Page 185 Acute Pain Management

In patients having hand surgery, IVRA using a combination of lignocaine and dexamethasone
resulted in lower pain scores and lower analgesic requirements for 24 hours compared with
lignocaine alone or lignocaine IVRA with dexamethasone in the non‐operative arm (Bigat et al,
2006 Level II).
The addition of dexamethasone to lignocaine for axillary brachial plexus block prolonged the
duration of sensory and motor blockade compared with lignocaine alone (Movafegh et al, 2006
Level II).
There is insufficient evidence to support the use of injection therapy, including corticosteroids,
in subacute and chronic low‐back pain. However, it cannot be ruled out that specific
subgroups of patients may respond to a specific type of injection therapy (Staal et al, 2009
Level I). Lumbar epidural steroid injections may provide short‐term relief from acute radicular
pain but did not impact on function, need for surgery, or provide long‐term pain relief beyond
3 months (Armon et al, 2007 Level I).
Topical
Topical corticosteroids have not been shown to have consistent efficacy in acute herpes zoster
(Hempenstall et al, 2005 Level I).

Key messages
1. Subacromial injections of corticosteroids are superior to oral NSAIDs in treating rotator cuff
tendonitis (N) (Level I).
2. Lumbar epidural steroid administration is effective for short ‐term relief of acute radicular
pain (N) (Level I).
3. Following knee joint arthroscopy, intra‐articular steroids in combination with either local CHAPTER 5
anaesthetic or opioids reduce pain, analgesic consumption and duration of immobilisation
(N) (Level II).
4. Intravenous regional anaesthesia combining dexamethasone with lignocaine improves
analgesia for up to 24 hours (N) (Level II).
5. There is a risk of septic arthritis with intra‐articular steroids (N) (Level IV).
5.4.2 Non-steroidal anti-inflammatory drugs

Peripheral sites
Intra‐articular nsNSAIDs such as tenoxicam and ketorolac resulted in improved pain relief after
surgery (Elhakim et al, 1996 Level II; Cook et al, 1997 Level II; Convery et al, 1998 Level II; Colbert et al,
1999 Level II; Gupta et al, 1999 Level II); no long‐term follow‐up looking at any effect on bone
healing has been undertaken.
Topical
With topical application of diclofenac, tissue levels are higher and plasma levels lower than
following oral administration (Zacher et al, 2008). Topical diclofenac significantly reduced pain
and inflammation in a range of sports, traumatic and inflammatory acute and chronic
conditions compared with placebo and was comparable to other topical NSAIDs (although
there were no direct comparisons) and oral diclofenac, ibuprofen and naproxen. (Zacher et al,
2008 Level I). Topical ketoprofen used for up to one week in acute painful conditions (strains,
sprains or sports injuries) had a NNT of 3.8, which was significantly better than other topical
NSAIDs, although in non‐comparative (head‐to‐head) trials. (Mason et al, 2004 Level I). Topical
indomethacin did not have proven efficacy (Moore RA et al, 1998 Level I).

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