DOI: 10.26820/recimundo/9.(2).abril.2025.361-386

URL: https://recimundo.com/index.php/es/article/view/2652

EDITORIAL: Saberes del Conocimiento

REVISTA: RECIMUNDO

ISSN: 2588-073X

TIPO DE INVESTIGACIÓN: Artículo de revisión

CÓDIGO UNESCO: 32 Ciencias Médicas

PAGINAS: 361-386

Optimization of regional anesthesia in orthopedic surgery:

Benets in postoperative pain management

Optimización de la anestesia regional en cirugía ortopédica: beneﬁcios

en el tratamiento del dolor postoperatorio

Otimização da anestesia regional em cirurgia ortopédica: benefícios no

tratamento da dor pós-operatória

Danny Sebastián Acuña Meza1; Pablo Xavier Anda Suárez2; Giovanni Joel Estrada Segura3;

Katia Alexandra Acosta Pastrano4

RECIBIDO: 10/03/2025 ACEPTADO: 19/04/2025 PUBLICADO: 03/06/2025

1. Médico Cirujano; Prep. Student in Center Kaplan Medical; New Jersey, Estados Unidos; acuadanny@

gmail.com; https://orcid.org/0009-0008-5336-7734

2. Médico Cirujano; Residente en la Clínica Novocorpo; Quito, Ecuador; pabloxavieranda@gmail.com;

https://orcid.org/0009-0007-6320-6099

3. Médico; Investigador Independiente; Quito, Ecuador; gjoelestrada.s@gmail.com; https://orcid.

org/0009-0005-7036-8454

4. Médica Cirujana; Investigadora Independiente; Quito, Ecuador; kacostapastrano@gmail.com; https://

orcid.org/0009-0007-7245-2443

CORRESPONDENCIA

Danny Sebastián Acuña Meza

acuadanny@gmail.com

New Jersey, Estados Unidos

ABSTRACT

One of the most noble medical procedures from a humanitarian standpoint is anesthesia. It offers the advantage of temporarily blocking

the brain's response to painful stimuli. This action allows the surgeon to carry out their work smoothly and the patient to feel no pain,

beneﬁting both parties. To explore the optimization of regional anesthesia in orthopedic surgery and its beneﬁts in postoperative pain

management, a comprehensive literature review was conducted. This review encompassed original articles, reviews, and meta-analyses

published primarily in English and Spanish from. Relevant studies were identiﬁed through systematic searches in the Cochrane Library,

EMBASE, and LILACS databases, employing a combination of controlled descriptors and free-text terms. Modern regional anesthesia

(RA) techniques, such as ultrasound-guided blocks and continuous catheters, signiﬁcantly improve postoperative pain management in

orthopedic surgery compared to general anesthesia and traditional systemic analgesia. Ultrasound guidance enhances precision and

safety, leading to effective, localized pain control, reduced opioid use and side effects, faster recovery, and increased patient satisfaction.

Continuous catheters prolong these beneﬁts, offering sustained and adjustable pain relief, facilitating rehabilitation, potentially decreasing

chronic pain and shortening hospital stays. Although requiring specialized training and protocols, the strong evidence supports the value

of these RA techniques in optimizing postoperative pain management and potentially improving healthcare costs and long-term outco-

mes, making their integration a priority in contemporary orthopedic practice.

Keywords: Anesthesia, Orthopedic, Pain, Postoperative.

RESUMEN

Uno de los procedimientos médicos más nobles desde el punto de vista humanitario es la anestesia. Ofrece la ventaja de bloquear

temporalmente la respuesta del cerebro a los estímulos dolorosos. Esta acción permite al cirujano realizar su trabajo con ﬂuidez y al pa-

ciente no sentir dolor, lo que beneﬁcia a ambas partes. Para explorar la optimización de la anestesia regional en la cirugía ortopédica y

sus beneﬁcios en el manejo del dolor postoperatorio, se llevó a cabo una revisión bibliográﬁca exhaustiva. Esta revisión abarcó artículos

originales, revisiones y metaanálisis publicados principalmente en inglés y español. Los estudios relevantes se identiﬁcaron mediante

búsquedas sistemáticas en las bases de datos Cochrane Library, EMBASE y LILACS, empleando una combinación de descriptores

controlados y términos de texto libre. Las técnicas modernas de anestesia regional (AR), como los bloqueos guiados por ecografía y los

catéteres continuos, mejoran signiﬁcativamente el tratamiento del dolor postoperatorio en la cirugía ortopédica en comparación con la

anestesia general y la analgesia sistémica tradicional. La guía ecográﬁca mejora la precisión y la seguridad, lo que conduce a un control

eﬁcaz y localizado del dolor, una reducción del uso de opioides y de los efectos secundarios, una recuperación más rápida y una mayor

satisfacción del paciente. Los catéteres continuos prolongan estos beneﬁcios, ya que ofrecen un alivio del dolor sostenido y ajustable,

facilitan la rehabilitación, pueden reducir el dolor crónico y acortar la estancia hospitalaria. Aunque requieren formación y protocolos

especializados, las sólidas pruebas respaldan el valor de estas técnicas de AR para optimizar el tratamiento del dolor postoperatorio y

mejorar potencialmente los costes sanitarios y los resultados a largo plazo, lo que hace que su integración sea una prioridad en la prác-

tica ortopédica contemporánea.

Palabras clave: Anestesia, Ortopedia, Dolor, Postoperatorio.

RESUMO

Um dos procedimentos médicos mais nobres do ponto de vista humanitário é a anestesia. Ela oferece a vantagem de bloquear tempora-

riamente a resposta do cérebro aos estímulos dolorosos. Esta ação permite que o cirurgião realize o seu trabalho sem problemas e que o

paciente não sinta dor, beneﬁciando ambas as partes. Para explorar a otimização da anestesia regional em cirurgia ortopédica e os seus

benefícios no controlo da dor pós-operatória, foi realizada uma revisão exaustiva da literatura. Esta revisão englobou artigos originais, re-

visões e meta-análises publicados principalmente em inglês e espanhol. Os estudos relevantes foram identiﬁcados através de pesquisas

sistemáticas nas bases de dados Cochrane Library, EMBASE e LILACS, empregando uma combinação de descritores controlados e termos

de texto livre. Técnicas modernas de anestesia regional (AR), como bloqueios guiados por ultrassom e cateteres contínuos, melhoram

signiﬁcativamente o controle da dor pós-operatória em cirurgia ortopédica em comparação com a anestesia geral e a analgesia sistêmica

tradicional. A orientação por ultrassom aumenta a precisão e a segurança, levando a um controle eﬁcaz e localizado da dor, redução do uso

de opióides e dos efeitos colaterais, recuperação mais rápida e maior satisfação do paciente. Os cateteres contínuos prolongam estes bene-

fícios, oferecendo um alívio sustentado e ajustável da dor, facilitando a reabilitação, diminuindo potencialmente a dor crónica e encurtando

os períodos de internamento hospitalar. Embora exija treino e protocolos especializados, a forte evidência apoia o valor destas técnicas de

AR na otimização da gestão da dor pós-operatória e na potencial melhoria dos custos dos cuidados de saúde e dos resultados a longo

prazo, tornando a sua integração uma prioridade na prática ortopédica contemporânea.

Palavras-chave: Anestesia Ortopédica, Dor Pós-Operatória.

363

RECIMUNDO VOL. 9 N°2 (2025)

Introduction

One of the most noble medical procedures

from a humanitarian standpoint is anesthe-

sia. It offers the advantage of temporarily

blocking the brain's response to painful sti-

muli. This action allows the surgeon to carry

out their work smoothly and the patient to

feel no pain, beneﬁting both parties. When

discussing anesthesia, it is convenient to

consider an anatomical structure of vital in-

terest: the vertebral column. Its importance

lies in the protection it offers to the spinal

cord and the nerve roots that originate from

it. These structures are the target of the tech-

niques used to administer anesthetic drugs.

Among the types of anesthesia most used

in practice are general anesthesia, epidu-

ral anesthesia, spinal anesthesia, and local

anesthesia (1).

Pain is part of the human body as a warning

to protect it, thereby triggering a series of

reactions to limit damage. The International

Association for the Study of Pain (IASP) has

deﬁned pain as “an unpleasant sensory and

emotional experience associated with actual

or potential tissue damage, or described in

terms of such damage” (2).

The use of Regional Anesthesia is increasin-

gly involved in the anesthetic and especially

analgesic management of various orthope-

dic procedures. During the surgical proce-

dure, very intense pain occurs in response

to direct or indirect aggression caused by

the surgical act, including the surgical tech-

nique, as well as the anesthetic technique,

inadequate postures, muscle contractures,

and inﬂuences important negative repercus-

sions such as physical condition, causing

generalized hemodynamic and neuroendo-

crine responses, in addition to affecting the

emotional and economic state of the patient

and medical institutions (3).

One of the most effective techniques for con-

trolling postoperative pain is the use of anal-

gesics via spinal administration, especially

when chronic pain occurs in the ﬁrst hours.

It is mainly indicated in major surgery of the

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

thorax, upper abdomen, and major orthope-

dic surgery. For these, a variety of techniques

are used to manage severe postoperative

pain, which include the use of the neuroaxial

approach, especially epidural (4).

