Summary Recommendations

Notes on PROSPECT recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Grades of recommendation (GoR) and levels of evidence (LoE)

GoRs are assigned according to the overall LoE on which the recommendations are based, which is determined by the quality and source of evidence: Relationship between quality of the study and levels of evidence (LoE) and grades of recommendation.

Notes on pain after rotator cuff repair surgery

Rotator cuff repair surgery is associated with significant postoperative pain, and effective pain control can affect early postoperative rehabilitation (Sgroi 2018) and long-term outcomes (Novoa-Boldo 2018). Pain continues to be a significant concern after rotator cuff repair as it may result in prolonged admissions or readmissions (Marhofer 2015).

Recommended: Pre- and intra-operative interventions

Recommended: Pre- and intra-operative interventions Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision and ‘intra-operative’ refers to interventions applied after incision and before wound closure Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Paracetamol and NSAIDs/COX-2-selective inhibitors	Paracetamol and NSAID or COX-2-speciﬁc inhibitor are recommended, administered pre-operatively or intra-operatively and continued postoperatively, unless there are contra-indications (Grade D). The analgesic beneﬁts and opioid-sparing effects of these simple analgesics are well described (Joshi 2014, Martinez 2017, Ong 2010, Nir 2016, Apfel 2013).
IV dexamethasone	Although there is limited procedure-speciﬁc evidence, IV dexamethasone is recommended (Grade B) for its ability to increase the analgesic duration of interscalene block and decrease supplemental analgesia use, as well as for its antiemetic effects. The analgesic beneﬁts and antiemetic effects of dexamethasone are well described (Waldron 2013, Henzi 2000).
Interscalene brachial plexus blockade	Interscalene brachial plexus blockade is recommended as the ﬁrst-choice regional analgesic technique. Continuous interscalene brachial plexus block is recommended (Grade A). Single-shot interscalene brachial plexus block is recommended (Grade A). A continuous interscalene block is favoured over a single-shot interscalene block.
Suprascapular nerve block with or without axillary nerve block	Suprascapular nerve block with or without axillary nerve block is recommended (Grade B) as an alternative to interscalene block, but not as the ﬁrst choice. A suprascapular nerve block reduces pain scores and/or opioid use after surgery but does not seem to have analgesic advantages over interscalene block.
Surgical technique	Whenever possible, rotator cuff repair should be performed using an arthroscopic approach (Grade B), as it is associated with lower postoperative pain

Recommended: Post-operative interventions

Unless otherwise stated, ‘postoperative’ refers to interventions applied at or after wound closure
Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period

Paracetamol and NSAIDs/COX-2-selective inhibitors

Paracetamol and NSAID or COX-2-speciﬁc inhibitor are recommended, administered pre-operatively or intra-operatively and continued postoperatively, unless there are contra-indications (Grade D).
The analgesic beneﬁts and opioid-sparing effects of these simple analgesics are well described (Joshi 2014, Martinez 2017, Ong 2010, Nir 2016, Apfel 2013).

Opioids