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A Meta-analysis

Brian M. Block, MD, PhD; Spencer S. Liu, MD; Andrew J. Rowlingson, BA; Anne R. Cowan, MD; John A. Cowan, Jr, MD; Christopher L. Wu, MD

JAMA. 2003;290:2455-2463.

Context  Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial.

Objective  To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative technique.

Data Sources  Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to April 25, 2002) and other sources for studies related to postoperative epidural analgesia.

Study Selection  Inclusion criteria were a comparison of epidural therapy vs parenteral opioids for postoperative analgesia, measurement of pain using a visual analog scale (VAS) or numeric rating scale, randomization of patients to either therapy, and adult patients (18 years). A total of 1404 abstracts were identified, 100 of which met all inclusion criteria.

Data Extraction  Each article was reviewed and data extracted from tables, text, or extrapolated from figures as needed. Weighted mean pain scores, weighted mean differences in pain score, and weighted incidences of complications were determined by using a fixed-effect model.

Data Synthesis  Epidural analgesia provided better postoperative analgesia compared with parenteral opioids (mean [SE], 19.40 mm [0.17] vs 29.40 mm [0.20] on the VAS; P<.001). When analyzed by postoperative day, epidural analgesia was better than parenteral opioids on each postoperative day (P<.001 for each day after surgery). For all types of surgery and pain assessments, all forms of epidural analgesia provided significantly better postoperative analgesia compared with parenteral opioid analgesia (P<.001 for all), with the exception of thoracic epidural analgesia vs opioids for rest pain after thoracic surgery (weighted mean difference, 0.6 mm; 95% confidence interval, –0.3 to 1.5 mm; P = .12). The complication rates were lower than expected for nausea or vomiting and pruritus but comparable with existing data for lower extremity motor block.

Conclusion  Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids.

Author Affiliations: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Md (Drs Block and Wu, and Mr Rowlingson); Department of Anesthesiology, Virginia Mason Medical Center, University of Washington, Seattle (Dr Liu); Department of Anesthesiology (Dr A. R. Cowan) and Department of Neurosurgery (Dr J. A. Cowan), University of Michigan, Ann Arbor.

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