 Oct 06] Available athttpscoreacukdownloadpdf71052735pdf

8 Ramiacuterez-Goacutemez M Schlufter-Stolberg RM Sciatic-femoral blockthree in one Rev Mex Anestesiol 20103379ndash87

9 Whizar-Lugo V Flores-Carrillo JC Preciado-Ramiacuterez S et al Spinalanesthesia for ambulatory surgery in plastic surgery Anest Mex201729 (suppl 1)41ndash63

10 Borghi B Stagni F Bugamelli S et al Unilateral spinal block foroutpatient knee arthroscopy a dose-finding study J Clin Anesth200315351ndash356

11 Geier KO lsquo3-in-1rsquo blockade partial total or overdimensionedblock Correlation between anatomy clinic and radio images RevBras Anestesiol 200454566ndash572

12 Abdulatif M Fawzy M Nassar H et al The effects of perineuraldexmedetomidine on the pharmacodynamic profile of femoralnerve block a dose-finding randomised controlled double-blindstudy Anaesthesia 2016711177ndash1185

13 Jaacuteuregui A Siboney G Eficacia analgeacutesica del bloqueo femoralguiado por ultrasonido para cirugiacutea de rodilla en el CentenarioHospital Miguel Hidalgo [Internet] Sinaloa Universidad Auton-oma de Aguas Calientes 2017 [Cited 2017 Oct 06] Available athttpbdigitaldgseuaamx8080xmluihandle1234567891278

14 Zetlaoui PJ Locoregional anesthesia and analgesia in medicalpractice EMC-Tratado de Medicina 2018221ndash10

15 Capurro J Sforsini CD Seguridad en anestesia loco-regional (ALR)complicaciones de los bloqueos nerviosos perifeacutericos Rev ArgentAnestesiol 201270101ndash112

16 Casati A Cappelleri G Fanelli G et al Regional anaesthesia foroutpatient knee arthroscopy a randomized clinical comparison oftwo different anaesthetic techniques Acta Anaesthesiol Scand200044543ndash547

17 Bonet A Sabate A Otero I et al Ultrasound-guided saphenousnerve block is an effective technique for perioperative analgesia inambulatory arthroscopic surgery of the internal knee compart-ment Rev Esp Anestesiol Reanim 201562428ndash435

18 Flores WR Prevalencia de dolor post quirurgico inmediatautilizando escala Eva en pacientes de 20 a 50 antildeos de edadsometidos a Artroscopia de rodilla por trastorno interno de rodillasin la utilizacioacuten de torniquete en el Hospital Enrique GarceacutesQuitondashEcuador periodo de enero 2015 a enero 2017 [Internte]Quito UCE 2017 [Cited 2018 Oct 18] Available at httpwwwdspaceuceeduechandle2500016135

19 Gonzaacutelez Gavilanez AM Vicuntildea PozoMF Villena GalarzaMV et alManagement of postoperative pain in patients undergoingarthroscopic surgery Rev Cubana Reumatol 201719111ndash118

20 Pentildea Atrio GA Aguilar Romaacuten F Torres Garciacutea J et al Bupivacaineas a local anesthetic in knee arthroscopies Rev Cubana de OrtopTraumatol 19991327ndash30

21 Aydın F Akan B Susleyen C et al Comparison of bupivacainealone and in combination with sufentanil in patients undergoingarthroscopic knee surgery Knee Surg Sports Traumatol Arthrosc2011191915ndash1919

22 Ates Y Kinik H BiacutennetMS Ates Y Canakci N Kecik Y Comparisonof prilocaine and bupivacaine for post-arthroscopy analgesia aplacebo-controlled double-blind trial Arthroscopy Arthroscopic199410108ndash109

23 Higgins DGA Gotzsche PC Juumlni P et al The Cochrane Collabo-rationrsquos tool for assessing risk of bias in randomised trials BMJ2011343d5928

24 The Nordic Cochrane Centre The Cochrane Collaboration ReviewManager (RevMan) [Computer program] Version 53 The NordicCochrane Centre The Cochrane Collaboration Copenhagen2014

25 Centro Cochrane IberoamericanoManual Cochrane de Revisionessistemaacuteticas [Internet] [Cited 2018 Oct 18] Available at httpsescochraneorgsitesescochraneorgfilespublicuploadsManual_Cochrane_510_reduitpdf

26 Spasiano A Flore I Pesamosca A et al Comparison betweenspinal anaesthesia and sciaticndashfemoral block for arthroscopicknee surgery Minerva Anestesiol 20077313ndash21

