Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities

Brian M. Ilfeld, MD, MS

Anesth Analg. 2017;124(1):308-335.

Abstract and Introduction

Abstract

A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered, providing a prolonged block that may be titrated to the desired effect. In the decades after its first report in 1946, a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia article. The current update is an evidence-based review of the CPNB literature published in the interim. Novel insertion sites include the adductor canal, interpectoral, quadratus lumborum, lesser palatine, ulnar, superficial, and deep peroneal nerves. Noteworthy new indications include providing analgesia after traumatic rib/femur fracture, manipulation for adhesive capsulitis, and treating abdominal wall pain during pregnancy. The preponderance of recently published evidence suggests benefits nearly exclusively in favor of catheter insertion using ultrasound guidance compared with electrical stimulation, although little new data are available to help guide practitioners regarding the specifics of ultrasound-guided catheter insertion (eg, optimal needle–nerve orientation). After some previous suggestions that automated, repeated bolus doses could provide benefits over a basal infusion, there is a dearth of supporting data published in the past few years. An increasing number of disposable infusion pumps does now allow a similar ability to adjust basal rates, bolus volume, and lockout times compared with their electronic, programmable counterparts, and a promising area of research is communicating with and controlling pumps remotely via the Internet. Large, prospective studies now document the relatively few major complications during ambulatory CPNB, although randomized, controlled studies demonstrating an actual shortening of hospitalization duration are few. Recent evidence suggests that, compared with femoral infusion, adductor canal catheters both induce less quadriceps femoris weakness and improve mobilization/ambulation, although the relative analgesia afforded by each remains in dispute. Newly published data demonstrate that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB. Few new CPNB-related complications have been identified, although large, prospective trials provide additional data regarding the incidence of adverse events. Lastly, a number of novel, alternative analgesic modalities are under development/investigation. Four such techniques are described and contrasted with CPNB, including single-injection peripheral nerve blocks with newer adjuvants, liposome bupivacaine used in wound infiltration and peripheral nerve blocks, cryoanalgesia with cryoneurolysis, and percutaneous peripheral nerve stimulation.

Introduction

A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered. Such a "perineural local anesthetic infusion" provides a prolonged peripheral nerve block that may be titrated to the desired effect.^[1] In the decades after its first report in 1946,^[2] a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia review.^[1] The current update is an evidence-based review of the CPNB literature published in the interim. Because of publication limitations, the majority of information—including 364 citations—included in the previously published review is not repeated here.^[1] Consequently, the current update is most likely best utilized in concert with the previous review article to provide a complete overview of CPNB. Because there are literally thousands of CPNB-related publications, only those that provide the highest quality data (eg, randomized controlled trials [RCTs]) and/or are the most influential (eg, unique case reports and observational studies) are included.

In addition, a variety of novel, alternative analgesic modalities are currently under development/testing. These techniques are also reviewed and compared/contrasted with CPNB.