Currently, different drugs are available that

not only provide an analgesic effect but also

help prevent postoperative complications

and consequently lead to an increase in

perioperative morbidities. Among the best-

known drugs are non-steroidal anti-inﬂam-

matory drugs (NSAIDs), opioids, recently al-

pha-2 agonists such as dexmedetomidine,

ketamine, pregabalin, as well as analgesic

techniques such as regional analgesia and

patient-controlled analgesia (PCA) (5).

Methods

To explore the optimization of regional anes-

thesia in orthopedic surgery and its beneﬁts

in postoperative pain management, a com-

prehensive literature review was conducted.

This review encompassed original articles,

reviews, and meta-analyses published pri-

marily in English and Spanish from. Relevant

studies were identiﬁed through systematic

searches in the Cochrane Library, EMBA-

SE, and LILACS databases, employing a

combination of controlled descriptors and

free-text terms. The selection of studies was

based on predeﬁned criteria related to the

administration of regional anesthesia techni-

ques in orthopedic procedures and the eva-

luation of postoperative pain as a primary or

secondary outcome.

Results

1. Fundamentals of Regional Anesthesia

in Orthopedics

1.1. History and Evolution of Regional Te-

chniques

It was approximately 100 years ago when

the ﬁrst peripheral nerve block was perfor-

med, a procedure carried out by Hirschel,

and in recent years, its use has greatly in-

creased due to ultrasound devices. The ear-

liest evidence of ultrasound-guided blocks

364 RECIMUNDO VOL. 9 N°2 (2025)

dates back about 20 years, but due to the

improvement of these systems and the de-

velopment of portable ultrasound machines,

the use of regional blocks has surged. Em-

ploying ultrasound systems allows for the

visualization of different structures in real-ti-

me, as well as observing the diffusion of the

local anesthetic around the anesthetized

nerve, thereby limiting over-dosage and

potential systemic toxicity. Within regional

anesthesia, we can discuss Peripheral Ner-

ve Blocks, epidural and spinal anesthesia,

and regional intravenous anesthesia (6).

The advancement and improvement of re-

gional anesthesia methods for various sur-

gical procedures, particularly in obstetric,

ophthalmic, and orthopedic surgeries, as

well as the continuous enhancement of con-

tinuous regional analgesia, persist. In re-

gional anesthesia training within the ﬁelds

of anesthesiology and intensive care medi-

cine, the emphasis on mastering essential

techniques such as spinal block, epidural

block, axillary brachial plexus block, femo-

ral nerve block, and intravenous regional

anesthesia is typically considered compre-

hensive. Generally, performing more peri-

pheral blocks tends to reduce the occurren-

ce of complications and adverse effects.

Peripheral regional anesthesia is a crucial

aspect of contemporary perioperative care.

Peripheral regional anesthesia can be per-

formed effectively with simple techniques,

such as fascia iliaca compartment blocks,

which require minimal technological resour-

ces. Among other methods, ultrasound has

gained widespread clinical acceptance in

this ﬁeld to guide needle movement towards

nerves, minimizing the risk of needle con-

tact with critical structures and reducing po-

tential complications (7).

Various types of blocks exist, each applied

to a speciﬁc area of the body. Some of the

most common include:

• Brachial plexus block: Performed on a

group of nerves that control muscles and

sensations in the arm and hand (8).

• Cervical plexus block: Performed on a

group of nerves that control muscles and

sensations in the neck and upper extre-

mities (8).

• Lumbar plexus block: Originates nu-

merous branches that innervate various

muscles and regions of the posterior ab-

dominal wall and the lower extremity. To-

gether with the sacral plexus, they form a

union known as the lumbosacral plexus,

which gives rise to all the motor and sen-

sory nerves of the lower extremity (8).

• Sacral plexus block: This plexus emits

several branches including anterior, pos-

terior, and one terminal branch; these

provide motor and sensory innervation

to the posterior portion of the thigh, the

lower portion of the leg, the entire foot,

and a part of the pelvis (8).

1.2. Mechanism of Action

Figure 1. How is regional block achie-

ved?

Source: Tamayo Gómez (9).

Regional anesthesia blocks the perception

of pain by interrupting the transmission of

nerve impulses from the area of the body

where the surgery will be performed to the

central nervous system. When a painful

stimulus occurs in the periphery, nerve re-

ceptors detect it and generate an electrical

signal that travels through sensory nerves

towards the spinal cord and, subsequently,

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

365

RECIMUNDO VOL. 9 N°2 (2025)

to the brain, where it is interpreted as pain.

Regional anesthesia, by injecting a local

anesthetic near the peripheral nerves, pre-

vents the propagation of this nerve signal.

By blocking the conduction along these

nerves, pain information cannot reach the

spinal cord or ascend to the brain, resulting

in the absence of painful sensation in the

anesthetized region. In essence, regional

anesthesia acts as a barrier that silences

the nervous communication between the

surgical site and the pain processing cen-

ters in the central nervous system (9).

1.3. Comparison with General Anesthesia

This differs from general anesthesia in that

it does not affect the patient's level of cons-

ciousness to relieve pain. There are several

advantages over general anesthesia, such

as avoiding airway manipulation, reduced

doses of systemic drugs, fewer side effects

from systemic drugs, faster recovery time,

and signiﬁcantly lower pain levels after sur-

gery (10).

2. Current Regional Anesthesia Techni-

ques Used

2.1. Peripheral Nerve Blocks (e.g., Femo-

ral, Sciatic, Brachial Plexus)

The brachial plexus, a crucial nerve network

for the innervation of the upper limb, ori-

ginates from the C5-T1 nerve roots, which

are organized into trunks (superior, midd-

le, and inferior). These trunks further divide

into anterior and posterior divisions, which

then regroup to form three fascicles: lateral,

posterior, and medial. From these fascicles

emerge the ﬁve main terminal branches that

innervate the arm, forearm, and hand: mus-

culocutaneous, axillary, radial, median, and

ulnar. Brachial plexus block is a widely used

regional anesthesia technique that can be

performed via supraclavicular, infraclavicu-

lar, and axillary approaches. The supracla-

vicular block, in particular, provides comple-

te and rapid anesthesia of the entire upper

limb with a single injection, being especially

useful for surgeries of the arm, forearm, and

hand. The choice of local anesthetic and

its concentration (lidocaine for short proce-

dures, bupivacaine or ropivacaine for more

extensive surgeries) is adapted to the esti-

mated duration of the procedure and posto-

perative needs (6).

The femoral nerve block, also known as the

crural nerve block, is an anesthetic techni-

que used primarily for surgeries on the ante-

rior aspect of the thigh and for postoperative

pain control in this region. It is often combi-

ned with other blocks, such as the sciatic

nerve block, to achieve complete analgesia

of the knee. The femoral nerve, the largest

of the lumbar plexus (L2-L4), innervates

muscles such as the iliacus and pectineus,

as well as the anterior muscles of the thi-

gh (except the fascia lata), and provides

sensation to the lateral and frontal aspects

of the middle thigh, the medial part of the

leg and foot, and the knee and hip joints.

The block is performed at the level of the

groin, frequently using ultrasound to guide

the needle towards the nerve, which is ge-

nerally located lateral to the femoral artery.

Approximately 20 ml of local anesthetic is

usually injected, sometimes with epinephri-

ne to prevent vascular puncture. Complica-

tions are rare but may include hematoma,

nerve injury, and catheter infection if left in

place for continuous analgesia (6).

The sciatic nerve, the largest peripheral ner-

ve in the body, originates in the pelvis (sa-

cral plexus), exits through the greater scia-

tic notch, and descends along the posterior

aspect of the thigh. In the lower third of the

femur, it divides into the tibial nerve (internal

popliteal sciatic) and the common peroneal

nerve (external popliteal sciatic). The tibial

nerve branches into the medial and late-

ral plantar nerves, while the peroneal ner-

ve gives rise to branches around the knee

and to the sural, superﬁcial peroneal, and

deep peroneal nerves. Occasionally, this

division occurs at the origin of the sciatic

nerve. To block this nerve, approximately 20

ml of local anesthetic is generally sufﬁcient,

considering whether the goal is surgical or

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

366 RECIMUNDO VOL. 9 N°2 (2025)

analgesic. The block can be performed via

a posterior approach (classic or parasa-

cral in the gluteal region) or posterior in the

popliteal fossa. It is a common technique

for surgeries of the knee, calf, and for the

symptomatic treatment of the Achilles ten-

don, ankle, and foot. Complications are rare

and include local muscle spasms in the thi-

gh, vascular puncture, and muscle spasms

in the foot or toes (6).

The innervation of the foot comes from ﬁve

main nerves: the internal saphenous (me-

dial aspect), the sural or external saphe-

nous (lateral aspect), the posterior tibial

(deep plantar structures and sole), the su-

perﬁcial peroneal or musculocutaneous of

the leg (dorsum), and the deep peroneal or

anterior tibial (deep dorsal structures and

the interdigital space between the ﬁrst and

second toes). The block of these nerves is

performed at different points depending on

the area to be intervened, and all ﬁve can

even be blocked simultaneously. Although

some nerves innervate deep structures and

a complete block is not always required,

studies suggest that total foot block for fo-

refoot surgeries offers better postoperative

pain control than selective block. The choi-

ce of local anesthetic (lidocaine, mepivacai-

ne, bupivacaine, or ropivacaine, or combi-

nations) depends on the estimated duration

of the surgery, with lidocaine for short pro-

cedures and bupivacaine or ropivacaine

for prolonged analgesia. Other types of re-

gional blocks, such as spinal and epidural

anesthesia, will be discussed below (6).