27 Montes FR Zaacuterate E Grueso R et al Comparison between spinalanaesthesia and sciatic-femoral block for arthroscopic kneesurgery Rev Colomb Anestesiol 20073545ndash52

28 Sarmiento Aacutelvarez KA Anestesia raquiacutedea con dosis miacutenimasefectivas de bupivacaina hiperbaacuterica al 0 5 maacutes opioide versusanestesia raquiacutedea con dosis habituales a pacientes sometidos aartroscopias del hospital Manuel Ygnacio Monteros de la ciudad


65

REV

IEW

de Loja periodo abril 2013-enero 2014 [Internet] Loja Universi-dad Nacional de Loja 2014 [Cited 2018 Oct 18] Available at httpdspaceunleduechandle12345678918751

29 Imbelloni LE Volpato Passarini G Ganem EM et al Comparativestudy between combined sciatic-femoral nerve block via a singleskin injection and spinal block anesthesia for unilateral surgeryof the lower limb Rev Bras Anestesiol 201060588ndash592

30 Whizar-Lugo VM Flores-Carrillo JC Preciado-Ramiacuterez S et alControversy in subarachnoid anesthesia Anestesia en Meacutexico200416241ndash250

31 Nadal JL Yera M Vargas G et al Postoperative analgesia inarthroscopic knee surgery Multicentric Study Rev Cubana deAnestesiol Reanim 2003231ndash36

32 Marangoni LD Giacossa R Malvarez A et al Spinal anesthesiaversus intra-articular anesthesia in arthroscopic surgery of theknee Rev Asoc Argent Ortop Traumatol 201681258ndash263

33 Marroacuten-Pentildea GM Adverse events of neuraxial anesthesia iquestWhatto do when they occur Rev Mex Anestesiol 200730 (s1)357ndash375

34 Martiacutenez Navas A Complications of peripheral nerve blocks RevEsp Anestesiol Reanim 200653237ndash248

35 Pellicer G Goacutemez R Martiacutenez F Bloqueos nerviosos perifeacutericos enla extremidad inferior para la analgesia postoperatoria de la

artroplastia total de rodilla [Internet] Zaragoza Universidad deZaragoza 2014 [Cited 2018 Oct 18] Available at wwwtdxcathandle10803134145

36 Contreras-Domiacutenguez VA Carbonell-Bellolio P Ojeda-Greciet Aacuteet al Extended three-in-one block versus intravenous analgesiafor postoperative pain management after reconstruction ofanterior cruciate ligament of the knee Rev Bras Anestesiol200757280ndash288

37 Vloka JD Hadzic A Mulcare R et al Combined popliteal andposterior cutaneous nerve of the thigh blocks for short saphenousvein stripping in outpatients an alternative to spinal anesthesia JClin Anesth 19979618ndash622

38 Calvo R Figueroa D Arellano S et al Femoral nerve block inanterior cruciate ligament surgery a prospective randomisedtrial Rev Chil Ortop Traumatol 20165714ndash19

39 Muntildeiz M Rodriacuteguez J Escudero JA et al Peripheral nerve blocksfor surgical anesthesia and postoperative analgesia of the lowerextremity Rev Esp Anestesiol Reanim 200350510ndash520

40 Bajo Pesini R del Cojo Peces E Delgado Garciacutea I et al Managementof postoperative pain in knee arthroplastyarthroscopy in SpainLack of anaesthetic department support Rev Soc Esp Dolor20101789ndash98


66

REV

IEW

ANNEX

Annex 1 Search strategies

Database Terms

Ovid MEDLINE(R) lt1946 to September Week 4 2017gtOvid MEDLINE(R) Epub Ahead of Print ltOctober 062017gt Ovid MEDLINE(R) In-Process amp Other Non-Indexed Citations ltOctober 06 2017gt Ovid MEDLINE(R) Daily Update ltOctober 06 2017gt

1 exp Arthroscopy (22520)2 Arthroscopi

lowasttiab (21233)

3 (Arthroscopic adj6 Surgical adj6 Procedurelowast)tiab (214)

4 (Arthroscopic adj6 Surgerlowast)tiab (3604)

5 1 or 2 or 3 or 4 (29642)6 exp Knee (13554)7 kneetiab (125425)8 6 or 7 (130189)9 5 and 8 (9973)10 exp Anesthesia Spinal (11974)11 (Spinal adj6 Anesthesia

lowast)tiab (8145)

