Regional Anesthesia and Pain outcomes after ACLR surgery: Some answers but some more questions too!
Allison M Fernandez, Galaxy Li, Tessa Mandler, Vidya Chidambaran and Kesavan Sadacharam
The PAAD’s executive council now has over 20 members. Although I assign most of the reviews to specific reviewers, occasionally, I screw up and more than one team gets the same article. This happened with today’s PAAD. The same articles were reviewed just last week. I am posting this one as well, primarily because of the important message at the end o the review. The Society for Pediatric Anesthesia Improvement Group (SPAIN) is a multicenter collaborative group of great importance to our specialty and will have a committee meeting at the upcoming annual meeting of the Society for Pediatric Anesthesia. SPA committees are open to all to attend and join. I would urge any of you with an interest in this to go and meet the leaders of this committee who will be at the meeting and authored today’s PAAD.. Myron Yaster MD
Original article
Sadacharam K, Furstein JS, Staffa SJ, Li G, Karroum R, Booth JM, Kim E, McCahan SM, Muhly WT, Chidambaran V; SPAIN-ACL Investigators. Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report. Reg Anesth Pain Med. 2024 Apr 18:rapm-2024-105381. doi: 10.1136/rapm-2024-105381. Epub ahead of print. PMID: 38637132.
Original article
Sadacharam K, Mandler T, Staffa SJ, Pestieau SR, Fuller C, Ellington M, Sparks JW, Fernandez AM; SPAIN-ACL Investigators. Regional Anesthesia and Pain Outcomes After Anterior Cruciate Ligament Reconstruction Surgery in Pediatric Patients: Society of Pediatric Anesthesia Improvement Network. Anesth Analg. 2025 Jan 29. doi: 10.1213/ANE.0000000000007376. Epub ahead of print. PMID: 39879136.
The Society for Pediatric Anesthesia Improvement Group (SPAIN) is a multicenter collaborative group formed through the Society for Pediatric Anesthesia (SPA). The mission of this group is to study various perioperative outcomes with a focus on both short- and long-term pain and functional outcomes after various procedures. Our most recent study is to understand pain, psychological and functional outcomes of children and adolescents who undergo an anterior cruciate ligament reconstruction (ACLR).
For today’s PAAD we will review two manuscripts from this multicentered prospective observational study. 519 subjects in the study from 15 sites, following pain scores and opioid use in the recovery room, on postoperative day 1 (POD1), week 6, and month 6. Of the subjects, 92% suffered sports related injury, and 64% were noncontact injuries.1 Only 2 subjects reported taking opioids prior to surgery.2 All subjects received general anesthesia. Notably, 86% of subjects received a regional block and 14% received intraarticular injections.1 The most common blocks were adductor canal blocks (62%), popliteal nerve blocks (29.8%) and IPACK blocks (15.9%).1,2 Nerve catheters were used in 24% of patients.2 There were no adverse events with peripheral nerve blocks and the aborted/unsuccessful block rate was 0.4%.2 Perineural adjuvants were used in 42%, and 11% received a combination of perineural adjuvants. Dexmedetomidine (17%) and clonidine (10%) were the most commonly used adjuvants. All patients received intraoperative opioids and 2.7% required hospitalization for post operative pain control.1,2 The mean number of oxycodone doses used was 2.75 on POD1, 1.83 on POD3, and 0 at week 6 and month 6. Postoperative anti-inflammatory medication use varied across sites with 76% of patients using ibuprofen or ketorolac on POD1, but only 64% reported the use of acetaminophen on POD 1. Ibuprofen or acetaminophen use was reported by 12% of respondents on week 6 and by 4% at month 6.1 The incidence of self-reported numbness and weakness at week 6 and month 6, revealing respective incidences of 11.1% and 15.5% for numbness and 4.1% and 2.1% for weakness.2
We categorized the patients into no blocks, anterior peripheral nerve blocks (A-PNB) only, and anterior and posterior (A+P-PNB) PNB. The median pain score in the recovery room was 3 of 10 although 32.7% reported a (numeric pain score) NPS>7.2 Not surprisingly, we found that those patients that received an A+P PNB had better pain control in the immediate postoperative period and reduced opioid use in the perioperative period.2 However, those patients that received an A+P PNB had increased pain scores on (POD 1) compared to those who had not received PNB. We believe that this is a result of the resolution of the sensory PNB. 60% received opioids in the post anesthetic care unit (PACU) 1.2 There was no difference in opioid use between all groups at POD 3, week 6 and month 6.2
Important results we want to highlight in this PAAD are that a large percentage of patients experienced elevated pain scores (NPS>7) in PACU (32.7%), on POD 1 (25.7%), POD 3 (10%), 0.6% at week 6 and 3% at month 6.1,2 Again, it’s important to reiterate that 3% of patients developed chronic persistent pain following this surgery. Multivariable analysis included surgical factors, pain medications, and regional block utilized found the only variable associated with severe pain scores on POD 1 was the administration of local anesthetic concentration (LAC) >0.25%. (2) Another interesting finding was that there was no difference in pain control when comparing the patients with PNB catheters vs single shot injections on POD 3, week 6 or month 6. (2) Only on POD 1 did the catheter groups report less pain compared to the single shot group.(2) We also found no difference in pain scores or opioid use between patients that received PNB with and without perineural adjuvants.(2) Another important aspect to highlight is the lack of multimodal analgesia used in the post operative period, ie none of the nonopioid adjuvants were postoperatively continued.
