Comparison of the efficacy of different interventions for rebound pain after brachial plexus block in upper extremity surgery

BACKGROUND: Rebound pain is a common transient severe pain after peripheral nerve block subsidence, impairing block efficacy and patient satisfaction. OBJECTIVE: This study aimed to evaluate the preventive and therapeutic effects of six interventions - dexamethasone, esketamine, dexmedetomidine, liposomal bupivacaine, continuous nerve block and combined nerve block (brachial plexus block via multiple approaches) - on rebound pain after upper extremity surgery brachial plexus block to provide evidence-based references for optimising clinical analgesic regimens. DESIGN: Bayesian network meta-analysis. DATASOURCES: PubMed, Web of Science, Embase and Cochrane Library were searched up to 10 October 2025. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) assessing the efficacy of the above interventions for rebound pain prevention and treatment after brachial plexus block in upper extremity surgery. RESULTS: A total of 22 RCTs involving 1699 patients were included. Network meta-analysis showed that compared with placebo, dexamethasone [odds ratio (OR) = 0.22 (95% CI, 0.11 to 0.42), dexmedetomidine (OR = 0.23 (95% CI, 0.08 to 0.68)] and continuous nerve block [OR = 0.04 (95% CI, 0.01 to 0.33)] significantly reduced rebound pain incidence. Dexamethasone [mean difference (MD) = -2.54 (95% CI, -4.76 to -0.26)] and continuous nerve block [MD = -3.10 (95% CI, -5.86 to -0.23)] lowered 12-h postoperative pain scores. Compared with placebo, combined nerve block [MD = -0.86 (95% CI, -1.59 to -0.13)] reduced postoperative 24-h pain scores. SUCRA results ranked continuous nerve block as the most favourable intervention for reducing rebound pain and 12-h/24-h postoperative pain scores. These reflect relative probabilities rather than absolute efficacy and require further validation. CONCLUSION: In patients undergoing upper-extremity surgery with brachial plexus block, current network meta-analysis findings suggest that continuous nerve block is associated with a lower incidence of rebound pain and reduced pain scores at 12 and 24 h postoperatively, although further validation is still required. We recommend that continuous nerve block may be considered for patients at high risk of rebound pain to balance efficacy and safety. Given the limited certainty of evidence, these findings should be regarded as exploratory and hypothesis-generating rather than definitive conclusions. TRIAL REGISTRATION: PROSPERO (CRD420251251811).