The fascia iliaca block is an alternative to the

femoral or lumbar plexus block, based on the

location of the femoral and lateral femoral cu-

taneous nerves below this fascia. By depo-

siting a sufﬁcient amount of local anesthetic

under the fascia iliaca, the aim is to anesthe-

tize both nerves simultaneously. The techni-

que is usually guided by ultrasound, using a

linear transducer to visualize the fascia ilia-

ca, which is located above the nerves and

the iliopsoas muscle. After anesthetizing the

skin, a needle (22 gauge) is inserted until it

pierces the fascia, which is conﬁrmed visua-

lly with the ultrasound and by the tactile sen-

sation. Between 30-40 ml of local anesthetic

is injected to ensure successful blockade of

the femoral and lateral femoral cutaneous

nerves, although obturator nerve block with

this technique is variable. Complications are

rare, including block failure, local hemato-

mas, neuropraxia, systemic toxicity from the

anesthetic, quadriceps weakness, peritoneal

perforation, and bladder puncture. Vascular

or nerve puncture is very infrequent due to

the distance of the block site from the neuro-

vascular bundle (6).

The obturator nerve, originating from the

L2-L4 nerve roots, emerges from the psoas

muscle and bifurcates into two terminal

branches. The anterior branch innervates

the obturator externus, adductor brevis and

longus, pectineus muscles, as well as the

medial aspect of the thigh cutaneously. The

posterior branch innervates the obturator

externus, adductor magnus, the hip joint,

and the popliteal region cutaneously. For

percutaneous block of the obturator nerve,

although ultrasound guidance is preferred,

non-ultrasound techniques such as Labat's

(puncture lateral and caudal to the pu-

bic spine) and the paravascular approach

(puncture at the midpoint of the inguinal line

between the femoral artery and the tendon

of the adductor longus) exist. The three-in-

one block, which aims to anesthetize the

femoral, lateral femoral cutaneous, and ob-

turator nerves with a single injection, is also

mentioned (6).

The lateral femoral cutaneous nerve, com-

posed of the L2-L4 nerve roots, is a purely

sensory nerve that, after passing the ingui-

nal region, divides into an anterior branch

(sensation of the anterolateral thigh) and a

posterior branch (lateral innervation of the

thigh). Its block is used in superﬁcial surge-

ries such as graft placement or interventions

on the lateral aspect of the thigh, and also in

the treatment of meralgia paresthetica. The

technique is performed under ultrasound

guidance, and the anesthetics of choice are

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

367

RECIMUNDO VOL. 9 N°2 (2025)

usually mepivacaine or bupivacaine, some-

times combined with triamcinolone or me-

thylprednisolone (6).

2.2. Epidural and Spinal Anesthesia: Indi-

cations and Differences

Epidural Anesthesia: Both the intradural (ID)

and epidural (EPI) techniques share many

methodological aspects, which is why they

are analyzed together. In both cases, the lo-

cal anesthetic (LA) is placed in contact with

sensory, motor, and vegetative nerve roots,

leading to a metameric sensory, motor, and

autonomic blockade, although with differen-

ces (11).

Spinal Intradural Anesthesia (AI): This in-

volves the direct injection of local anesthe-

tic (LA) into the subarachnoid space after

lumbar puncture, with an immediate effect

that blocks sensation, motor function, and

the autonomic system below the level of

injection and some superior metameres.

Hypotension is a complication dependent

on the extent of the blockade. It is used for

infraumbilical surgery with high-concentra-

tion, low-volume LA but is contraindicated

in certain conditions such as shock or intra-

cranial hypertension.

Spinal Epidural Anesthesia (AE): In contrast,

this involves depositing the LA into the epi-

dural space, allowing for a more selective

and slower-onset but longer-duration bloc-

kade, with a lower risk of hypotension and

the possibility of continuous analgesia via

a catheter. Bupivacaine is a common drug

used, with less cephalad migration and a

lower risk of post-dural puncture headache

compared to AI (11).

Table 1. Differences between Epidural and Spinal Anesthesia.

Characteristic

Spinal Anesthesia

(Intradural) Epidural Anesthesia

Site of Injection

Intradural (subarachnoid)

space, where CSF is located

Epidural (virtual) space,

between the dura mater and the

ligamentum flavum

Contact with CSF

Yes, the anesthetic mixes

with the CSF

No, the anesthetic is deposited

outside the dura mater

Type of Needle Fine needle, with a sharp tip

Thicker needle (e.g., Touhy),

with a blunt tip

Loss of Resistance

Dura mater is pierced, with

CSF outflow

Loss of resistance is noted upon

entering the epidural space

Onset of Block

Very rapid (immediate)

Slower (10-20 minutes)

Duration of Block (Single

Dose)

Generally shorter (1-2

hours)

Generally longer (depends on

dose and drug)

Extent of Block

More predictable and dense

for a given level

More variable and segmental,

extent can be better controlled

Motor Block Generally dense

Can be selective (sensory block

with less motor block)

Autonomic Block

(Hypotension)

More intense and rapid,

higher risk of hypotension

Less intense and more gradual,

lower risk of hypotension

Catheter for

Repeated/Continuous

Doses

Not usually used (risk of

meningeal infection)

Commonly used to prolong

analgesia or anesthesia

Volume of Local

Anesthetic

Low (2-3 ml)

Higher (10-20 ml or more)

Concentration of Local

Anesthetic

High

More variable, can be lower for

analgesia

Post-Dural Puncture

Headache

Higher risk (due to direct

dural puncture)

Lower risk (unless accidental

dural puncture)

Common Uses

Short to moderate duration

infraumbilical surgery

Surgery of variable duration,

labor analgesia, postoperative

analgesia

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

368 RECIMUNDO VOL. 9 N°2 (2025)

Source: Hernánz de la Fuente & Rabanal Llevot (11).

Characteristic

Spinal Anesthesia

(Intradural)

Epidural Anesthesia

Site of Injection

Intradural (subarachnoid)

space, where CSF is located

Epidural (virtual) space,

between the dura mater and the

ligamentum flavum

Contact with CSF

Yes, the anesthetic mixes

with the CSF

No, the anesthetic is deposited

outside the dura mater

Type of Needle

Fine needle, with a sharp tip

Thicker needle (e.g., Touhy),

with a blunt tip

Loss of Resistance

Dura mater is pierced, with

CSF outflow

Loss of resistance is noted upon

entering the epidural space

Onset of Block

Very rapid (immediate)

Slower (10-20 minutes)

Duration of Block (Single

Dose)

Generally shorter (1-2

hours)

Generally longer (depends on

dose and drug)

Extent of Block

More predictable and dense

for a given level

More variable and segmental,

extent can be better controlled

Motor Block

Generally dense

Can be selective (sensory block

with less motor block)

Autonomic Block

(Hypotension)

More intense and rapid,

higher risk of hypotension

Less intense and more gradual,

lower risk of hypotension

Catheter for

Repeated/Continuous

Doses

Not usually used (risk of

meningeal infection)

Commonly used to prolong

analgesia or anesthesia

Volume of Local

Anesthetic Low (2-3 ml) Higher (10-20 ml or more)

Concentration of Local

Anesthetic High

More variable, can be lower for

analgesia

Post-Dural Puncture

Headache

Higher risk (due to direct

dural puncture)

Lower risk (unless accidental

dural puncture)

Common Uses

Short to moderate duration

infraumbilical surgery

Surgery of variable duration,

labor analgesia, postoperative

analgesia

2.3. Use of Ultrasound in Regional Anes-

thesia

The ultrasound technique for central neu-

roaxial block involves the use of a low-fre-

quency curvilinear probe in different planes.

Five basic views of the vertebral column are

performed to visualize the lumbar sonoa-

natomy, which is easier than in the thoracic

region due to the more favorable anatomy.

Ultrasound can be performed before the

procedure or in real-time and has proven

particularly useful in patients with speciﬁc

physical characteristics or medical condi-

tions. The real-time ultrasound-guided tech-

nique has shown positive results compared

to pre-procedure ultrasound (12).