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Next Section

Table 1. Catheter Locations
Surgical Site	Major Approaches	Randomized and Controlled Study Design? (for Catheter Site)	Comments	Comparative CPNB Studies
Head and neck	Mandibular, maxillary, lesser palatine nerves, and cervical plexus	No^1,38,426	Effectiveness of techniques unclear without RCT
Shoulder and proximal humerus	Interscalene	Yes^{20,98,99,108,116,119,130,131,145–147,153,163,164,173,176,195,427} No^{4,5,8,16,77–81,159,162,168–172,175,428,429}	Recent RCT demonstrated a 2-d continuous interscalene block decreases pain 7 d after major shoulder surgery compared with a single-injection ropivacaine block¹⁷⁶	A recent RCT demonstrated that a supraclavicular infusion is noninferior to an interscalene infusion and reduced the incidence of complete or partial hemidiaphragmatic paresis (analgesia was superior to the interscalene catheters in the recovery room)⁴²⁷
	Cervical paravertebral	No⁶	Little published since the widespread adoption of ultrasound-guided catheter insertion
	Intersternocleidomastoid	No¹	Little published since the widespread adoption of ultrasound-guided catheter insertion
	Supraclavicular	Yes⁴²⁷ No^77,165,430	Relatively rare catheter site relative to the interscalene location for shoulder surgery¹; however, the largest series to date was recently published (n = 498)¹⁶⁵
	Suprascapular	No⁴³¹	Effectiveness of technique unclear without RCT
Elbow, forearm, and hand	Supraclavicular	Yes¹¹⁸ No^{9,32,77,81,159,165}	Relatively rare catheter site relative to the infraclavicular and—historically—axillary locations¹; however, the largest series to date was recently published (n = 271)¹⁶⁵	Infraclavicular provides superior analgesia to both supraclavicular⁴³² and axillary⁴³³ catheters for hand, forearm, and elbow surgery; 1 new RCT detected few differences between supraclavicular and infraclavicular infusions benefits but was underpowered for these secondary endpoints, and there were trends in favor of the infraclavicular location⁴³⁴
	Infraclavicular	Yes^173,434 No^{19,77–80,102,127,173}	A recent RCT provided 60 h of infraclavicular infusion to all participants and randomized subjects to remain hospitalized for 1 vs 3 nights¹⁷³; total hospital cost of care was 15% lower in the early discharge group and no other differences between treatment groups including elbow range of motion
	Axillary	Yes⁴³³ No^{31,77,79–81,127,128,435}	Dramatic decrease in publications since the widespread adoption of ultrasoundguided catheter insertion
	Median, ulnar nerves	No^39,436	Effectiveness of techniques unclear without RCT
Thorax and breast	Thoracic paravertebral	Yes^{27,135,158,167,177,204,221,437} No^{21–23,77,83,109,438}	For mastectomy, mixed evidence^439,440 with RCTs demonstrating no infusion benefits over placebo²²¹ and single-injection, ⁴⁴¹ yet others demonstrating benefits both during^167,437 and after (up to 1 y) perineural infusion^177,221	There are no studies comparing these CPNB techniques
	Intercostal	No^24–26	Effectiveness of this technique unclear without RCT
	Interpectoral	No^42,43	Effectiveness of this relatively novel technique unclear without RCT
Abdomen and inguinal region	Paravertebral	No^{37,77,83,442,443}	New published data include pediatric patients^77,83,442
	Transversus abdominis plane	Yes^33,36 No^{28,34,35,77,256,444}	Remains unvalidated with an RCT: one RCT was negative compared with placebo but was underpowered,³³ and a second RCT detected few differences between a continuous subcostal TAP and epidural infusion but was designed as a superiority study and the negative results should therefore be considered inconclusive and not equivalente³⁶
