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

Objective: 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. Data Sources: MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov were searched (1 January 2005 to 1 March 2025). Methods: A systematic review was conducted in accordance with PRISMA guidelines and was registered prospectively with PROSPERO (CRD420251233062). Exploratory meta-analyses of post-operative acute pain, opioid requirements, phantom limb pain, and death were undertaken, with PNBs and PNCs grouped together as a single peripheral nerve intervention. GRADE criteria were used to express certainty of pooled results. 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 and or 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 mg; p = .005; I2 = 90.51%; GRADE, very low). Findings were maintained in subgroup analyses restricted to PNB and or 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. Conclusion: PNB and or PNC use may improve early pain outcomes after major lower limb amputation, without impacting longer term phantom limb pain.