3. Optimization in the Postoperative

Context

The use of opioids for postoperative pain

management in orthopedic surgery, despi-

te its tradition, entails signiﬁcant short-term

risks (adverse effects, longer hospital stays,

dependence, death) and long-term risks

(opioid epidemic, substance use disorder,

mortality). The increasing prescription, es-

pecially in opioid-naïve patients, is associa-

ted with a higher risk of chronic use, even

after minor surgeries such as total knee and

hip arthroplasty. Furthermore, a conside-

rable proportion of prescribed opioids are

unused and not safely disposed of, contri-

buting to their diversion. To mitigate depen-

dence, it is crucial to implement multimodal

pain management programs that integrate

peripheral nerve blocks, local anesthetic in-

ﬁltration, paracetamol, NSAIDs, gabapenti-

noids, cannabinoids, and non-pharmacolo-

gical therapies, recognizing the challenges

in older patients and those with chronic pain

(13). Regional anesthesia (RA) in orthope-

dic procedures attenuates several compli-

cations linked to general anesthesia (GA),

such as nausea, vomiting, airway trauma,

hypoxia, respiratory depression, and the risk

of pulmonary aspiration. The advantages

of RA include superior postoperative pain

control, reduced opioid consumption and

its side effects, shorter hospital stays, early

initiation of physical therapy, reduced read-

mission rates, greater patient satisfaction,

faster recovery, fewer unplanned admis-

sions for pain, better intraoperative muscle

relaxation, less blood loss, and a reduction

in urinary retention and ileus (14).

Contrary to the initial belief that continuous

regional analgesia would increase costs, a

2009 study demonstrated that the implemen-

tation of multimodal anesthesia and analge-

sia based on regional techniques was not

only not more expensive but decreased the

total cost of the procedure by 15%, main-

ly due to the lower need for opioids, fewer

related adverse effects and their treatment

costs, shorter operating room time, and shor-

ter hospital stays (15). The length of hospital

stay (LHS) is considered an indirect indi-

cator of efﬁciency, and enhanced recovery

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

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RECIMUNDO VOL. 9 N°2 (2025)

after surgery (ERAS) protocols aim to redu-

ce it through a multidisciplinary approach,

incorporating RA to decrease acute pain

and postoperative nausea and vomiting, in

addition to improving mobilization. Both RA

alone and in combination with GA appear

to reduce LHS in orthopedic surgery and

other specialties, although the difference in

the largest meta-analysis was measured in

hours. In outpatient surgery, while unplan-

ned admission rates are low, a higher risk

has been demonstrated with GA compa-

red to RA (16). A prospective observational

study by Doo et al (17) found no signiﬁcant

differences in patient-centered quality of re-

covery between RA (brachial plexus block

with dexmedetomidine) and GA (sevoﬂura-

ne with remifentanil) in orthopedic forearm

surgery, even though the RA group showed

better outcomes in the PACU (less pain,

opioid consumption, and nausea/vomiting),

suggesting that patient expectations or pre-

vious anesthesia experiences might inﬂuen-

ce the perception of recovery.

4. Technological Innovations and Recent

Advances

4.1. Image-Guided Techniques (Ultra-

sound vs. Neurostimulators)

Ultrasound enhances the success of nerve

blocks by visualizing anatomical structures

through sound waves reﬂected by tissues

(18). Its ability to evaluate soft tissues in re-

al-time is operator-dependent and requires

a thorough understanding of anatomy (18).

Precise nerve localization, crucial for avoi-

ding complications of "blind" techniques, is

optimized with ultrasound (5-10 MHz pro-

bes, even better with 12-15 MHz), overco-

ming the limitations of non-visual or costly

methods like MRI and CT (18). The puncture

technique, inﬂuenced by anatomy and the

nerve's relationship with adjacent structu-

res, varies depending on the block (inters-

calene proximal to the transducer, supracla-

vicular in-plane needle-transducer, axillary

with the arm abducted and inﬁltration near

the artery) (18).

Neurostimulators

Fifty years ago, Dr. Greenblat published the

ﬁrst report on the use of neurostimulators,

demonstrating 100% speciﬁcity and 74%

sensitivity, making it a less precise techni-

que than ultrasound (19).

Compared to the conventional nerve block

method using anatomical localization and

paresthesia, localization via neurostimula-

tion is more precise, objective, and safer.

However, neurostimulator guidance opera-

tes blindly, and there is a high failure rate

in patients with anatomical variations. The

use of neurostimulation increases the suc-

cess rate of nerve blocks and reduces the

blocking time compared to conventional pa-

resthesia guidance. Sia et al. compared the

difference between paresthesia guidance

and neurostimulation guidance in brachial

plexus block. The results showed that the

neurostimulation group was superior to the

paresthesia group in the success rate (91%

versus 76%, respectively) and in the onset

time of the block. Additionally, in a three-

point axillary brachial plexus block, nerve

block guided by neurostimulation can shor-

ten the block onset time and the waiting time

for surgeons, which is helpful for emergency

surgery and patient satisfaction, as well as

reducing the discomfort of a tourniquet. This

is related to the high precision of localization

and a more effective block of the musculo-

cutaneous nerve (20).

Ultrasound vs. Neurostimulators

In current practice, ultrasound offers more

intuitive and precise guidance, showing

the relationship between nerves, vessels,

and muscles in real-time, and allowing for

the monitoring of local anesthetic spread.

Although neurostimulation provides impro-

vements over paresthesia, ultrasound is po-

sitioned as a superior technique due to its

direct visualization capabilities and its po-

tential to minimize complications and optimi-

ze the administration of regional anesthesia.

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

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370 RECIMUNDO VOL. 9 N°2 (2025)

4.2. New Local Anesthetics and Adjuvants

• Dexmedetomidine: Dexmedetomidi-

ne, an α2 adrenergic agonist appro-

ved for intravenous sedation, is used

off-label as an adjuvant in peripheral

nerve blocks and neuroaxial anesthe-

sia, showing efﬁcacy and a relatively

good safety proﬁle in preclinical and

clinical studies. Its combination with

local anesthetics appears well-tolera-

ted, with no evidence of neurotoxicity

or axonal/myelin damage, and it may

even attenuate the acute pro-inﬂam-

matory effects of these. A study with

epidural ropivacaine (7.5 mg/ml) and

dexmedetomidine (1 μg/kg) demons-

trated a signiﬁcant prolongation of

the duration of sensory block (+160

min), motor block (+126 min), and

postoperative analgesia (+184 min),

with a tolerable side effect of more

pronounced sedation. Another study

found that epidural dexmedetomidine

reduced the need for propofol for the

induction of general anesthesia (21).

• Lidocaine: The ﬁrst amide local

anesthetic introduced into clinical

practice, notable for its versatility and

common use due to its potency, ra-

pid onset of action, and moderate

duration (prolongable with epinephri-

ne), as well as its activity as a topical

anesthetic. It is used in various con-

centrations for inﬁltration, peripheral

nerve blocks, and epidural anesthe-

sia, and in hypertonic solution for

short-duration spinal anesthesia. It is

also used topically in multiple formu-

lations. Additionally, lidocaine is used

as a class Ib antiarrhythmic, effective

mainly in ventricular arrhythmias. Its

primary metabolism is hepatic, pro-

ducing monoethylglycinexylidide (an

active antiarrhythmic with a prolon-

ged half-life) and then xylidide (less

active and eliminated by urine) (22).

• Dexamethasone: Dexamethasone,

an α2 adrenergic agonist, is used as

an adjuvant in regional anesthesia to

prolong analgesia, although its exact

perineural mechanism and the best

route of administration (perineural vs.

intravenous) are still under investiga-

tion. Studies suggest that both routes

reduce postoperative pain and opioid

consumption, with possible superiori-

ty of the perineural route in the dura-

tion of the block. However, safety, es-

pecially neurotoxicity associated with

corticosteroid excipients, is a signiﬁ-

cant concern, and the optimal peri-

neural dose is not yet clearly deﬁned,

with even a possible ceiling effect

and the need for more high-quality

research to conﬁrm its long-term efﬁ-

cacy and safety (23).

• Triamcinolone: Perineural triamcino-

lone has been shown to reduce ecto-

pic nerve discharges and prevent

their development in newly resected

nerves. Although its clinical evidence

is less than that of dexamethasone,

one study showed prolonged pain

relief with few opioid requirements in

interscalene blocks. However, the ge-

neral neurotoxicity of glucocorticoids,

associated with preservatives such as

parabens and solvents such as ben-

zyl alcohol and polyethylene glycol,

warrants caution. Dilution with saline

and local anesthetics may not redu-

ce the particle size of some steroids,

including triamcinolone. Microscopic

studies have found large particles

(>10,000 microns) in triamcinolo-

ne and methylprednisolone, unlike

dexamethasone and betamethasone,

which behave more like liquids. Ano-

ther study observed smaller particles

in both types of compounds. It is sug-

gested that dexamethasone has sig-

niﬁcantly smaller particles with less

tendency to aggregate, which could

reduce the risk of embolic infarctions

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

371

RECIMUNDO VOL. 9 N°2 (2025)

from accidental intra-arterial injection,

something that has not been assured

for triamcinolone (23).

• Magnesium Sulfate: Magnesium

sulfate is not a direct analgesic but

an adjuvant that enhances the effect

of other analgesics. Discovered by

Humphrey Davy and with depressant

effects on the axial neuromuscular

plate identiﬁed by Claude Bernard,

its analgesic properties have been

known since the early 20th century,

where its use with ether to produce

deep anesthesia was suggested. It

is considered a neuronal depressant

that acts on the CNS and neuromus-

cular reﬂexes at the neuromuscular

junction, and when applied directly,

it depresses the electrical function of

nerve tissue. Another fact mentioned

by Gutiérrez et al. is that magnesium

sulfate is also used to generate hyp-

nosis and analgesia in intravenous

anesthesia because it reduces the

requirements for sevoﬂurane, desﬂu-

rane, propofol, and opioids (24).

