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Nerve block: A better way to manage pain
New applications of anesthesia have revolutionized the field of pain management, and is part of an important and necessary shift away from opioid use
Imagine waking up post-surgery and feeling alert — no nausea, no pain, no waiting for the general anesthesia to wear off.
This is the reality we see in recovery rooms every day now that anesthesiologists are performing nerve block to manage patients’ pain during and after surgery instead of the traditional IV opioids. Significantly less general anesthesia is needed to keep patients asleep during surgery, enabling them to wake up sooner and recover quicker, all while avoiding the side effects of opioids. Nurses, doctors and anesthesiologists like myself are also happier because of the impact we’re having on patients — not just in managing their pain but in reducing the risks of opioid use – and the potential for abuse.
What is a nerve block?
A nerve block is the placement of a numbing medication, known as a local anesthetic, around a nerve or group of nerves that relay sensations from a certain body part to the brain. And depending on the type of local anesthetic we use, we can control the onset and duration of the block.
One of the most familiar nerve blocks are epidurals used during labor. These block pain signals at the spinal cord level, but other types of nerve block injections target smaller areas and provide pain relief to specific parts of the body. These include nerves located above the shoulder (interscalene nerve), groin (femoral nerve), underneath the knee (popliteal or a sciatic nerve) and abdomen (transverse abdominal plane).
Nerve block: An ultrasound-guided procedure
This procedure is a very safe injection to do under ultrasound, which enables the anesthesiologist to visualize the tip of the needle and ensure accurate placement near a nerve. Nerve block injections can address a variety of pain issues. A femoral nerve block, for example, is used in the treatment of hip fractures and injuries of the thigh and knee. An anesthesiologist will use a local anesthetic to numb the major hip flexor muscles, as well as knee extension muscles.
Before the ultrasound, doctors relied entirely on their knowledge of someone’s anatomy when performing a nerve block. Physicians skilled in this sub-specialty were left “poking and hoping” to achieve accurate placement around the nerve. Now they can visualize the needle tip in relation to the nerve to ensure accurate placement. This transformative advance has been a giant step forward in improving patient safety and minimizing complications.
How long does a nerve block last?
That depends on the need — a nerve block can last a short or long period of time. There are short-acting local anesthetics like lidocaine that last only six hours. To prolong the duration of a nerve block, we add adjuvant medication. If novocaine is used as the local anesthetic, we may use:
- Decadron (steroids)
- Buprenorphine
- Clonidine
The types of nerve block we use in anesthesia can last up to 36 hours. This reduces and in some cases eliminates the need for opioids or morphine-like pain medications.
Side effects: Nerve block vs opioids
One side effect of nerve block injections is the loss of sensation to a limb or area of the body — imagine how your mouth feels after getting a cavity filled. We educate patients on the need to take extra care with numbness: If their foot or legs are numb, for example, we might instruct patients to avoid putting any significant pressure on it or even to walk with crutches.
Nerve block injury — resulting from the injection of local anesthetic into a nerve rather than around the nerve — can lead to the feeling of pins and needles. Since the inception of ultrasound-guided regional analgesia, the rate of this complication has significantly decreased.
Opioids, on the other hand, can have several potentially troublesome side effects. These include nausea, vomiting, delirium and trouble sleeping. In severe cases, these medications can lead to trouble breathing. Addiction is another potential implication of opioid use.
In 1980, the New England Journal of Medicine deemed opioids as nonaddictive, setting off widespread prescriptions and the epidemic.
Read more
Nerve block's role in reducing opioid use
Health care plays a role in the opioid crisis in the U.S. and anesthesiologists can help reduce the harm.
Opioids are still a part of pain management, but these dangerous medications can lead to addiction and we’re looking for ways to minimize their use. About 3-4% of patients undergoing elective surgery who have never taken an opioid develop a dependency, according to research. The addiction rate is higher for some types of procedures.
Patients coming in for knee surgery, for example, would go home with a three-month supply of oxycodone — 180 pills. Here’s the problem: These patients only needed enough for three days. Huge vials of narcotics filled medicine cabinets across the U.S., a contributing factor to the epidemic that saw overdose deaths involving prescription opioids skyrocket from 3,442 in 1999 to 17,029 in 2017, according to the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention database, CDC Wonder.
Today, those same patients go home with a three-day supply of medication — and they’re also getting much milder formulations that combine anti-inflammatories like ibuprofen or acetaminophen with a small amount of a very light narcotic. This is a necessary change that is made possible, in large part, thanks to the advent of nerve block injections. The numbing effect, while a minor inconvenience, gives the body a 24-to-36-hour head start on the healing process.
Surviving an Opioid Addiction
How does one person go from a teen with a knee injury to a young man addicted to opioids? Jon will tell you in his own words.
Pain does not last forever. In fact, it starts to get better every hour following surgery. By the time a nerve block wears off, the patient’s pain is much more manageable and requires less medication and, as a result, the abuse potential is significantly decreased.
No longer is the question only: “How do we get rid of your pain.” Now we all must ask, “How do we manage pain and reduce harm?”
Surgeons are the biggest proponents of this new approach to pain management and patients are quickly catching on, learning to ask the question prior to surgery: How will you manage my pain?
A systemic approach
At Northwell, we use nerve block injections for a majority of orthopedic surgeries and a growing number of others, such as weight-loss surgery and C-sections. In addition to the analgesia afforded by an epidural during C-sections, anesthesiologists now use the transverse abdominis plane (TAP) block to extend the pain relief for these patients. This peripheral nerve block numbs the nerves that supply sensation to the abdomen, offering significant pain relief to patients after giving birth.
Epidurals are used during labor to control pain. Learn what it is and what to expect in this video from The Well.
Total knee and total hip replacement patients once had to stay in the hospital for four or five days; now, thanks to the nerve block and minimally-invasive surgical techniques, they’re able to go home much earlier.
Are there patients who shouldn’t get a nerve block?
People who may still require traditional anesthesia include those who:
- have a pre-existing nerve injury
- have a nerve syndrome such as multiple sclerosis
- have an infection at the site of the injection
- are taking anticoagulants or have a bleeding disorder
More about pain management
When treating painful emergency conditions like hip fractures, a femoral nerve block offers emergency department physicians a new, safer method of pain management.
An innovative pain management technique is reducing surgical pain and minimizing the risk of opioid dependency in kids who need scoliosis surgery.
In recognition of International Overdose Awareness Day on August 31, Northwell Health held a system-wide event to provide resources to help prevent future overdoses, as well as recognizing those whose lives have already been cut short by substance use.
A father shares his experience partnering with parents and health systems to address substance use disorders in the family.