Peri-operative Percutaneous Nerve Blocks and Catheters in Major Lower Limb Amputation: A Systematic Review with Meta-analysis.

Abstract

Major lower limb amputation is associated with substantial post-operative pain. While surgically placed nerve catheters are commonly used, the role of peri-operative percutaneous peripheral nerve blocks (PNBs) and percutaneous peripheral nerve catheters (PNCs) for anaesthesia and or post-operative analgesia remains incompletely defined. This systematic review synthesised the published evidence on post-operative outcomes associated with PNBs and PNCs in patients undergoing major lower limb amputation. MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov were searched (1 January 2005 to 1 March 2025). A systematic review was conducted in accordance with PRISMA guidelines and was prospectively registered with PROSPERO (CRD420251233062). Exploratory meta-analyses of post-operative acute pain, opioid requirements, phantom limb pain, and mortality were undertaken, with PNBs and PNCs grouped together as a single peripheral nerve intervention. GRADE criteria were used to express certainty of pooled results. Forty-one studies involving 913 patients undergoing PNB and or PNC were included, comprising randomised controlled trials (n = 4), observational studies (n = 10), and case series or reports (n = 27). PNBs and PNCs were most commonly used as an adjunct to general anaesthesia (54.6%, 95% confidence interval [CI] 51.2 - 58.0%), followed by sole anaesthesia (22.9%, 95% CI 20.2 - 25.9%) and adjunct use with sedation (22.5%, 95% CI 19.7 - 25.4%), and were almost always performed pre-operatively. Compared with general anaesthesia alone, PNB/PNC ± general anaesthesia use was associated with lower post-operative 0 - 10 pain scores (mean difference [MD] -1.70, 95% CI -2.48 - -0.92; p < .001; I² = 85.4%; GRADE, very low) and reduced post-operative opioid requirements (MD -18.28 mg, 95% CI -31.02 - -5.54; p = .005; I² = 90.51%; GRADE, very low). Findings were maintained in subgroup analyses restricted to PNB/PNC use as an adjunct to general anaesthesia, for both acute pain scores and post-operative morphine requirements. PNB or PNC use did not impact long term pain. Complications were rare. PNB/PNC use may improve early pain outcomes after major lower limb amputation, without impacting longer term phantom limb pain.