Regional anaesthesia prevents chronic postsurgical pain — and the technique you choose matters

Design

PRISMA-compliant systematic review and network meta-analysis of randomised trials, searched to October 2025, GRADE/CINeMA appraisal

Population

158 randomised controlled trials, 18,794 adults undergoing surgery

Primary outcome

incidence of chronic postsurgical pain beyond three months, and long-term opioid use

Effect

CPSP RR 0.73 (95% CI 0.67 to 0.80), sustained to 12 months; opioid use RR 0.88 (95% CI 0.61 to 1.28), not significant

This network meta-analysis brought together 158 randomised trials and 18,794 patients to ask whether regional anaesthesia reduces pain persisting beyond three months. Overall it did: risk ratio 0.73 (95% CI 0.67 to 0.80), with the effect still present at 12 months. The benefit held within specific operations — mastectomy (RR 0.69, 95% CI 0.59 to 0.79), thoracotomy (RR 0.72, 95% CI 0.55 to 0.96), video-assisted thoracoscopic surgery (RR 0.73, 95% CI 0.56 to 0.96) and knee arthroplasty (RR 0.71, 95% CI 0.52 to 0.97).

The network component answers the question that pairwise analysis cannot. For thoracic surgery, neuraxial techniques outperformed peripheral ones: after thoracotomy, neuraxial RR 0.64 (95% CI 0.49 to 0.83) against peripheral RR 0.84 (95% CI 0.73 to 0.96), and after video-assisted thoracoscopic surgery, 0.60 (0.45 to 0.80) against 0.77 (0.63 to 0.94). Meta-regression found no effect of surgery type, sex or baseline risk on how well regional anaesthesia worked.

Two caveats belong in the same breath as the headline. Long-term opioid use did not differ (RR 0.88, 95% CI 0.61 to 1.28), so this is prevention of pain rather than of dependence. And certainty was graded low for chronic pain and low to very low for the network comparisons — the direction is consistent across a large body of trials, the precise ranking of techniques is not settled. What changes today is the consenting conversation: for mastectomy, thoracic surgery and knee arthroplasty, a block is now defensible as a long-term intervention and not only an analgesic one.

• Raise chronic postsurgical pain explicitly when consenting for mastectomy, thoracotomy, VATS and knee arthroplasty
• Prefer a neuraxial technique over a peripheral one for thoracic surgery where both are feasible and safe
• Do not promise reduced long-term opioid use — that outcome was not significantly different
• Flag the patient's block in the discharge summary so persistent pain at three months can be traced back to technique
• Set up a three-month pain check for these operations if your service has none; the outcome is invisible without one

The statistics, in plain English

A risk ratio of 0.73 with an interval well clear of 1.0 across 158 trials is a consistent effect, but GRADE certainty was low — meaning the true effect could still differ meaningfully from 0.73, usually because the included trials were small, unblinded, or measured chronic pain inconsistently. The opioid result (RR 0.88, 95% CI 0.61 to 1.28) crosses 1.0 in both directions, so it is compatible with a real reduction, no change, or an increase: an inconclusive result rather than a negative one. The network comparisons of neuraxial against peripheral are the least certain part of the paper, because fewer trials compared them head to head.

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