	Quadratus lumborum	No^44–46	Effectiveness of this relatively novel technique unclear without RCT
Hip, thigh, and leg	Posterior lumbar plexus Femoral	Yes^133,206 No^{3,6,77–80,178} Yes^29,203 No^{3,7,9,18,19,30,77–81,150,159,162}	Published RCTs dramatically diminished in numbers within the past few years, possibly indicating a general preference for other catheter locations	For hip arthroplasty, patients with femoral (vs posterior lumbar plexus) catheters: no difference in resting pain scores, but ambulation suffered; dynamic pain scores either higher or no difference; and increased opioid-related side effects and satisfaction¹
	Fascia iliaca	Yes⁴⁴⁵	First study validating this technique for hip analgesia recently published⁴⁴⁵
	Parasacral	No¹	Effectiveness of this technique unclear without RCT involving hip, thigh, or leg surgery
Knee (femoral nerve)	Posterior lumbar plexus	Yes¹ No^77–80,96	Published RCTs dramatically diminished in numbers within the past few years, possibly indicating a general preference for other catheter locations	Compared with femoral infusion, adductor canal CPNB induces less quadriceps femoris muscle weakness⁵⁰ and ambulatory disability^57,58,74; however, the evidence is mixed regarding comparable analgesia,^50,57,58,74 and further research is required to draw definitive conclusions
	Femoral	Yes^{50,57–59,74,85,91,93,95,101,104,121,132,138,198,216,446,447} No^{77–80,97,100,201,205,448–451}	Until recently, the most commonly published catheter location for knee surgery, but concerns regarding associated falls have raised interest in alternative catheter locations such as the adductor canal
	Adductor canal	Yes^{47,50,57–59,61–65,73,74,144} No^{156,263,279,452–456}	Relatively recently validated with randomized, placebo-controlled trials,^47,61–65 but multiple issues remain in dispute^66–71 or unclear/unknown^72,73 such as relative analgesia afforded compared with a femoral infusion^50,57,58,74
	Fascia iliaca	Yes¹ No⁷⁷	Dramatic decrease in publications since the widespread adoption of ultrasound-guided catheter insertion
Knee (sciatic nerve), leg, ankle, and foot	Subgluteal/parasacral	Yes^{94,96,97,126,201} No^{77,78,82,128,159}	Three recent RCTs have investigated the effects of adding a continuous sciatic nerve block to a continuous femoral or posterior lumbar plexus (psoas compartment) block after total knee arthroplasty^96,97,201; all demonstrated lower pain scores and decreased supplemental analgesic consumption,^96,97,201 and one detected a lower incidence of nausea and vomiting as well as improved knee flexion and ambulation²⁰¹	No major analgesic differences found between subgluteal and popliteal¹
	Popliteal	Yes^{88,92,134,194,200} No^{9,12–15,18,19,77–81,100,128,162,165,174,457,458}	A recent RCT provided 3 d of popliteal sciatic infusion to all participants (n = 120) and randomized subjects to remain hospitalized for 0 vs 2 nights after major orthopedic foot surgery¹⁹⁴; total costs of care were decreased 79% in the early discharge group, and no other differences between treatments were detected, including pain scores, complications, and readmission rates
	Tibial, superficial peroneal and deep peroneal nerves	No^11,40,41	Effectiveness of these techniques unclear without RCT
	Femoral/saphenous	Yes¹	Femoral infusion in addition to—and not in place of—popliteal infusion for major ankle surgery

