The relative analgesic efficacy and side-effect profile of peripheral nerve blockade (PNB) techniques compared with lumbar epidural analgesia for major knee surgery is unclear. We undertook a systematic review and meta-analysis of all randomized trials comparing epidural analgesia with PNB for major knee surgery. Eight studies were identified that had enrolled a total of 510 patients of whom 464 (91%) had undergone total knee joint replacement. All were small trials and none was blinded (Jadad score 1-3). PNB technique was variable: in addition to a femoral catheter (n=5), femoral single shot (n=2), or lumbar plexus catheter (n=1) techniques, sciatic blockade was performed in three trials. There was no significant difference in pain scores between epidural and PNB at 0-12 or 12-24 h, WMD 0.22 (95% CI: -0.36, 0.81), 0.05 (-1.01, 0.91), respectively, and no clinically significant difference at 24-48 h, WMD -0.35 (-0.64, -0.02). There was also no difference in morphine consumption (mg) at 0-24 h, WMD -6.25 (-18.35, 5.86). Hypotension occurred more frequently among patients who received epidurals [OR 0.19 (0.08, 0.45)], but there was no difference in the incidence of nausea and vomiting. Two studies reported a higher incidence of urinary retention in the epidural group. Patient satisfaction was higher with PNB in two of three studies which measured this, although rehabilitation indices were similar. PNB with a femoral nerve block provides postoperative analgesia which is comparable with that obtained with an epidural technique but with an improved side-effect profile and is less likely to cause a severe neuraxial complication.

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The relative safety and efficacy of direct versus indirect methods of spinal cord stimulation for the production of descending motor-evoked responses was studied in pentobarbital-anesthetized rats (n = 39). Electrical stimuli were delivered for 1 h, either directly to the cord dorsum using silver ball electrodes or indirectly through jeweler's screws implanted in the intact laminae. Compound muscle action potentials (CMAPs) were recorded differentially in the quadriceps and evaluated for their morphology and reproducibility. The traumatic effects of stimulation were assessed using intraoperative somatosensory-evoked potentials, blinded neurological examinations for 2 weeks postoperatively, and histopathological and neurochemical analyses in postmortem spinal tissues. In separate experiments, the neural substrates of the muscle-evoked response to indirect cord stimulation were examined. Direct, epidural stimulation of the spinal cord at intensities sufficient to elicit reproducible CMAPs consistently resulted in mild behavioral deficits (13 of 18 animals) that were accompanied by postmortem changes in spinal histology and chemistry. Some of these behavioral deficits (5 of 13 animals) were resolved at 2 weeks. There was rarely an early sign of motor or sensory conduction derangement in these animals. In 2 animals with severe behavioral dysfunction, the somatosensory-evoked response was abolished immediately after spinal stimulation. However, CMAP responses were unaltered. Examination of the strength-duration relationship for the production of threshold responses to translaminar constant current stimulation, as well as experiments using selective transection of the dorsal columns, revealed the CMAP responses to be neurally mediated and conducted through the cord independent of the ascending sensory tracts that mediate the rat's somatosensory-evoked response. Data are discussed in terms of the potential experimental usefulness of CAMPs elicited by indirect dorsal spinal stimulation.

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