12 (Anesthesialowastadj6 Spinal)tiab (8145)

13 (spinal adj6 anaesthesialowast)tiab (3860)

14 10 or 11 or 12 or 13 (16731)15 exp Bupivacaine (11726)16 Bupivacainetiab (12258)17 Buvacainatiab (0)18 Dolanaesttiab (0)19 Sensorcainetiab (12)20 Marcaintiab (72)21 Carbostesintiab (24)22 Marcainetiab (314)23 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 (16010)24 14 and 23 (3068)25 exp Nerve Block (20305)26 (Nerve adj6 Block

lowast)tiab (14553)

27 (Blocklowastadj6 Nerve)tiab (14553)

28 (Nervelowastadj6 Blockade)tiab (2530)

29 (Blockadelowastadj6 Nerve)tiab (2311)

30 (combined adj6 sciatic-femoral adj6 nervelowastadj6 block

lowast)tiab (22)

31 (surgical adj6 blocklowast)tiab (2165)

32 25 or 26 or 27 or 28 or 29 or 30 or 31 (29476)33 24 or 32 (32069)34 9 and 33 (200)35 limit 34 to ldquotherapy (best balance of sensitivity and specificity) rdquo

(306)

EMBASE (((lsquoknee arthroscopyrsquoexp OR lsquoknee arthroscopyrsquo) OR (lsquokneearthroscopyrsquoexp) OR (lsquoknee arthroscopyrsquoabti)) AND ((lsquoarthroscopicsurgeryrsquo) OR (lsquoarthroscopic surgeryrsquoexp) OR (lsquoarthroscopic surgeryrsquoabti))) AND ((((lsquospinal anesthesiarsquo) OR (lsquospinal anesthesiarsquoexp) OR(lsquospinal anesthesiarsquoabti)) AND (((lsquobupivacainersquo) OR (lsquobupivacainersquoexp) OR (lsquobupivacainersquoabti)) OR ((dolanaestabti) OR (sensorcaineabti) OR (marcainabti) OR (carbostesinabti) OR (marcaineabti))))OR (((lsquosciatic nerve blockrsquo) OR (lsquosciatic nerve blockrsquoexp) OR (lsquosciaticnerve blockrsquoabti)) AND ((lsquofemoral nerve blockrsquo) OR (lsquofemoral nerveblockrsquoexp) OR (lsquofemoral nerve blockrsquoabti)))) AND ([controlledclinical trial]lim OR [randomized controlled trial]lim) (4)

The Cochrane Library (CLIB) 1 MeSH descriptor [Arthroscopy] explode all trees 14542 Arthroscopi

lowast2262

3 (Arthroscopic near Surgical near Procedurelowast) 22

4 (Arthroscopic near Surgerlowast) 1165

5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms

6 MeSH descriptor [Knee] explode all trees 7067 knee

lowast17993

8 6 or 7 179939 5 and 8 153210 MeSH descriptor [Anesthesia Spinal] explode all trees 220011 (Spinal near Anesthesia

lowast) 4931

12 (Anesthesialowastnear Spinal) 4931

13 (spinal near anaesthesialowast) 1999

14 10 or 11 or 12 or 13 555115 MeSH descriptor [Bupivacaine] explode all trees 389416 Bupivacaine 898917 Buvacaina 818 Dolanaest 319 Sensorcaine 1320 Marcain 4421 Marcaine 11422 Carbostesin 1223 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 902124 14 and 23 249125 MeSH descriptor [Nerve Block] explode all trees 336226 (Nerve near Block

lowast) 6028

27 (Blocklowastnear Nerve) 6028

28 (Nervelowastnear Blockade) 570

29 (combined near sciatic-femoral near nervelowastnear block

lowast) 22

30 (surgical near blocklowast) 698

31 (Blockadelowastnear Nerve) 534

32 25 or 26 or 27 or 28 or 29 or 30 or 31 646433 24 or 32 836834 9 and 33 in Trials 150