Due to publication limitations, includes selected reports published subsequent to a previously published review article (Ilfeld¹) and is not intended as an exhaustive list.
CPNB, continuous peripheral nerve block; RCT, randomized controlled trial.

Table 2. Local Anesthetic Delivery Regimens for Continuous Peripheral Nerve Blocks
Catheter Location	Infusate(s)	Treatment Groups				Primary Findings
Catheter Location	Infusate(s)	n	Basal (mL/h)	Bolus (mL)	Lockout (min)	Primary Findings
Interscalene¹⁴⁷ •Arthroscopic rotator cuff repair •Ultrasound in-plane •Nonstimulating needle •Nonstimulating catheter	Ropivacaine 0.2%	33	4	0	—	Two groups receiving ropivacaine had lower pain scores and consumed less supplemental analgesics than the control group No differences between the basal and bolus treatment groups
		33	0	4	60
	Control (no catheter)	33	—	—	—
Interscalene¹⁴⁶ •Arthroscopic rotator cuff repair •Ultrasound in-plane •Stimulating needle •Stimulating catheter	Ropivacaine 0.2%	32	4	4	60	Bolus group used a lower total volume of local anesthetic and experienced less motor block No other differences between the basal and the bolus treatment groups noted
		32	0	4	30
Interscalene¹⁵³ •Arthroscopic or open rotator cuff repair •Ultrasound out-of-plane •Nonstimulating needle •Nonstimulating catheter	Ropivacaine 0.2%	38	2	5	60	No differences detected between treatments with one exception: higher basal rate group required a temporary infusion cessation because of side effects (predominantly hand numbness)
				5 mL every 6 h^a
		43	5	5	60
Interscalene¹⁴⁵ •Major shoulder surgery •Ultrasound, out-of-plane •Stimulating needle •Nonstimulating catheter	Ropivacaine 0.2%	50	4	3	30	No differences detected between treatments
		51	0	3	30
				4 mL every h^a
Paravertebral¹⁵⁸ •Thoracotomy •Nonstimulating catheter •Inserted by surgeon under direct vision	Bupivacaine 0.5%	40	0	15 mL every 6 h^a		Pain scores lower in bolus group, although statistically significant only at 48 and 72 h Higher total volume of local anesthetic consumed by the basal group
	Bupivacaine 0.25%	40	5	0	—
Adductor canal¹⁴⁴ •Healthy volunteers •Ultrasound, in plane •Nonstimulating needle •Nonstimulating catheter	Ropivacaine 0.2%	24	8	0	—	Equivalence between treatments to tolerance to cutaneous electrical current and quadriceps femoris maximum voluntary isometric contraction strength
		24	0	8 mL every 1 h^a
Femoral⁹⁵ •Anterior cruciate ligament repair •Stimulating needle •Nonstimulating catheter	Bupivacaine 0.1%	16	5	5	30	Analgesia superior in basal + bolus group at rest and during mobilization
		19	0	5	15
Sciatic⁹⁴ •Total knee arthroplasty •Anterior approach •Stimulating needle •Nonstimulating catheter •Femoral catheter and continuous infusion also used for both groups	Ropivacaine 0.2%	56	6	10	<30 min	Few differences between groups, other than the basal + bolus group consumed a higher total volume of local anesthetic
		52	0	10	<30 min

Due to publication limitations, includes selected randomized, controlled trials specifically investigating varying local anesthetic delivery method completed subsequent to a previously-published review article (Ilfeld¹), and is not intended as an exhaustive list.
—, not included for this treatment group.
^aMandatory bolus doses administered (not as needed).

