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Written by

Professor Narinder Rawal Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Sweden

Postoperative pain: a review of evidence for multimodal analgesia, epidural analgesia, perineural techniques and infiltrative techniques

Published 11 March 2016

Professor Narinder Rawal discusses postoperative pain and the evidence for different management options

Key learning points

  • Despite being a decades-old problem, undertreatment of postoperative pain is still challenging.
  • Persistent postoperative pain (PPP) can last for years. High-risk patients should be informed preoperatively.
  • There is little evidence for the benefits of multimodal analgesia.
  • Epidural analgesia is no longer the gold standard.
  • Perineural techniques are underused and simple infiltrative techniques are surprisingly effective.
  • Standardised protocols, teaching programmes, a multidisciplinary approach and regular audits supervised by an Acute Pain Service are all necessary for improving postoperative pain management and recovery.

Recent surveys show that the decades-old problem of undertreated postoperative pain continues to be a challenge,1,2 particularly in pregnant women, children, elderly people and those who are opioid tolerant.  

Persistent postoperative pain

The incidence of persistent postoperative pain (PPP) is variable, after some procedures it may be as high as 50%.3,4 It can last months or years. Severe PPP affects 2–10% of the adult post-surgical population.5,6 Despite 20 years of research, there is no conclusive evidence for any intervention in the prevention or treatment of PPP. Risk factors include surgical, psychosocial, genetic and environmental factors.3,5 It is important to discuss the risk of pain preoperatively, particularly with patients at high risk.

Current management strategies include minimally invasive surgery with nerve-sparing techniques, intravenous ketamine (a modest role)6 and gabapentinoids such as gabapentin and pregabalin (literature is conflicting).6 Regional techniques such as epidural, paravertebral block and infiltrative techniques are promising.7


Despite limitations, strong opioids such as morphine remain the mainstay of postoperative pain management. Opioids are effective for opioid-sensitive, moderate to severe pain, do not have a ceiling effect and are available in many formulations. However, opioid-related adverse events have been associated with increased overall cost and length of hospital stay.8

Multimodal analgesia

Multimodal analgesia involves concurrent use of more than one class of analgesic drug or technique to improve pain relief while reducing or eliminating the use of opioids; however, recent literature shows that the 24-hour morphine-sparing effects of non-opioids are modest.9 There is good evidence (albeit more modest than previously believed) for combining paracetamol and NSAIDs,10 but hardly any literature on combining three or more analgesics which is common clinical practice.11 A review concluded that the benefits of combination analgesia were unimpressive and patients may be at increased risk of adverse events.9

Epidural analgesia

Epidural analgesia (EA) has long been the gold standard for postoperative pain management; however, recent reviews have contested this.12,13 The benefits of EA are not as impressive, and the risk of complications greater, than previously thought (Box 1).12–14

Box 1. Reasons for the diminishing role of EA in postoperative pain management

  • Increased morbidity with EA13
  • Minimally-invasive and endoscopic surgical techniques reduce the need for EA12
  • Benefits of EA over systemic opioids are less impressive than previously thought13
  • Failure rates can be high (13–47%)13
  • Side effects of EA include hypotension and urinary retention12,13 which can delay postoperative mobilisation and rehabilitation
  • The risks of serious neurological complications and death are greater than previously believed12,14
  • Monitoring requirements are labour intensive12
  • No convincing cost-effectiveness data12

Perineural techniques

Perineural techniques are highly effective and superior to intravenous opioids for postoperative analgesia.15 Meta-analyses have shown that paravertebral blocks are superior to EA because they are equally effective but cause less hypotension, urinary retention, pulmonary complications and postoperative nausea and vomiting.12,16 Perineural techniques are recommended as first choice for major orthopaedic procedures such as hip and knee replacement;12,17 however, actual use of perineural techniques is low.18

Infiltrative techniques

A review has recommended a shift to simple, local anaesthetic-based infiltrative techniques as a primary component of multimodal analgesia.19

Local infiltration analgesia (LIA)

LIA for knee and hip replacement is widely accepted by orthopaedic surgeons, for postoperative analgesia, it has favourable results compared with EA,20 intrathecal morphine21 and femoral nerve block.22 Knee replacement surgery is a good example of how analgesia has evolved in recent years (Figure 1).