LILACS ((((tw(artroscopia)) OR (tw(artroscopi$)) OR (tw(( ldquoartroscopiaquirurgico procedimiento$rdquo))) OR (tw(( ldquoArtroscopia quirurgic$rdquo))))AND ((tw(rodilla)) OR (tw(rodilla$)))) AND (((tw(Anestesia espinal))OR (tw(( ldquoespinal Anestesia$rdquo))) OR (tw(( ldquoAnestesia$ espinalrdquo))) OR(tw(( ldquoespinal anaestesia$rdquo)))) OR ((tw(Bupivacaine)) OR (tw(Buvacaina)) OR (tw(Dolanaest)) OR (tw(Sensorcaine)) OR (tw(Marcain)) OR (tw(Carbostesin)) OR (tw(Marcaine)))) AND ((tw(bloqueo nervioso)) OR (tw(( ldquobloqueo$ nerviosordquo))) OR (tw((ldquonervioso loqueo$rdquo))) OR (tw(( ldquoNervioso$ Bloqueadordquo))) OR (tw((ldquoBloqueado$ Nerviosordquo))) OR (tw(( ldquocombinar ciatico-femoral nervio$ bloqueo$rdquo))) OR (tw(( ldquoquirurgico bloqueo$rdquo))))) (6)

Google ((ldquoknee arthroscopyrdquo) and (((ldquospinal anesthesiardquo) and (bupivacaine))and ((ldquosciatic nerve blockrdquo) and (ldquofemoral nerve blockrdquo)))) (10)

Clinical Trialsgov ((ldquoknee arthroscopyrdquo) and (((ldquospinal anesthesiardquo) and (bupivacaine))and ((ldquosciatic nerve blockrdquo) and (ldquofemoral nerve blockrdquo)))) (0)

Open Grey ((ldquoknee arthroscopyrdquo) and (((ldquospinal anesthesiardquo) and (bupivacaine))and ((ldquosciatic nerve blockrdquo) and (ldquofemoral nerve blockrdquo)))) (0)

Source Authors


68

REV

IEW

and Portuguese with no date restrictions The information is

presented in narrative form

Results The search identified 478 studies of which 3 met the

eligibility criteria The effectiveness was evaluated based on total

anesthesia time and rescue analgesia Safety was evaluated with

heart rate monitoring and time to first micturition Patient

satisfaction was identified through surveys to measure the

acceptance of the anesthetic technique

Conclusion SA is effective as assessed based on the motor-

sensory blockade effect and pain control but its adverse events

shall be taken into consideration when making a decision The

anesthetic techniques of the peripheral sciaticndashfemoral nerve

block present less undesirable side effects than spinal analgesia

and provide better postoperative pain control

Resumen

Introduccioacuten La anestesia espinal y el bloqueo de nervios ciaacutetico-

femoral son las teacutecnicas de anestesia regionalmaacutes utilizadas para

la artroscopia de rodilla sin embargo existe controversia en

relacioacuten a queacute procedimiento anesteacutesico ofrece mayor seguridad

mejor control del dolor y satisfaccioacuten del paciente

Objetivo Evaluar la efectividad de la anestesia espinal

exclusiva con bupivacaiacutena vs el bloqueo de nervio ciaacutetico ndash

femoral sin distincioacuten de faacutermaco en el postoperatorio de

pacientes intervenidos con artroscopia de rodilla a traveacutes de

una revisioacuten sistemaacutetica de la literatura cientiacutefica

Meacutetodos se realizoacute una busqueda de Ensayos Cliacutenicos

Aleatorizados en las bases de datos Ovid Cochrane Embase

Lilacs al igual que en Open Grey ClinicalTrialsgov y Google

acadeacutemico tambieacuten se utilizoacute la teacutecnica bola de nieve para

encontrar estudios adicionales El disentildeo de la estrategia de

busqueda incluyoacute operadores boleanos y consideroacute estudios en

ingleacutes espantildeol y portugueacutes sin restriccioacuten de fecha La

informacioacuten se presenta de forma narrativa

Resultados la busqueda identificoacute 478 estudios de los cuales

tres cumplieron los criterios de elegibilidad La efectividad fue

valorada con el tiempo total de anestesia y analgesia de rescate

La seguridad fue evaluada conmonitoreo de frecuencia cardiaca y

tiempo de primeramiccioacuten La satisfaccioacuten del paciente se indagoacute

a traveacutes de encuestas de aceptacioacuten de la teacutecnica anesteacutesica

Conclusiones la anestesia espinal resulta efectiva valorada

por el efecto de bloqueo motor-sensitivo y control del dolor pero

sus eventos adversos deben ser considerados en la seleccioacuten Las

teacutecnicas anesteacutesicas de bloqueo perifeacuterico del nervio ciaacutetico-

femoral presentan menos efectos indeseables que la analgesia

espinal y ofrecen un mejor control del dolor postoperatorio

Introduction

Arthroscopy is an ambulatory minimally invasive anduseful technique for managing most pathological andtrauma lesions of the knee1ndash3 Through 2 or 3 ports orincisions the injured tissue is repairedThisproceduremaybe conducted under general regional or local anesthesia4