Table 3. Randomized, Controlled Clinical Trials Involving At Least 1 Treatment Group With a Continuous Peripheral Nerve Block
First Author, Year	Surgical Procedure	Treatment Group	Control Group(s) During Catheter Utilization	Primary Positive Findings During Catheter Use (Treatment Group Superior Unless Otherwise Noted)
Interscalene catheters
Fredrickson et al¹⁶³ (2010)	Minor arthroscopic shoulder	Ropivacaine 0.2% (n = 31) 2 mL/h + 5 mL PCB [60]	Catheters removed in recovery room (n = 30)	Lower resting and dynamic pain scores; less supplemental analgesic requirements
Malhotra et al²⁰ (2013)	Adhesive capsulitis manipulation	Ropivacaine 0.2% (n = 2) 8 mL/h + 4 mL PCB [30]	Normal saline (n = 2) 8 mL/h + 4 mL PCB [30]	Lower average and dynamic pain scores; lower opioid analgesics; fewer awakenings because of pain; greater shoulder range of motion on day 1 as well as weeks 6 and 12 (preliminary data from a pilot study—underpowered for definitive conclusions)
Salviz et al¹⁷⁶ (2013)	Arthroscopic rotator cuff repair	Ropivacaine 0.2% (n = 20) 5 mL/h + 5 mL PCB [60]	•Single injection only (n = 23) •No block or catheter (n = 20)	Catheter group with less pain, opioid requirements, and sleep disturbances; at 7 d (2-d infusion) only 26% of catheter group reported NRS ≥4 compared with 83% and 58% of single-injection and no block groups, respectively
Infraclavicular catheters
Eng et al¹⁷³ (2015)	Complex arthroscopic elbow	Ropivacaine 0.2% 7 mL/h + 5 mL PCB [30]		Total hospital cost of care was 15% lower in the early discharge group; no other differences between treatment groups including elbow range of motion
Eng et al¹⁷³ (2015)	Complex arthroscopic elbow	Discharge as early as postoperative day 1 (n = 19)	Required to remain hospitalized 72 h (n = 19)
Paravertebral catheters
Ilfeld et al^167,177 (2014) and (2015)	Mastectomy	Ropivacaine 0.4% (n = 30) 5 mL/h basal only	Normal saline (n = 30) 5 mL/h basal only	Lower resting and breakthrough pain scores; less pain-induced physical and emotional dysfunction during infusion; less chronic pain at 1 y
Karmakar et al²²¹ (2014)	Modified radical mastectomy	Ropivacaine 0.25% (n = 60) 0.1 mL/kg/h basal only	•Single injection only (n = 57) •No block or catheter (n = 60)	No differences among groups during infusion period nor chronic pain incidence at 3 or 6 mo, but at 3 and 6 mo, both infusion and single-injection group had less severe pain, exhibited fewer symptoms and signs of chronic pain, and experienced better physical and mental health-related quality of life
Pintaric et al²⁰⁴ (2011)	Thoracotomy (open lung surgery)	Levobupivacaine 0.125% and morphine 30 μg/mL (n = 16) 0.1 mL/kg/h + 0.1 mL/kg PCB [60]	Epidural levobupivacaine and morphine at same concentration and rate/bolus as paravertebral catheters	Similar analgesia but greater hemodynamic stability than epidural analgesia with less required colloid volume and vasopressors to maintain target oxygen delivery index
Transversus abdominis plane (TAP) catheters
Heil et al³³ (2014)	Abdominal or inguinal hernia repair	Ropivacaine 0.2% (n = 10) 10 mL/h basal only	Normal saline (n = 10) 10 mL/h basal only	No statistically significant difference in pain scores or supplemental analgesics (underpowered study because of curtailment of enrollment)
Niraj et al³⁶ (2011)	Open renal or hepatobiliary	Bupivacaine 0.375% (n = 29) 1 mg/kg each of bilateral catheters every 8 h	Epidural bupivacaine 0.125% with fentanyl 2 μg/mL (n = 33) 6–12 mL/h + 2 mL PCB [30]	No statistically significant differences in any outcomes between treatments except that the TAP group required a higher dose of rescue analgesics
Adductor canal catheters (placebo controlled)