• Ropivacaine: Ropivacaine, introdu-

ced in 1996 as an alternative to bupi-

vacaine due to its toxicity, has a simi-

lar structure but is a levorotatory (L)

isomer. L-isomers are generally more

potent, less toxic, and have a shorter

half-life. Ropivacaine is an amino-ami-

de local anesthetic, composed of an

amino residue (polar/hydrophilic) and

an aromatic group (hydrophobic) joi-

ned by an amide bond (24).

4.3. Continuous Infusion Pumps for Pro-

longed Blocks

Perineural administration of local anesthetic

(LA) is preferably performed with infusion

pumps due to clinical and logistical bene-

ﬁts over manual boluses. There is no ideal

pump, and the choice depends on the clini-

cal context, although they should generally

be precise, reliable, portable, and program-

mable. Vacuum and spring-powered pumps

are not very precise for routine practice.

Electronic pumps are the most accurate (5%

variation), allow for customization of basal

infusion, boluses, and lockout times, optimi-

zing dosage and featuring alarms and re-

ﬁll/reuse capability. Elastomeric pumps are

simpler, lighter, quieter, and more economi-

cal, ideal for outpatient use. However, their

basal infusion rate is more variable (10-30%

above the initial expected rate, then stabi-

lizes and increases again at the end), and

the rate depends on temperature and altitu-

de. Reﬁlling them is not recommended (25).

5. Safety and Complication Management

Despite its numerous beneﬁts, advanced

regional anesthesia presents risks of ner-

ve injury (minimized with proper technique

and volume), hematomas and infections

(preventable with asepsis and technique),

and local anesthetic toxicity (avoidable with

correct doses and monitoring); the mana-

gement of these complications, such as li-

pid emulsion for systemic toxicity, requires

in-depth knowledge to ensure patient safety

and block efﬁcacy (26).

Regional anesthesia techniques, although

with low complication rates, require early

identiﬁcation for appropriate patient-cente-

red management. Complications are clas-

siﬁed in various ways (immediate, interme-

diate, late; anatomical, physiological; mild,

moderate, severe), although their reporting

may be underestimated. Nerve injuries and

local anesthetic toxicity are the major compli-

cations, which may be due to neurotoxicity,

cardiotoxicity, hypersensitivity, mechanical

complications, or infection. Major complica-

tions (severe damage, disability, increased

costs and hospital stay) include dural punc-

ture, cardiorespiratory arrest, permanent

neurological injury, and death, while minor

complications include failed blocks, pares-

thesias, and vascular punctures. A signiﬁ-

cant percentage of procedures use neuroa-

xial regional anesthesia. The learning curve

is important, with a higher risk of failures and

complications at the beginning, highlighting

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

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372 RECIMUNDO VOL. 9 N°2 (2025)

the role of the instructor. Postoperative ner-

ve injuries can be difﬁcult to attribute to a

speciﬁc cause (anesthetic, surgical, positio-

nal, etc.). Local anesthetic systemic toxicity

(LAST) is a serious but infrequent complica-

tion. Adverse events in general anesthesio-

logy occur mostly in scheduled surgeries

and in the PACU, with failures in pre-anes-

thetic evaluation, informed consent, proto-

cols, and communication. Anesthesiologist

fatigue is associated with errors. Post-dural

puncture headache is frequent, benign, and

self-limited, while epidural and spinal hema-

tomas are more serious but less common

neuroaxial complications (27).

5.1. Contraindications

Regional anesthesia has absolute contrain-

dications such as patient refusal, infection

at the injection site, sepsis, circulatory in-

sufﬁciency, increased intracranial pressure,

and severe coagulopathy (due to the risk

of epidural hematoma and neurological da-

mage). Increased intracranial pressure is

a contraindication due to the risk of brain

herniation from cerebrospinal ﬂuid loss. In

sepsis, sympathetic blockade can worsen

hypoperfusion. Relative contraindications

include infection distant from the puncture

site (risk of meningitis), undeﬁned or evol-

ving neurological disease, and hypovolemic

patients. The decision to use the technique

should be based on medical judgment con-

sidering advantages and disadvantages.

Disadvantages include anesthetic failures

(lack of level or intensity, although the failure

rate is low), possible prolongation of surgery,

patient anxiety, need for operator experien-

ce, longer latency compared to general

anesthesia, inability to use it in all types of

surgeries, side effects of drugs, and risk of

permanent neurological complications (28).

• Patients with chronic diseases: The

effects of regional anesthesia should be

carefully evaluated in patients with con-

ditions such as diabetes, hypertension,

heart, lung, or kidney diseases (29).

• Patients with vascular diseases: Re-

gional anesthesia may not be suitable for

patients with peripheral vascular disea-

ses, as they may have an increased risk

of complications such as ischemia (30).

• Patients with allergies: Allergy to local

anesthetics is an absolute contraindica-

tion for regional anesthesia (30).

• Patients with infections: The presen-

ce of a local infection in the area to be

anesthetized may contraindicate regio-

nal anesthesia (31).

• Patients with coagulation disorders:

Patients with coagulation disorders may

have an increased risk of bleeding after

regional anesthesia (32).

• Elderly patients: Regional anesthesia

may have a greater effect in elderly pa-

tients, so caution should be exercised

and side effects considered (33).

• Patients with cognitive impairment:

Patients with cognitive impairment may

have difﬁculty understanding regional

anesthesia instructions and may require

more sedation (30).

To decrease complications in regional

anesthesia, adequate assessment, mana-

gement, and thorough documentation are

crucial, including pre-operative evalua-

tion, maneuvers, and postanesthetic notes

for potential legal defense. Alertness and

adherence to protocols are essential; trai-

ning, supervision, avoiding working alone,

maintaining order, and labeling drugs are

recommended. Regional anesthesia is as-

sociated with lower perioperative mortality

than general anesthesia. Care strategies

include reviewing anticoagulated patients

for neuroaxial anesthesia, controlling per-

fusion pressure in the sitting position, and

improving postoperative opioid manage-

ment. Preventive measures for injuries by

the anesthesiologist include vigilance of

position, fractional injection, use of a nerve

locator and ultrasound for peripheral bloc-

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

373

RECIMUNDO VOL. 9 N°2 (2025)

ks, and ﬁne needles. The use of ultrasound,

new needles, and local anesthetics in lower

concentrations and volumes has decreased

local anesthetic systemic toxicity (LAST),

and lipid emulsion has improved its treat-

ment. In neuroaxial blocks, rapid diagnosis

of high block, advanced monitoring, and low

blocks are important. Other strategies inclu-

de teamwork, training, standardization, and

error reporting. Staying updated in regional

anesthesia is fundamental. Medico-legal

claims are a concern, so knowing the le-

gal framework and correctly completing the

anesthetic record are vital (27).

6. Perspectives of Regional Anesthesia

in Outpatient Orthopedic Surgery

6.1. Hip

In hip surgery, the most commonly used

anesthetic technique is typically subarach-

noid anesthesia, which allows for good pain

control and adequate muscle relaxation,

reaching a metameric level of T10. Additio-

nally, it is frequently complemented with pe-

ripheral nerve blocks, such as the femoral,

iliofascial, or PENG block, to further impro-

ve postoperative analgesia and reduce the

need for opioids. The choice between ge-

neral anesthesia and the regional technique

depends on the patient's history. Basic mo-

nitoring, including ECG, non-invasive blood

pressure, and SpO₂, is routine, and in cases

of general anesthesia, additional monitoring

such as BIS is added. Antibiotic prophylaxis

with cefazolin is administered beforehand,

and in some cases, tranexamic acid is used

to reduce the risk of bleeding. This strategy

seeks to minimize complications, optimize

pain control, and promote a safer and more

comfortable recovery (34).

6.2. Shoulder and Upper Extremities

Regional anesthesia (RA) is frequently used

in shoulder and upper extremity surgery

due to its ability to provide both anesthesia

and postoperative analgesia, which is cru-

cial for pain management, as it can be sig-

niﬁcant after these interventions. RA techni-

ques, such as the interscalene block (ISB),

supraclavicular block, infraclavicular block,

and axillary block, allow anesthesiologists

to block speciﬁc nerves or groups of ner-

ves that innervate the surgical area. The use

of ultrasound guidance (USG) has become

essential to increase the accuracy of these

techniques, allowing real-time visualization

of nerve structures and the placement of lo-

cal anesthesia, which improves the effecti-

veness of the block and reduces the risk of

complications. Compared to general anes-

thesia, RA offers advantages such as redu-

ced postoperative pain, decreased need for

opioids, decreased postoperative nausea

and vomiting, and faster patient recovery

(35, 36).

