Regional Anesthesia and Other Interventions

The type of trauma influences the pain management plan. Patients with blunt chest trauma have a high mortality rate associated with injury to the heart and lungs and are especially vulnerable to the adverse effects on the respiratory system imposed by pain and opioids. It is therefore generally accepted that regional analgesia should be instituted whenever possible in patients at high risk (e.g., elderly, multiple rib fractures, heart and lung injuries) (Karmakar and Ho 2003, Cohen et al. 2004). This is supported by studies demonstrating the superiority of epidural analgesia compared to parenteral opioids and intercostal nerve blocks after thoracotomy (Moon et al. 1999, Yildirim et al. 2000, Behera et al. 2008) and more recent studies showing that continuous paravertebral blocks provide comparable analgesia to epidurals (Casati et al. 2009, Szebla and Machala 2008). For interpleural analgesia, the results of clinical studies have been mixed at best (Schneider et al. 1993, Miguel and Hubbell 1993). In view of the high systemic blood levels when lipid-soluble opioids are administered epidurally, insertion close to the area of trauma is recommended.

Trauma-related amputations comprise over 15% of all amputations and a majority of upper extremity amputations. Whereas most of these involve digits, many involve full or partial limbs. Trauma-related amputations require frequent revisions, which makes epidural analgesia (lower extremity) and peripheral nerve blocks (upper extremity) ideal techniques. Heterotopic ossification is also more common in trauma-related than planned amputations and can be very painful. Epidemiological studies have found no difference in the prevalence rates of postamputation pain between traumatic and planned amputations (Sherman and Sherman 1985).

There are several factors that may affect the incidence of postamputation residual limb and phantom pain, including pre-morbid psychopathology, location, and preoperative and postoperative pain intensity. The evidence supporting preemptive analgesia to reduce the incidence of phantom pain is mixed and largely irrelevant for traumatic amputations.

However, the strong correlation between postoperative pain intensity and chronic postsurgical pain, the frequent need for multiple procedures, and the other benefits afforded by regional anesthesia strongly augur for the use of epidural and continuous peripheral nerve blocks for traumatic amputations.

Vertebral compression fractures represent a significant cause of morbidity and mortality, especially in the elderly. The prevalence of neurological deficits varies widely in the literature and is contingent on the type, number, location, and extent of injury. However, the incidence of neurological deficits is often reported to exceed 25% (Gertzbein 1992). Along with spinal cord injury and radicular pain, patients with vertebral fractures are at increased risk for facetogenic and discogenic pain.

In addition to NSAIDs and opioids, which are first-line treatments for acute nocicep-tive bone pain, several other treatment options exist. Vertebroplasty and kyphoplasty may be useful in patients with vertebral fractures secondary to osteoporosis and malignancy, but are generally less beneficial in young patients with traumatic fractures. Contraindications to both techniques include bleeding disorders, unstable fractures with posterior element involvement, and definitive neurological symptoms. Whereas multiple uncontrolled studies have demonstrated efficacy for both vertebroplasty and kyphoplasty, a recent double-blind, placebo-controlled study failed to show benefit for vertebroplasty (Kallmes et al. 2009).

In patients with radicular or other neuropathic symptoms secondary to traumatic vertebral fractures, epidural steroid injections and neuropathic agents may provide pain relief and functional improvement. For bone pain, bisphosphonates and calcitonin have been shown to alleviate pain in addition to preventing future fractures.

Traumatic brain injury (TBI) is another common cause of chronic pain and disability, affecting nearly 1.5 million Americans per year. The prevalence of pain following TBI varies dramatically, ranging from 18% to over 90% depending on the surveillance method, severity, and associated trauma (Cohen et al. 2004). The most common pain complaints in patients with mild TBI (Glasgow Coma Scale 13-15, loss of consciousness <1 h) are headache (69%), neck pain (40%), and back pain (32%). First-line treatments for headache prophylaxis include tricyclic antidepressants, topiramate, and gabapentin. The most frequent cause of neck pain after trauma is facet arthropathy, which may be treated with radiofrequency denervation (Lord et al. 1996, Cohen et al. 2007). Other causes of chronic neck pain after trauma include occipital neuralgia, which may respond to nerve blocks and pulsed radiofrequency, cervical discogenic pain, and myofascial pain.

In patients with moderate to severe TBI, the development of spasticity (especially extensor hypertonia of the lower limbs) can contribute to chronic pain. Tizanidine, cutaneous electrical stimulation, and cryotherapy have been beneficial in relieving spasticity; in refractory cases, intrathecal baclofen and injections of botulinum toxin or alcohol neurolysis have been shown to be effective (Lahz and Bryant 1996, Branca et al. 2004).

Extremity trauma represents the leading cause of survivable war injuries (>67%), sports injuries, and work-related trauma. In patients with orthopedic extremity injuries, peripheral nerve blocks may improve acute pain control, reduce opioid consumption, and facilitate discharge as either stand-alone therapy or an adjunct to systemic opioids. Brachial plexus blocks can be useful in upper extremity trauma, whereas lumbar plexus and sciatic blocks are indicated in patients with lower extremity injuries. When multiple operations or prolonged hospitalization is anticipated, a catheter can be placed to provide continuous analgesia.

Regional techniques, however, may be less useful in patients with multiple injuries and open wounds and contraindicated in patients with untreated infection. Furthermore, the risks of a regional technique may outweigh its benefits in patients who are sedated (i.e., for ventilatory-dependent respiratory failure) or those with acute changes in mental status, as a practitioner may not readily recognize nerve injury during placement or local anesthetic toxicity.

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