Figure 1. How analgesic techniques for knee replacement surgery have evolved 


Intraperitoneal local anaesthetic

In abdominal surgical procedures, intraperitoneal local anaesthetic techniques are comparable to EA for analgesia at rest and with movement, but have fewer adverse effects.23 Catheter position is important, preperitoneal placement is recommended for colonic surgery24 and subfascial placement for caesarean section.25

Transversus abdominis plane (TAP) block

TAP block delivers local anaesthetic to the space between the internal oblique and tranversus abdominis muscles. It can be useful in bowel surgery, appendectomy, hernia repair, umbilical surgery and gynaecological surgery. A meta-analysis has also shown TAP to be effective for pain after cesarean section.26

Postoperative pain management guidelines

The PROSPECT recommendations27 are based on systematic review of the literature for specific surgical procedures, use of analgesic drugs and techniques and the impact of anaesthetic and surgical techniques on postoperative pain.

In addition, regular audits under the supervision of low cost Acute Pain Services have been shown to be effective in improving postoperative pain management.19

  • Professor Narinder Rawal is a Professor at the Department of Anaesthesiology and Intensive Care, Örebro University, Sweden


  1. Gan TJ, Habib AS, et al. Current Medical Research and Opinion 2014;30(1):149–160.
  2. Benhamou D, Berti M, et al. Pain 2008;136(1-2):134–141.
  3. Wu CL, Raja SN. The Lancet 2011;377(9784):2215–2225.
  4. Werner MU, Soholm L, et al. Anesthesia & Analgesia 2002;95(5):1361–1372.
  5. Werner MU, Kongsgaard UE. British Journal of Anaesthesia 2014;113(1):1–4.
  6. Chaparro LE, Smith SA, et al. Cochrane Database of Systematic Reviews 2013; Issue 7. Art. No: CD008307. DOI:10.1002/14651858.CD00830.pub 2.
  7. Andreae MH, Andreae DA. British Journal of Anaesthesia 2013;111(5):711–720.
  8. Oderda GM, Said Q, et al. Annals of Pharmacotherapy 2007;41(3):400–406.
  9. Dahl JB, Nielsen RV, et al. Acta Anaesthesiologica Scandinavica 2014,58(10):1165–1181.
  10. Ong CK, Seymour RA, et al. Anesthesia & Analgesia 2010;110(4):1170–1179.
  11. Joshi GP, Schug SA, et al. Best Practice & Research Clinical Anaesthesiology 2014;28(2):191–120.
  12. Rawal N. Regional Anesthesia and Pain Medicine 2012;37(3):310–317.
  13. Kooij FO, Schlack WS, et al. Anesthesia & Analgesia 2014;119(3):740–744.
  14. Pitkänen MT, Aromaa U, et al. Acta Anaesthesiologica Scandinavica 2013;57(5):553–564.
  15. Richman JM, Liu SS, et al. Anesthesia & Analgesia 2006;102(1):248–257.
  16. Davies RG, Myles PS, et al. British Journal of Anaesthesia 2006;96(4):418–426.
  17. Fowler SJ, Symons J, et al. British Journal of Anaesthesia 2008;100(2):154–164.
  18. Rawal N. Regional Anesthesia and Pain Medicine 2012;37(1):72–78.
  19. Rawal N. European Journal of Anaesthesiology 2016;33(3):160–171.
  20. Andersen KV, Bak M, et al. Acta Orthopaedica 2010;81(5):606–610.
  21. Kuchalik J, Granath B, et al. British Journal of Anaesthesia 2013;111(5):793–99.
  22. Affas F, Nygårds E-B, et al. Acta Orthopaedica 2011;82(4):441–447.
  23. Ventham NT, Hughes M, et al. British Journal of Surgery 2013;100(10):1280–1289.
  24. Beaussier M, El´Ayoubi H, et al. Anesthesiology 2007;107(3):461–468.
  25. Ranta PO, Ala-Kokko TI, et al. International Journal of Obstetric Anesthesia 2006;15(3):189–194.
  26. Abdallah FW, Halpern SH, et al. British Journal of Anaesthesia 2012;109(5):679–687.
  27. Prospect: Procedure Specific Postoperative Pain Management. Available from: www.postoppain.org (accessed 5 February 2016).

Date of preparation: February 2016; MINT/PAEU-15027