6.3. Knee

Different regional anesthesia techniques

exist for knee arthroscopy (KA). While epi-

dural analgesia (EA) and intrathecal morphi-

ne are options, special attention is paid to

the femoral nerve block (FNB) and the ad-

ductor canal block (ACB). The FNB is noted

to provide good pain control but can cause

quadriceps weakness, increasing the risk of

falls. In contrast, the adductor canal block

is presented as an alternative that provides

sensory analgesia with minimal effect on

quadriceps strength, facilitating faster re-

covery and decreasing opioid consumption

and the risk of falls (37). Local anesthesia

for the knee is a simple and safe technique,

suitable for outpatient arthroscopic surge-

ries, involving anesthetic inﬁltration and se-

dation, useful in patients with contraindica-

tions to other anesthetics, although limited

for long surgeries and with potential risks of

cartilage cytotoxicity. Peripheral nerve bloc-

ks, guided by ultrasound, offer analgesia

with fewer complications, where the femo-

ral block is common for the anterior aspect

(with the risk of quadriceps motor block)

and the adductor canal block is an alterna-

tive with less motor block; the sciatic nerve

block is used for the posterolateral aspect,

and although nerve blocks have risks such

as nerve injury, infection, or toxicity, they

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

374 RECIMUNDO VOL. 9 N°2 (2025)

allow for effective analgesia, whether short-

term or prolonged with catheters, balancing

beneﬁts and potential complications (38).

6.4. ERAS Protocol

The ERAS (Enhanced Recovery After Sur-

gery) protocol, developed by Dr. Olle Ljun-

gqvist, is introduced as a multimodal pro-

gram that seeks to attenuate the loss of

functional capacity and improve postopera-

tive recovery. The objectives of ERAS inclu-

de enhancing patient safety and quality, re-

ducing morbidity, shortening recovery time,

decreasing surgical stress, and optimizing

pain control, early mobilization, and diet. As

a result, the aim is to reduce hospital leng-

th of stay and costs. The text also mentions

the creation of the ERAS group and Society

in 2001, and the development of the ERAS

project, a multimodal rehabilitation program

with preoperative, intraoperative, and posto-

perative strategies based on scientiﬁc evi-

dence to improve patient recovery and mi-

nimize the response to surgical stress (39).

Figure 2. Perioperative care process based on the ERAS protocol

Source: Carrillo Esper & Mejía Terrazas (39).

The ﬂowchart illustrates the perioperative

care process under the ERAS protocol, star-

ting with patient admission and progressing

through preoperative preparation, surgery

and anesthesia, hospital stay (either in a

specialized unit or surgical ward), to home

discharge, with "recovery" as a continuous

process throughout the postoperative pha-

se. This scheme highlights comprehensive

patient management and the importance

of monitoring protocol compliance and the

outcomes obtained.

Figure 3. Recommended strategies ERAS protocol

Source: Carrillo Esper & Mejía Terrazas (39).

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

375

RECIMUNDO VOL. 9 N°2 (2025)

The anesthesiologist plays a crucial role

in optimizing postoperative outcomes, ad-

dressing three fundamental pillars of the

ERAS protocol: control of the surgical stress

response, adequate ﬂuid therapy, and

effective analgesia. Central regional anes-

thesia, such as epidural, has demonstrated

the ability to mitigate the activation of the

neuroendocrine system and prevent sur-

gery-induced immunosuppression, offering

immunological and metabolic advantages

compared to general anesthesia. Regar-

ding pain management, while intravenous

opioids are common, they are associated

with longer hospital stays. Epidural anesthe-

sia and analgesia with short-acting agents

attenuate the stress response, relieve pain

(improving respiratory function), and promo-

te intestinal recovery, although caution is re-

quired due to potential side effects such as

hypotension and urinary retention. The opti-

mal analgesic strategy should allow for ear-

ly and safe mobilization, and in orthopedic

surgery, regional anesthesia combined with

paracetamol, NSAIDs, and gabapentinoids

is prioritized to minimize opioid use, with lo-

cal inﬁltration being a promising technique

for effective pain control with less impact on

mobility (40).

6.5. Benets in Older Adults and Patients

with Comorbidities

In elderly patients undergoing traumatolo-

gical surgery, particularly orthopedic pro-

cedures like knee and hip arthroplasty or

hip fracture repair, the presence of multiple

comorbidities elevates their risk proﬁle, ma-

king pre-existing conditions and the nature

of the surgery more critical than age itself

in determining functional recovery (41). In-

adequate perioperative pain management

in this population, whose physiological re-

serves and homeostatic mechanisms are

diminished with aging, leading to altered

pharmacokinetics and pharmacodynamics

of pain medications and increased sensiti-

vity to stressors, can result in complications

that negatively impact the ﬁnal outcome

(41). Regional anesthesia in older adults

requires speciﬁc considerations, including

potentially more challenging epidural tech-

niques with the need for lower local anes-

thetic volumes due to increased cephalad

spread and faster onset with greater motor

block intensity, and prolonged spinal block

duration with greater cephalad spread of

hyperbaric solutions and increased risks

with intrathecal opioids and bleeding; whi-

le peripheral blocks are useful, caution is

advised due to vascular and nerve fragili-

ty, potential pre-existing neuropathy, and

a higher risk of local anesthetic systemic

toxicity necessitating total dose reduction

(41). Epidural anesthesia/analgesia is an

effective technique for perioperative pain

management in the elderly, offering superior

relief compared to systemic opioids and po-

tentially reducing postoperative morbidity,

although with a higher risk of pruritus and

motor block, requiring careful titration due to

age-related changes in opioid requirements

and reduced renal function affecting meta-

bolite clearance, while age also inﬂuences

the diffusion and effective concentration of

local anesthetics in the neuroaxial space,

necessitating adjustments in volume and

concentration to avoid adverse effects like

hypotension (42).

7. Proposals for Improvement and Future

Research Directions

7.1. Standardized Protocols According to

Type of Surgery

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

376 RECIMUNDO VOL. 9 N°2 (2025)

Figure 4. Postoperative Acute Pain Protocol

Source: Hernández-Hernández (43).

Table 2. Electronic Pumps: Continuous Infusion

Source: Hernández-Hernández (43).

Indication

Puncture Level

Punta-catéter Level

Thorax, upper and middle

T6-T9

T6-T7

Thorax, lower and abdomen

T11-T12

T9-T10

Lower limbs

L2-L3 or L3-L4

L2-L3

Local Anesthetic

Concentration

Bupivacaine

0.125% + fentanyl 5 μg/mL

L-bupivacaine

2 mg/mL + fentanyl 4 μg/mL

Ropivacaine

Not specified in this table

Local

Anesthetic

Concentration

Infusion Rate

Bupivacaine

125%

Initial 4-6 mL/h, increase by 2 mL/h

based on response

L-bupivacaine

Same as Bupivacaine

implicitly

Same as Bupivacaine implicitly

Table 3. Epidural Analgesia Protocols

Source: Hernández-Hernández (43).

Indication

Puncture Level

Punta-catéter Level

Thorax, upper and middle

T6-T9

T6-T7

Thorax, lower and abdomen

T11-T12

T9-T10

Lower limbs

L2-L3 or L3-L4

L2-L3

Local Anesthetic

Concentration

Bupivacaine

0.125% + fentanyl 5 μg/mL

L-bupivacaine

2 mg/mL + fentanyl 4 μg/mL

Ropivacaine

Not specified in this table

Local

Anesthetic

Concentration

Infusion Rate

Bupivacaine

125%

Initial 4-6 mL/h, increase by 2 mL/h

based on response

L-bupivacaine

Same as Bupivacaine

implicitly

Same as Bupivacaine implicitly

Table 4. Elastomeric Infusers

Source: Hernández-Hernández (43).

Indication

Puncture Level

Punta-catéter Level

Thorax, upper and middle

T6-T9

T6-T7

Thorax, lower and abdomen

T11-T12

T9-T10

Lower limbs

L2-L3 or L3-L4

L2-L3

Local Anesthetic

Concentration

Bupivacaine

0.125% + fentanyl 5 μg/mL

L-bupivacaine

2 mg/mL + fentanyl 4 μg/mL

Ropivacaine

Not specified in this table

Local

Anesthetic

Concentration

Infusion Rate

Bupivacaine

125%

Initial 4-6 mL/h, increase by 2 mL/h

based on response

L-bupivacaine

Same as Bupivacaine

implicitly

Same as Bupivacaine implicitly

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

377

RECIMUNDO VOL. 9 N°2 (2025)

The protocolization of treatments is funda-

mental to standardize postoperative anal-

gesia and reduce therapeutic variability,

necessitating the development of speciﬁc

guidelines per surgical procedure to optimi-

ze care and outcomes, and further research

into their impact (43). Effective postopera-

tive pain management relies on multimodal

analgesia, combining various agents like

NSAIDs, opioids, and regional anesthesia,

and the principles of balanced analgesia

which prioritize opioid-sparing techniques

(43). Patient preferences are crucial in se-

lecting analgesic management, alongside

protocols to minimize common and serious

side effects; regional analgesia, particular-

ly continuous epidural or PCEA, proves hi-

ghly effective for major surgeries, offering

superior pain control and reduced opioid

use, potentially attenuating surgical stress

and improving recovery (43). When regio-

nal techniques are not feasible, PCA or IV

infusions with scheduled paracetamol and

NSAIDs, within a multimodal approach, are

recommended, emphasizing the role of acu-

te pain units in ensuring consistent care and

communication (43). Peripheral nerve bloc-

ks and local inﬁltrations effectively reduce

postoperative pain and opioid consumption

in orthopedic surgery, with oral multimodal

analgesia being an option for minor proce-

dures, while the role of adjuvant modalities

like cryotherapy and TENS requires further

investigation, and intravenous dexmedeto-

midine shows promise as an opioid-sparing

adjunct (44). However, signiﬁcant knowle-

dge gaps regarding optimal protocols and

long-term outcomes highlight the ongoing

need for high-quality research to reﬁne

postoperative pain management in orthope-

dic surgery (44).