Besides pain control, we also wanted to study functional outcomes. We did find a subset of patients that self-reported numbness at week 6 and month 6. Unfortunately, there was no physical exam to assess the numbness reported by the patient. Multivariable logistic regression analysis found no association between persistent numbness and block type, catheter placement, graft type, or tourniquet duration.2 Instead, patient self reported numbness was related to administration of LAC ≥0.25% for the anterior nerve block distribution at week 6 and perineural steroid adjuvant (methylprednisolone or dexamethasone) at month 6.2 Our analysis found no association between self-reported persistent weakness and block type, catheter utilization, graft type, tourniquet duration, or local anesthetic type or concentration.2 Of note, there was also a lot of variability in objective functional outcome testing of this patient population. The first objective functional outcome testing was performed at 6 months after surgery at most sites (9/14), but timing varied from 3 to 9 months and the type of assessments also varied.1
Our study also highlights the large variability in pain management for ACLR in the pediatric population. An editorial was written by Soffin et al.3 highlighting unwanted variability in pain management for this study. Unwarranted variation in healthcare refers to differences in healthcare practices and outcomes that cannot be explained by patient illness, medical evidence, or patient preferences.3 Instead, these variations are often attributed to differences in healthcare policies, payment systems, and organizational structures that influence how care is provided.3 This point of unwanted variability is an important obstacle to tackle, especially in pain management, as uncontrolled pain is a risk factor for the development of chronic pain.
Although we hoped to find more clarity for pain management in this patient population, we have more questions and opportunities for investigation. How should we educate families to manage postoperative pain after this procedure? if single shot PNB with adjuvant(s) would be more effective than PNB infusions via catheter, what is the clinical significance of the patients’ self- reported numbness? Further research is needed to investigate steroid use as a perineural adjuvant, and any association with numbness and/or its clinical relevance. Other areas of research include how to reduce pain management variability, how implementation science can help reduce pain management variability, and how to standardize rehabilitation methods and testing for this patient population.
If you find these mysteries as intriguing as we do, please keep your eye out for more articles from the ACLR database. We recently published “Preoperative Psychological Factors, Postoperative Pain Scores, and Development of Posttraumatic Stress Disorder Symptoms After Pediatric Anterior Cruciate Ligament Reconstruction.”4 (PS from Myron: we will review this article when it appears in print!) The primary aim of this study is to assess whether patient preoperative temperament, anxiety, and depression is associated with the development of PTSD. The secondary aim is to investigate whether higher levels of postoperative pain are associated with an increased likelihood of developing PTSD. more detailed analysis of regional anesthesia and its effects on functional outcomes after ACLR at week 6 and month 6. We are also currently writing a manuscript on how pain management strategies during ACLR surgery influence short and long term (6 months) functional outcomes.
As you can see, SPAIN is a very active group. If you are interested in learning more about us or are interested in joining SPAIN please visit our website:
Society for Pediatric Anesthesia Improvement Network (SPAIN) | Society for Pediatric Anesthesia
We are always looking for more members and opportunities to collaborate. For more information, contact and/or join us at the Annual SPA meeting next week:
Kesavan Sadacharam, MD (Kesavan.Sadacharam@nemours.org ) – President
Galaxy Li, MD (Galaxy.Li@nemours.org)– President Elect
Allison Fernandez MD MBA (aferna27@jh.edu) Past President
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Sadacharam K, Furstein JS, Staffa SJ, et al. Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report. Regional anesthesia and pain medicine 2024 (In eng). DOI: 10.1136/rapm-2024-105381.
2. Sadacharam K, Mandler T, Staffa SJ, et al. Regional Anesthesia and Pain Outcomes After Anterior Cruciate Ligament Reconstruction Surgery in Pediatric Patients: Society of Pediatric Anesthesia Improvement Network. Anesthesia and analgesia 2025 (In eng). DOI: 10.1213/ane.0000000000007376.
3. Soffin EM, Abdallah FW, Mariano ER. Unwarranted variation in perioperative pain management for pediatric anterior cruciate ligament reconstruction: a call to improve the quality of quality improvement. Regional anesthesia and pain medicine 2024 (In eng). DOI: 10.1136/rapm-2024-105637.
4. Sadacharam K, Uhl K, Kelleher S, et al. Preoperative Psychological Factors, Postoperative Pain Scores, and Development of Posttraumatic Stress Disorder Symptoms After Pediatric Anterior Cruciate Ligament Reconstruction. Anesthesia and analgesia 2025 (In eng). DOI: 10.1213/ane.0000000000007371.