Andersen et al⁶⁴ (2013)	Total knee arthroplasty	Ropivacaine 0.75% (n = 20) 15 mL "twice daily"	Normal saline (n = 20) 15 mL "twice daily"	Lower average resting and breakthrough (maximum) pain scores and fewer sleep disturbances; ambulation possible in 100% vs 65% of subjects in the ropivacaine vs saline groups, respectively
Grevstad et al⁶⁵ (2015)	Severe pain on flexion after total knee arthroplasty	Ropivacaine 0.75% (n = 24) 30 mL single injection	Normal saline (n = 25) 30 mL single injection	Reduced pain during active flexion of the knee, but a large proportion (78%) still had at least moderate pain on flexion
Hanson et al⁶¹ (2014)	Total knee arthroplasty	Ropivacaine 0.2% (n = 36) 8 mL/h basal only	Sham catheter (n = 40)	Decreased resting and dynamic pain scores, lower required supplemental analgesics, greater quadriceps strength, greater ambulation distance, and higher satisfaction
Jaeger et al⁴⁷ (2012)	Total knee arthroplasty	Ropivacaine 0.75% (n = 21) 30 mL single injection	Normal saline (n = 20) 30 mL single injection	Decreased pain during hours 1–6 and less nausea
Jæger et al⁶³ (2014)	Revision total knee arthroplasty	Ropivacaine 0.75% (n = 14) 30 mL bolus; 6 h later 0.2% 15 mL bolus; then ropivacaine 0.2% 8 mL/h	Normal saline (n = 13) administered at the same time points and volumes as the ropivacaine group	Lower pain on knee flexion at 4 h (underpowered study for remainder of endpoints)
Jenstrup et al⁶² (2012)	Total knee arthroplasty	Ropivacaine 0.75% (n = 34) 30 mL bolus; then 15 mL bolus at 6, 12, 18, and 24 h	Normal saline (n = 37) administered at the same time points and volumes as the ropivacaine group	Lower dynamic pain on flexion and supplemental analgesic requirements, superior ambulation, and mobilization at 24 h
Fisker et al⁴⁵⁹ (2015)	Major ankle surgery	Continuous popliteal sciatic blocks for all subjects		No differences between treatment groups detected
Fisker et al⁴⁵⁹ (2015)	Major ankle surgery	Ropivacaine 0.2% (n = 20) 5 mL/h basal only	Normal saline (n = 24) 5 mL/h basal only	No differences between treatment groups detected
Adductor canal catheters (versus femoral catheters)
Elkassabany et al⁵⁹ (2016)	Total knee arthroplasty	Adductor ropivacaine 0.2% (n = 31) 8 mL/h basal only	Femoral ropivacaine 0.2% (n = 31) 8 mL/h basal only	Greater quadriceps femoris strength^a
Jæger et al⁵⁰ (2013)	Total knee arthroplasty	Adductor ropivacaine 0.2% (n = 22) 8 mL/h basal only	Femoral ropivacaine 0.2% (n = 26) 8 mL/h basal only	Greater quadriceps femoris strength (52% vs 18% of baseline)
Machi et al⁵⁸ (2015)	Total knee arthroplasty	Adductor ropivacaine 0.2% (n = 39) 6–8 mL/h + 4 mL PCB [30]	Femoral ropivacaine 0.2% (n = 39) 4–8 mL/h + 4 mL PCB [30]	Improved ability to stand, sit, and ambulate, but higher dynamic pain scores than femoral infusion
Shah and Jain⁷⁴ (2014)	Total knee arthroplasty	Adductor ropivacaine 0.75% (n = 48) 30 mL, then ropivacaine 0.25% 30 mL every 4 h until postoperative day 2	Femoral ropivacaine 0.75% (n = 50) 30 mL, then ropivacaine 0.25% 30 mL every 4 h until postoperative day 2	Improved ability to stand, sit, and ambulate, as well as climb stairs; decreased time until actual discharge (3.1 vs 3.9 d)
Sztain et al⁵⁷ (2015)	Unicompartment knee arthroplasty	Adductor ropivacaine 0.2% (n = 15) 6–8 mL/h + 4 mL PCB [30]	Femoral ropivacaine 0.2% (n = 15) 2–6 mL/h + 4 mL PCB [30]	Fewer days until discharge readiness; improved ability to sit, stand, and ambulate; but higher resting pain scores than femoral infusion
Zhang et al²⁰⁹ (2014)	Total knee arthroplasty	Adductor ropivacaine 0.2% (n = xx) 5 mL/h + 5 mL PCB [30]	Femoral ropivacaine 0.2% (n = x) 5 mL/h + 5 mL PCB [30]	Greater quadriceps femoris strength (52% vs 18% of baseline)
Femoral catheters
Al-Zahrani et al⁴⁴⁷ (2015)	Total knee arthroplasty	Femoral bupivacaine 0.2% (n = 25) 5 mL/h basal only (singleinjection sciatic block 15 mL bupivacaine 0.25%)	Epidural bupivacaine 0.0625% + fentanyl 2 μg/mL (n = 25) 5–10 mL/h basal only	No differences between treatment groups detected