7.2. Training and Learning Curve for Anes-

thesiologists

Over the last two decades, Regional Anes-

thesia (RA) has experienced a technolo-

gy-driven revitalization, although fundamen-

tal anatomical knowledge remains essential

to avoid sonoanatomy errors. RA training

has signiﬁcantly advanced through simula-

tion, offering a safe environment for deve-

loping technical and non-technical skills via

practice and expert feedback. Simulation,

combined with didactic teaching, provides

an effective balance of learning and cost.

Organizations like the ASA and ASRA have

established minimum experience require-

ments and certiﬁcation programs in ultra-

sound-guided regional anesthesia (UGRA),

highlighting the importance of supervised

practice. Ultrasound guidance has impro-

ved success rates and reduced block onset

times. RA simulation includes various mo-

dalities, from in vitro models to virtual rea-

lity and crisis simulation. The future of RA

training is geared towards evaluating the

cost-effectiveness of different simulation te-

chniques and their impact on patient safety,

within a competency-based medical educa-

tion framework. Establishing a standardized

RA curriculum is crucial for ensuring training

quality and improving patient access to this

technique, integrating it into basic anesthe-

sia training and continuous professional de-

velopment (45).

The American Society of Anesthesiologists

(ASA) has established minimum experien-

ce thresholds for neuroaxial anesthesia (50

blocks for epidural and spinal), but recom-

mendations for peripheral nerve blocks (40

for blocks and 25 for pain management) are

less speciﬁc and do not detail block types,

potentially leading to superﬁcial training.

These recommendations are based on lear-

ning curve studies, such as Kopacz and

Neal's, which demonstrated an initial impro-

vement in procedural success around 20-25

attempts, followed by a potential decrease

and recovery with 50 or more procedures.

However, the quality of execution is not gua-

ranteed by quantity. Learning curves vary by

procedure, with regional anesthesia being

more complex than basic general anesthe-

sia skills, and epidural particularly challen-

ging, requiring a high number of attempts

to achieve competency. Analyzing these

curves is crucial for residency program su-

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

378 RECIMUNDO VOL. 9 N°2 (2025)

pervision, individual learning assessment,

determining the appropriate number of ca-

ses for training, adopting new techniques,

and planning program capacity, conside-

ring faculty-to-resident ratios and the need

to maintain medical staff skills (46).

7.3. Evaluation of Long-Term Impact on

Postoperative Chronic Pain

Postoperative chronic pain (PPCP) in or-

thopedic surgery varies signiﬁcantly (15%-

65%) and is associated with factors such

as surgical technique, acute postoperative

pain (APOP), prior opioid use, smoking, and

mood disorders. One study found unusual

factors like "excessive" clinical follow-up,

teaching institutions, and insurance type.

Orthopedic trauma surgery presents the

highest incidence of PPCP (65%), with risk

factors including female sex, prior trauma

surgery, and preoperative pain intensity,

which impacts functionality, causes disa-

bility, and increases resource utilization. In

total knee arthroplasty, up to 34% persist

with moderate to severe PPCP at three mon-

ths, with preoperative pain, APOP intensity,

anxiety, and expected pain being impor-

tant risk factors. Surprisingly, up to 32.7%

of patients undergoing knee arthroscopy, a

procedure to treat chronic pain, experience

moderate to severe PPCP at 18 months, with

preoperative pain and preoperative analge-

sic use being identiﬁed risk factors (47).

Postoperative chronic pain (PPCP) is a com-

mon complication in various orthopedic sur-

geries, with an overall prevalence of around

20%, although it varies by surgery type. In

hip arthroplasty, the patient's preoperative

status is a signiﬁcant predictor of postope-

rative outcome, while iliac crest graft har-

vesting can cause persistent pain. In knee

arthroplasty, a considerable proportion of

patients experience PPCP, often with a neu-

ropathic component, and pre-existing pain

and central sensitization are important risk

factors. Knee arthroscopy, paradoxically,

can also lead to PPCP. Similarly, in shoul-

der surgery, preoperative pain is a key pre-

dictive factor for postoperative pain, and in

shoulder arthroplasty, various clinical and

demographic variables inﬂuence the chroni-

city of pain. Rotator cuff repair is particularly

associated with postoperative pain, where

preoperative pain also plays a crucial role.

In general, preoperative pain emerges as

a consistent risk factor for the development

of PPCP in multiple types of orthopedic sur-

gery (48).

8. Analysis of New Technologies.

8.1. Articial Intelligence-Controlled Blocks

Artiﬁcial Intelligence (AI) is revolutionizing

postoperative pain management by offering

personalized predictions based on patient

history, allowing for adjustments in analge-

sic doses to avoid overmedication or insufﬁ-

cient relief. AI-powered monitoring devices

track pain in real-time and automatically

adjust medication, improving the patient ex-

perience. AI is also integrated with biofee-

dback and virtual reality to distract and re-

duce pain perception. However, excessive

reliance on technology and the importance

of maintaining doctor-patient communica-

tion are cautioned (49).

Speciﬁc AI techniques, such as predictive

algorithms based on machine learning and

deep neural networks, analyze large amounts

of data to forecast pain intensity and respon-

se to analgesics, thereby personalizing treat-

ment. Natural Language Processing (NLP)

is used to interpret patients' descriptions of

pain, offering additional insights. The accura-

cy of these systems depends on the quality

of the training data, and ensuring their inter-

pretability is crucial (49).

AI-based tools and platforms include mobile

applications for pain logging and monitoring

that alert to intense episodes and offer re-

minders and exercises. Wearable devices

detect physiological changes correlated

with pain, allowing for real-time adjustments.

Patient-controlled analgesia systems with

AI automatically adjust medication. In re-

search, AI analyzes large datasets to identi-

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

379

RECIMUNDO VOL. 9 N°2 (2025)

fy biomarkers and future therapies. Despite

its potential, challenges such as data priva-

cy and the need for adequate training must

be addressed, emphasizing AI's comple-

mentary role in patient care to achieve more

precise and personalized treatment (49).

8.2. Portable Ultrasound and Color Doppler

Figure 5. Color Doppler superimposed on 2D ultrasound of the anterolateral area of the

neck at the C6/C7 level. Observing only the 2D ultrasound image, one might confuse the

vertebral artery (2) with a nerve root. Both can appear similar on 2D ultrasound. Color

Doppler helps to distinguish nerve roots from blood vessels. 1) Carotid artery; 2) Vertebral

artery; 3) Inferior thyroid vein

Source: Boezaart & Ihnatsenka (50).

Color Doppler assists in distinguishing mo-

ving structures, such as blood ﬂow within

vessels, which is particularly useful as hypoe-

choic proximal nerves can be mistaken for

blood vessels (50). While 2D ultrasound can

be ambiguous, color Doppler helps differen-

tiate nerve roots from blood vessels and de-

termine blood ﬂow direction (50). However,

color Doppler is most effective when ultra-

sound waves are nearly parallel to the ﬂow,

and may produce false negatives at near-90°

angles or with low ﬂow; tilting the probe and

using power Doppler can improve vessel re-

cognition in such cases (50).

The advent of portable ultrasound devices

has enabled point-of-care (POC) diagnostics,

bringing imaging to the patient's bedside ra-

ther than a separate lab (51). Studies show

that adding portable ultrasound to routine

clinical exams changes, adds, or conﬁrms a

signiﬁcant diagnosis in one out of three pa-

tients, making it indispensable for diagnos-

tic purposes (51). This bedside accessibility

also facilitates faster diagnosis and immedia-

te treatment initiation, improving patient out-

comes (51). Furthermore, it can reduce the

need for invasive tests by aiding in diagnosis

at the bedside (51). Portable devices are es-

pecially beneﬁcial in out-of-hospital settings

like remote medical camps and low-income

treatment centers (51).

Applications

Portable ultrasound devices have various

applications. In musculoskeletal issues,

they can diagnose conditions like partial or

full rotator cuff tears with sensitivity compa-

rable to arthroscopy, potentially avoiding

unnecessary MRIs and saving time and mo-

ney (51). They are also used in knee joints

to rule out meniscus tears and in emergency

departments to detect inﬂamed joints, hel-

ping exclude joint effusion (51). Furthermo-

re, portable ultrasound guides treatments in

the operating room, such as administering

regional anesthetic blocks and detecting

lesions/masses for ultrasound-guided biop-

sies. In vascular surgery, they aid in identif-

ying relevant blood vessels (51).

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

380 RECIMUNDO VOL. 9 N°2 (2025)

8.3. Automated Infusion Systems for Continuous Regional Analgesia

Figure 6. Automated Infusion Systems. Electronic Infusion Pump (left). Variable Rate Infu-

ser + PCA (right)

Source: Eimil Rúa (52).