Postoperative pain control is a crucial clinical factor forthe recovery of the patient since pain limits adequaterehabilitation and resuming of daily activities56 withsubsequent social and economic impact not just for thepatient but also for the healthcare system7

There are different techniques for regional anesthesiabased on the site of administration of the local anesthetic(LA) agents and 2 of these are sciaticndashfemoral peripheralnerve block (SFNB) and spinal anesthesia (SA) adminis-tered with bupivacaine as the only LA These techniqueshave been used in daily practice of anesthesiology andorthopedics for the last decades specially due to the lowerincidence of complications greater convenience andusefulness8

SA is considered to be safe though not risk-free9 One ofits advantages is easier administration and patientcomfort however some disadvantages have been de-scribed such as puncture site pain post-punctureheadache urinary retention and a high level of nerveblock that compromises the heart rate (HR) This tech-nique requires longer patient isolation time and delays thestart of the surgical procedure10

The sciaticndashfemoral nerve block technique requires thelocalization of the site of needle insertion using anatomi-cal landmarks and neurostimulation or ultrasound-guided support1112 as indicated in some studies13 TheSFNB is effective for controlling postoperative pain14 andsome of its advantages include lesser hemodynamicchanges and preserved intestinal and bladder functionwith a lower risk of neuro-infectious complications15

Some of the disadvantages described are the time requiredfor administration and the need of technologies to guidethe placement of the LA agent the development ofhematomas and potential HR alterations1617

There is currently a controversy around the selection ofthe anesthetic technique for knee arthroscopy1819 insearch of effectiveness safety patient satisfaction andpractitioner comfort However in clinical practice there isa preference for bupivacaine as the LA of choice for thesetechniques20 but over the last few decades the combina-tion between LAs and the peripheral nerve block tech-nique has emerged in the quest for postoperativemanagement that favors early rehabilitation21 and lessadverse events such as bladder globus and postoperativejoint pain that requires rescue analgesia

Due to the rapid administration and thereforeshorter time to start surgery some anesthesiologistsprefer SA with bupivacaine22 which is a long-lastingLA agent that provides up to 6hours range for thesurgical procedure No instances of decreased levels ofhemoglobin in blood have been described and allergicreactions are minor as compared against other LAagents However the presence of other adverse eventsand limitations such as anatomical alterations of thelumbosacral spine mostly in elderly patients increasesthe use of peripheral nerve blocks20 that have anatomical


58

REV

IEW



Method




















Results




59

REV

IEW













60

REV

IEW




SA SFNB


Casatiet al16







Monteset al27

05Hyperbaric

Bupivacaine









Spasianoet al26











Casati et al16 2000 50 M 54F 46




Montes et al27 2007 50 M 41F 59










61

REV

IEW
























62

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW



Method




















Results




59

REV

IEW













60

REV

IEW




SA SFNB


Casatiet al16







Monteset al27

05Hyperbaric

Bupivacaine









Spasianoet al26











Casati et al16 2000 50 M 54F 46




Montes et al27 2007 50 M 41F 59










61

REV

IEW
























62

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW













60

REV

IEW




SA SFNB


Casatiet al16







Monteset al27

05Hyperbaric

Bupivacaine









Spasianoet al26











Casati et al16 2000 50 M 54F 46




Montes et al27 2007 50 M 41F 59










61

REV

IEW
























62

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW




SA SFNB


Casatiet al16







Monteset al27

05Hyperbaric

Bupivacaine









Spasianoet al26











Casati et al16 2000 50 M 54F 46




Montes et al27 2007 50 M 41F 59










61

REV

IEW
























62

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW
























62

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW

Discussion








No of patients 25 25 25 24 16 16



















63

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW














Conclusion




64

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW




Acknowledgments


Financing




References






























65

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW
















66

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW

ANNEX


Database Terms



lowasttiab (21233)




lowast)tiab (8145)




lowast)tiab (14553)





lowast)tiab (22)



(306)



lowast2262



5 1 or 2 or 3 or 4 2755


67

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW

Database Terms


lowast17993


lowast) 4931




lowast) 6028




lowast) 22








Source Authors


68

REV

IEW

Documents

Colombian Journal of Anesthesiology · Data selection and data mining Two authors (FACO, AAMO) independently selected the trials following the Cochrane methodology for SRs. The ﬁrst