Sakai et al¹⁹⁸ (2013)	Total knee arthroplasty	Femoral ropivacaine 0.15% (n = 30) 4 mL/h basal only	Epidural ropivacaine 0.15% (n = 30) 4 mL/h basal only	Shorter time to achieve 120° knee flexion (8 vs 15 d), improved dynamic analgesia, and lower supplemental analgesic requirements
Baranović et al¹⁹⁶ (2011)	Total knee arthroplasty	Femoral levobupivacaine 0.25% (n = 35) 5–6 mL/h basal only	No catheter (n = 36)	Improved analgesia, improved knee flexion on postoperative day 2, lower intravenous morphine requirements, and dramatically lower opioid-related adverse events such as urinary retention, sedation, and nausea/vomiting
Peng et al²¹⁶ (2014)	Total knee arthroplasty	Femoral ropivacaine 0.15% (n = 127) 5 mL/h + 5 mL [30]	No catheter (n = 123)	Less supplemental analgesics required and improved knee flexion during infusion, and lower incidence of chronic pain and improved knee flexion at 3 and 6 mo after surgery
Wu and Wong¹⁹⁷ (2014)	Total knee arthroplasty	Femoral levobupivacaine 0.08% (n = 30) 8–12 mL/h basal only	No catheter (n = 30)	Lower intravenous opioid requirements, fewer opioid-related side effects, improved satisfaction with analgesia, and increased ambulation ability
Sciatic catheters
Elliot et al²⁰⁰ (2010)	Hind foot or ankle surgery	Bupivacaine 0.25% (n = 27) 4 mL/h + 1 mL [60]	Normal saline (n = 27) 4 mL/h + 1 mL [60]	Lower pain scores and less supplemental analgesic requirements
Saporito et al¹⁹⁴ (2014)	Toes 2–5 osteotomy or hallux valgus correction	Ropivacaine 0.2% 5 mL/h + 5 mL PCB [60]		Total costs of care were 79% lower in the early discharge group; no other differences between treatment groups including pain scores, complications, and readmission rates
Saporito et al¹⁹⁴ (2014)	Toes 2–5 osteotomy or hallux valgus correction	Discharged day of surgery (n = 60)	Required to remain hospitalized 2 nights (n = 60)
Cappelleri et al⁹⁶ (2011)	Total knee arthroplasty	Continuous posterior lumbar plexus blocks for all subjects		Lower resting and dynamic pain scores, less supplemental opioids, lower incidence of nausea and vomiting, improved knee flexion and ambulation
Cappelleri et al⁹⁶ (2011)	Total knee arthroplasty	Subgluteal levobupivacaine 0.06% (n = 19) 0.1 mL/kg/h	Subgluteal normal saline (n = 19) 0.1 mL/kg/h
Sato et al²⁰¹ (2014)	Total knee arthroplasty	Continuous femoral nerve blocks for all subjects		Lower resting pain scores and less supplemental opioids
Sato et al²⁰¹ (2014)	Total knee arthroplasty	Subgluteal ropivacaine 0.2% (n = 30) 5 mL/h	Subgluteal normal saline (n = 30) 5 mL/h	Lower resting pain scores and less supplemental opioids
Wegener et al^97,220 (2011) and (2013)	Total knee arthroplasty	Continuous femoral nerve blocks for all subjects		Catheter group with lower dynamic pain scores compared with the other 2 treatment groups on postoperative days 1 and 2 during the infusion; and in a subset of the most initially disabled subjects preoperatively, joint stiffness was reduced at 3 and 12 mo, and dynamic pain reduced at 3 mo compared with the no block or catheter group
Wegener et al^97,220 (2011) and (2013)	Total knee arthroplasty	Parasacral levobupivacaine 0.125% (n = 30) 10 mL/h	•Parasacral single injection only (n = 30) •No block or catheter (n = 30)

Due to publication limitations, includes selected reports published subsequent to a previously-published review article (Ilfeld¹), and is not intended as an exhaustive list. In addition, investigations included in Table 2 are excluded.
NRS, numeric rating scale for pain (0–10, 0: no pain, 10: worst imaginable); PCB, patient-controlled bolus volume (lockout period in minutes).
^aInfusions were discontinued morning of postoperative day 1 before endpoint evaluation.

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