Benets:

• Prolongs postoperative analgesia time.

• Increases analgesic quality.

• Minimizes opioid-related side effects.

• Allows for the successful incorporation

of new surgical procedures.

• Improves patient satisfaction.

• Decreases sleep disturbances.

• Shortens hospital stay.

• Facilitates early rehabilitation (52).

Features:

• Lightweight and comfortable to wear

• .Easy to handle and understand for the

patient and caregiver.

• Possibility of continuous infusion and/or

boluses.

• Adaptation to analgesic needs.

• Ability to administer different doses.

• Infusion time adjusted to patient needs,

duration 2-5 days.

• Sufﬁcient capacity for the required local

anesthetic.

• Possibility of reprogramming to adjust to

analgesia requirements.

• Variable basal ﬂow rate (maximum pos-

sible ﬂow range).

• Adequacy between the programmed

and administered dose.

• Consistency in perfusion.

• Lowest possible cost (52).

The viability of an automated continuous in-

fusion system in different clinical contexts

depends on several factors, including the

technology used, the ability to integrate into

the hospital environment, patient safety, and

cost-effectiveness.

Potential Advantages:

• Precision and Control: Allows for preci-

se administration of medications or nu-

trients, adapting to the speciﬁc needs of

the patient.

• Consistency: Reduces human errors in

dosage and infusion control.

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

381

RECIMUNDO VOL. 9 N°2 (2025)

• Real-time Monitoring: Facilitates the

early detection of complications or chan-

ges in the patient's condition.

• Efficiency: Can decrease the workload

of healthcare personnel and optimize re-

sources (53).

Clinical Contexts Where It May Be Viable:

• Intensive Care: For continuous adminis-

tration of vasoactive drugs, sedatives, or

parenteral nutrition.

• Neonatology: For infants with precise

and delicate requirements.

• Surgery: During procedures requiring

controlled and precise infusions.

• Oncology: For continuous or frequently

administered chemotherapy.

• Rehabilitation and Pain Management:

With analgesics or sedatives in automa-

ted infusion pumps (53).

9. Comparison of Strategies.

Ultrasound-Guided Blocks vs. General

Anesthesia:

• Precision and Safety: Ultrasound gui-

dance allows real-time visualization of

nerves, vessels, and the needle, ena-

bling precise local anesthetic placement

and reducing complications like vascular

or nerve puncture compared to anatomi-

cal landmark-based techniques. General

anesthesia, inducing unconsciousness,

necessitates comprehensive airway and

cardiovascular control with inherent risks

related to intubation, mechanical ventila-

tion, and systemic effects of anesthetic

drugs (19, 54–56).

• Recovery: Patients receiving ultra-

sound-guided blocks often experience

faster recovery with fewer systemic side

effects (e.g., nausea, vomiting) than tho-

se under general anesthesia. This is due

to the localized nature of regional anes-

thesia, avoiding whole-body exposure

to anesthetic drugs. General anesthesia

can lead to a longer recovery period due

to residual drug effects (19, 54–56).

• Postoperative Analgesia: Ultrasound-gui-

ded peripheral nerve blocks can pro-

vide excellent postoperative pain relief

in the blocked region, often decreasing

the need for systemic analgesics, inclu-

ding opioids, and their associated side

effects. Analgesia after general anesthe-

sia typically relies on systemic medica-

tions (19, 54–56).

• Suitability: General anesthesia is ne-

cessary for extensive surgeries, proce-

dures requiring complete immobility, or

in patients who cannot tolerate regional

anesthesia. Ultrasound-guided blocks

are ideal for surgeries on extremities, the

abdominal wall, and other speciﬁc areas

where selective nerve blockade is possi-

ble (19, 54–56).

Continuous Catheters vs. Systemic Anal-

gesia:

• Prolonged Pain Control: Continuous

catheters, placed near peripheral nerves

or in the epidural space, allow for conti-

nuous or intermittent administration of lo-

cal anesthetic for several days. This pro-

vides more sustained and effective pain

control compared to systemic analgesia

(oral or intravenous), which often results

in ﬂuctuations in pain levels (19, 54–56).

• Opioid Reduction: Continuous regional

analgesia can signiﬁcantly reduce the

need for systemic opioids, which in turn

decreases opioid-related side effects

such as sedation, constipation, nau-

sea, and the risk of respiratory depres-

sion. Systemic analgesia often relies on

opioids for moderate to severe pain, with

their consequent adverse effects (19,

54–56).

• Functional Recovery: Better pain con-

trol with continuous catheters facilita-

tes early mobilization, physical therapy,

OPTIMIZATION OF REGIONAL ANESTHESIA IN ORTHOPEDIC SURGERY: BENEFITS IN POSTOPERATIVE

PAIN MANAGEMENT

382 RECIMUNDO VOL. 9 N°2 (2025)

and ultimately, faster functional recovery

compared to inadequate systemic anal-

gesia (19, 54–56).

• Personalized Management: Continuous

catheters allow for adjustment of the local

anesthetic dose and administration regi-

men according to individual patient needs

and pain intensity over time. Systemic

analgesia is often based on ﬁxed doses

or patient demand, which may not always

match changing pain needs (19, 54–56).

• Risks: Continuous catheters carry a

risk of infection at the insertion site and

the possibility of catheter displacement,

which could compromise analgesia. Sys-

temic analgesia, especially with opioids,

has its own risks, such as the side effects

mentioned above (19, 54–56).

Table 5. Comparative Table

Source: Arévalo Gutiérrez; Prat Calero et al; Ramírez Flores; Vera, Lorenti, López, Ron,

Solis, Zambrano, Romina, et al (19,54–56).

Feature

Ultrasound-Guided Blocks

(Single Dose)

Ultrasound-Guided

Continuous Catheters

Block Duration

Limited (hours to a day, depending

on the drug)

Prolonged (days, while the

catheter is active)

Need for Rescue

Analgesia

Higher, as the block effect

diminishes

Lower, with adjustable

continuous analgesia

Complications

Lower risk of systemic

complications, risk of

nerve/vascular puncture | Risk of

infection, catheter displacement,

complications similar to single

dose

Time to

Ambulation

Potentially faster (without

prolonged motor block) | May be

slower initially (if motor block is

present), but better long-term due

to better pain control

Additional Considerations:

• The duration of the block with single-do-

se techniques depends on the local

anesthetic used (e.g., lidocaine vs. bu-

pivacaine vs. ropivacaine) and can be

extended with adjuvants.

• The need for rescue analgesia is inver-

sely related to the duration and effective-

ness of the initial block. Catheters allow

for the administration of additional bolu-

ses or infusions to maintain analgesia.

• Complications from ultrasound-guided

blocks are generally low when perfor-

med correctly. Catheters introduce ad-

ditional risks but can avoid the need for

multiple injections.

• The time to ambulation may be initially

affected by motor block, but better long-

term pain control with catheters can fa-

cilitate earlier rehabilitation (19, 54–56).

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.

383

RECIMUNDO VOL. 9 N°2 (2025)

Conclusions

The optimization of regional anesthesia (RA)

in orthopedic surgery, through the imple-

mentation of modern techniques such as

ultrasound-guided blocks and continuous

catheters, represents a signiﬁcant advan-

cement in postoperative pain management

with multiple proven beneﬁts. Compared to

general anesthesia and traditional systemic

analgesia, modern RA offers greater preci-

sion and safety in the administration of local

anesthetics, resulting in more effective and

speciﬁc pain control in the surgical region.

Ultrasound-guided peripheral nerve bloc-

ks allow for real-time visualization of nerve

structures, minimizing the risk of complica-

tions and facilitating early and high-quality

postoperative analgesia, often with a signi-

ﬁcant reduction in the need for opioids and

their associated side effects. This translates

to faster recovery, early mobilization, and

greater patient satisfaction.

For their part, continuous catheters extend

the analgesic beneﬁts of RA for several

days, providing sustained and adjusta-

ble pain control tailored to the individual

patient's needs over time. This prolonged

analgesia facilitates rehabilitation, decrea-

ses the incidence of postoperative chronic

pain, and contributes to a potentially shorter

hospital stay.

While the successful implementation of

these techniques requires specialized tra-

ining and well-deﬁned protocols, current

evidence strongly supports their value in

optimizing postoperative pain management

in orthopedic surgery. Modern RA, by mini-

mizing exposure to general anesthetics and

reducing dependence on systemic opioids,

not only improves the patient experience

but can also have a positive impact on heal-

thcare costs and long-term outcomes. Con-

sequently, the integration and continuous

improvement of image-guided RA techni-

ques should be a priority in contemporary

orthopedic practice.

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CITAR ESTE ARTICULO:

Acuña Meza , D. S., Anda Suárez, P. X., Estrada Segura, G. J., & Acosta Pas-

trano , K. A. (2025). Optimization of regional anesthesia in orthopedic surgery:

Beneﬁts in postoperative pain management. RECIMUNDO, 9(2), 361–386. ht-

tps://doi.org/10.26820/recimundo/9.(2).abril.2025.361-386

ACUÑA MEZA , D. S., ANDA SUÁREZ, P. X., ESTRADA SEGURA, G. J., & ACOSTA PASTRANO , K. A.