Peri-articular infiltration analgesia for shoulder surgery: a systematic review and meta-analysis

Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. We searched literature for trials comparing peri-articular infiltration analgesia with control or with interscalene brachial plexus block. Control groups received no intervention, placebo or systemic opioids. The primary outcome was cumulative oral morphine equivalent consumption during the first 24 h postoperatively. Secondary outcomes included: rest pain scores up to 48 h; risk of side-effects; and durations of post-anaesthetic care unit and hospital stay. Data were pooled with random-effects modelling. Seven trials (383 patients) were included. Compared with control, peri-articular infiltration analgesia reduced 24-h oral morphine consumption by a mean difference (95%CI) of −38.0 mg (−65.5 to −10.5; p = 0.007). It also improved pain scores up to 6 h, 36 h and 48 h, with the greatest improvement observed at 0 h (−2.4 (−2.7 to −1.6); p < 0.001). Peri-articular infiltration analgesia decreased postoperative nausea and vomiting by an odds ratio (95%CI) of 0.3 (0.1–0.7; p = 0.006). In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique.     

Analgesia requirements after interscalene block for shoulder arthroscopy: the 5 days following surgery

Introduction  

Excellent initial post-operative analgesia for patients undergoing arthroscopic shoulder surgery can be provided with a single-shot interscalene brachial plexus block. However there have been concerns that when the block wears off, patients may experience pain and this may occur at home. Some investigators have advocated the use of continuous ambulatory local anaesthetic infusions following hospital discharge. We prospectively studied pain scores, analgesic requirements and satisfaction of patients at home in the first 5 days following arthroscopic shoulder surgery to see whether continuous infusion would be of benefit.     

Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery

BackgroundThe minimally invasive approach of arthroscopic shoulder surgery is beneficial; however, for optimal outcomes, perioperative pain management is essential. This cross-sectional study aimed to examine the analgesic effectiveness of intra-articular injection (IA) versus interscalene brachial plexus block (ISPB) among patients treated with arthroscopic shoulder surgeries.MethodsWe reviewed 100 consecutive patients who underwent shoulder arthroscopic surgery, of whom 50 each underwent IA (February 2019─January 2020; IA group) and ISPB (October 2018─July 2019; ISPB group). The primary outcome was the postoperative pain score measured using a Wong–Baker FACES Pain Rating Scale preoperatively and at 2, 6, 12, 24, and 48 h postoperatively. We performed multiple regression analysis to examine whether IA/ISPB selection is associated with acute-phase postoperative pain and adjusted for intra-articular injection, interscalene brachial plexus block, postoperative pain management, arthroscopic shoulder surgery, IA with 10 mg of morphine previously reported prognostic factors for postoperative pain (e.g., surgical procedures, operative time, older age, and preoperative pain). Furthermore, we examined induction time, total pentazocine dosage, and total postoperative nausea and vomiting (PONV) events.ResultsThere were no significant differences between the IA and ISPB groups in perioperative pain control during the acute-phase periods (p = 0.12, repeated analysis of variance). The difference in anesthesia method was not a prognostic factor for acute-phase postoperative pain (p = 0.11). The IA group (15.06 ± 4.00 min) had a significantly shorter mean anesthesia induction time than the ISPB group (29.23 ± 9.22 min) (p = 0.0001). There was no significant between-group difference in the total pentazocine dosage during the first 7 days (p = 0.3934) postoperatively. PONV was observed in eight (17.0%) and two (4.2%) patients in the IA and ISPB groups, respectively. There was no significant between-group difference in the PONV incidence (p = 0.1582).ConclusionsThere was no significant difference in acute-phase postoperative pain management between the IA and ISPB groups. The induction time was significantly shorter in IA.IRBApproval number: UOEHCRB20-078, IRB approval date: September 9th, 2020; study duration: October 2018 to January 2020.     

Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis

BackgroundBoth transversus abdominis plane (TAP) block and local anesthetic wound infiltration have been used to relieve pain after laparoscopic cholecystectomy. We undertook this systematic review and meta-analysis with trial sequential analysis to determine the best analgesic technique.MethodsWe systematically searched the literature for trials comparing TAP block with wound infiltration after laparoscopic cholecystectomy. The primary outcome was pain score during rest (analogue scale, 0–10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, pain scores during movement and intravenous morphine consumption at 2, 12 and 24 h, and postoperative nausea and vomiting. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, hematoma, visceral injury and local anesthetic systemic toxicity.ResultsTen trials including 668 patients were identified. There was a significant difference in pain score during rest at 2 postoperative hours in favour of TAP block when compared with wound infiltration (mean difference [95%CI]: −0.7 [−1.2, −0.2]; I2 = 71%; p = 0.008). Pain scores during rest at 12 and 24 h and pain scores during movement at 24 h were also significantly lower with TAP block than wound infiltration. Postoperative morphine consumption and the incidence of postoperative nausea and vomiting were significantly lower in patients who received a TAP block. Data were insufficient to compare block-related complications. The overall quality of evidence was moderate-to-high.ConclusionsThere is moderate-to-high level evidence that the TAP block provides superior analgesia when compared with wound infiltration in patients undergoing laparoscopic cholecystectomy.Trial registry number: PROSPERO CRD42020208057.     

Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery

Background and Objectives. Although interscalene brachial plexus block (ISBPB) is often used to provide anesthesia for arthroscopic shoulder surgery, its selective analgesic effect, provided by low-dose local anesthetic, has not been studied. We hypothesized that ISBPB using a low volume and low concentration of bupivacaine can provide effective postoperative analgesia for shoulder surgery without producing significant sensory or motor block elsewhere. Methods. In this double-blind study, 30 outpatients scheduled to undergo shoulder arthroscopy were randomly assigned to receive either an ISBPB with 10 mL 0.125% bupivacaine with epinephrine 1:400,000 (n = 15) or 10 mL of normal saline (n = 15). The block was performed preoperative, prior to a standardized general anesthetic. Postoperative pain scores, morphine and oral analgesic consumption, recovery profile, and patient satisfaction were recorded. Results. In the ISBPB group, verbal analog pain scores within 120 minutes after surgery were lower, morphine consumption in the postanesthesia care unit was significantly lower (2.7 ± 2.6 mg vs 9.5 ± 5.2 mg), the time to postoperative administration of the first systemic or oral analgesic was significantly longer (141 ± 182 minutes vs 13 ± 10 minutes), the degree of motor and sensory block 120 minutes after surgery was minimal, time to reach hospital discharge criteria was earlier, and patient satisfaction with postoperative analgesia at 24-hour follow-up was greater. Thirty-three percent of the patients receiving ISBPB did not require any analgesic prior to hospital discharge. Conclusions. Interscalene brachial plexus block with low-dose bupivacaine is a useful and selective analgesic technique for outpatient shoulder arthroscopic surgery.     

Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome

Suprascapular nerve block (SSNB) reportedly improves analgesia and 24-h outcomes after arthroscopic shoulder surgery performed under general anesthesia. In this study, we assessed the analgesic and clinical outcome efficacy of SSNB as an adjunct to interscalene brachial plexus block (ISB) for ambulatory nonarthroscopic shoulder surgery. Fifty patients were randomized to receive either a SSNB or sham injection as part of a standardized ISB-general anesthesia regimen. Time to first significant pain (the primary outcome measure) was significantly delayed in the SSNB group (594 +/- 369 min versus 375 +/- 273 min, respectively; P = 0.02). There were no other differences between groups with regard to postanesthesia recovery unit measures, 24-h assessment of pain, supplemental analgesic use, or quality of life outcomes. We conclude that adjunctive SSNB adds minimal value to a primary ISB anesthetic for nonarthroscopic shoulder surgery. IMPLICATIONS: When used as an adjunct to an interscalene block combined with general anesthesia, suprascapular nerve block with bupivacaine moderately prolongs analgesia without improving other outcome measures after ambulatory nonarthroscopic shoulder surgery.     

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (−1.9–3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.     

Dose–response relationship of perineural dexamethasone for interscalene brachial plexus block: a randomised,controlled, triple-blind trial

Perineural dexamethasone has a ceiling dose of 4 mg for prolongation of analgesia duration after injection of long-acting local anaesthetic for peripheral nerve block, but evidence for doses < 4 mg is lacking. This randomised controlled triple-blind trial tested the hypothesis that increasing doses of perineural dexamethasone between 1 mg and 4 mg would prolong the duration of analgesia in a dose-dependent manner. Eighty ASA physical status 1–2 patients scheduled for shoulder arthroscopy under general anaesthesia with ultrasound-guided interscalene brachial plexus block were randomly allocated to receive saline (control), dexamethasone 1 mg, 2 mg, 3 mg and 4 mg, together with 20 ml ropivacaine 0.5%. Postoperative analgesia consisted of paracetamol, diclofenac and oxycodone on request, using a pre-defined protocol. The primary outcome was the duration of analgesia, defined as the time between the block procedure and the first analgesic request. Secondary outcomes included rest and dynamic pain scores, and analgesic consumption at 2 h, 24 h and 48 h postoperatively. An analysis of the dose–response relationship was performed using multiple comparison procedure-modelling. The median (IQR [range]) duration of analgesia was significantly prolonged in a dose-dependent manner: control 685 (590–860 [453–1272]) min; 1 mg 835 (740–1110 [450–1375]) min; 2 mg 904 (710–1130 [525–1365]) min; 3 mg 965 (875–1025 [730–1390]) min; 4 mg 1023 (838–1239 [518–1500]) min (p = 0.03). There were no significant differences between the secondary outcomes. Perineural administration of dexamethasone with doses between 1 mg and 4 mg, combined with ropivacaine for interscalene brachial plexus block, prolongs duration of analgesia in a dose-dependent manner.     

Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis

Surgery is the primary therapeutic intervention for breast cancer and can result in significant postoperative pain. We searched the current literature and performed a meta-analysis in order to compare the analgesic efficacy of the pectoral type-2 (Pecs II) block with systemic analgesia alone and with a thoracic paravertebral block for breast cancer surgery. Primary outcome was postoperative opioid consumption in the first 24 h after surgery. Secondary outcomes were pain scores at 0, 3, 6, 9 and 24 h after surgery, intra-operative opioid consumption, time to first analgesic request and incidence of postoperative nausea and vomiting. We identified 13 randomised controlled trials that included 815 patients. The Pecs II block significantly reduced postoperative opioid consumption (standardised difference in means: −13.64 mg oral morphine equivalents; 95%CI: −21.22 to −6.05; p < 0.01) and acute postoperative pain at all intervals in the first 24 h after surgery compared with systemic analgesia alone. Compared with the thoracic paravertebral block, the Pecs II block resulted in similar postoperative opioid consumption (standardised difference in means: −8.73 mg oral morphine equivalents; 95%CI: −18.16 to 0.69; p = 0.07) and postoperative pain scores after first measurement. In conclusion, the Pecs II block offers improved analgesic efficacy compared with systemic analgesia alone and comparable analgesic efficacy to a thoracic paravertebral block for breast cancer surgery.     

Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL

Purpose

Interscalene brachial plexus block (interscalene block) complications usually depend on the dose administered. The objective of this study was to determine whether ultrasound-guided interscalene block with a 5-mL dose of 0.75% ropivacaine would have sufficient analgesic efficacy after shoulder arthroscopic surgery when compared with a 10-mL dose.

Methods

Patients undergoing arthroscopic rotator cuff repair surgery (n = 60) were assigned randomly to one of two groups receiving 5 mL (Group 5) or 10 mL (Group 10) of 0.75% ropivacaine. Ultrasound-guided interscalene block was performed using the in-plane technique, and general anesthesia was administered. Time to first analgesic request was recorded, and the following issues were assessed in the postanesthesia care unit at six, 12, 24, and 48 hr postoperatively: postoperative pain as determined by a visual analogue scale (VAS), patient satisfaction, hemidiaphragmatic paralysis, other block-related complications, and postoperative nausea and vomiting (PONV).

Results

There was no significant difference between groups in time to first analgesic requirement (median [interquartile range] for Group 5: 16 [12-48] hr, Group 10: 18 [12-48] hr; P = 0.907). The postoperative pain VAS score was similar in both groups. The incidence of hemidiaphragmatic paralysis on postoperative chest x-ray was 33% in Group 5 and 60% in Group 10 (P = 0.035). However, the incidences of other block-related complications, PONV, and patient satisfaction were not significantly different between groups.

Conclusion

Interscalene block performed under ultrasound guidance with 0.75% ropivacaine 5 mL showed analgesic efficacy similar to that with 0.75% ropivacaine 10 mL, but with a lower incidence of hemidiaphragmatic paralysis.     

Analgesic benefits and clinical role of the posterior suprascapular nerve block in shoulder surgery: a systematic review,meta-analysis and trial sequential analysis

The posterior suprascapular nerve block has been proposed as an analgesic alternative for shoulder surgery based on the publication of several comparisons with interscalene block that failed to detect differences in analgesic outcomes. However, quantification of the absolute treatment effect of suprascapular nerve block on its own, in comparison with no block (control), to corroborate the aforementioned conclusions has been lacking. This study examines the absolute analgesic efficacy of suprascapular nerve block compared with control for shoulder surgery. We systematically sought electronic databases for studies comparing suprascapular nerve block with control. The primary outcomes included postoperative 24-h cumulative oral morphine consumption and the difference in area under the curve for 24-h pooled pain scores. Secondary outcomes included the incidence of opioid-related side-effects (postoperative nausea and vomiting) and patient satisfaction. Data were pooled using random-effects modelling. Ten studies (700 patients) were analysed; all studies examined landmark-guided posterior suprascapular nerve block performed in the suprascapular fossa. Suprascapular nerve block was statistically but not clinically superior to control for postoperative 24-h cumulative oral morphine consumption, with a weighted mean difference (99%CI) of 11.41 mg (−21.28 to −1.54; p = 0.003). Suprascapular nerve block was also statistically but not clinically superior to control for area under the curve of pain scores, with a mean difference of 1.01 cm.h. Nonetheless, suprascapular nerve block reduced the odds of postoperative nausea and vomiting and improved patient satisfaction. This review suggests that the landmark-guided posterior suprascapular nerve block does not provide clinically important analgesic benefits for shoulder surgery. Investigation of other interscalene block alternatives is warranted.     

The safety and efficacy of intrabursal oxycodone and bupivacaine in analgesia after shoulder surgery

Background and Objectives. Peripherally administered opioids, e.g., intra-articular morphine, exert their analgesic action on local opioid receptors. The present study investigated the safety and efficacy of intrabursal oxycodone and bupivacaine in comparison with bupivacaine infiltration and interscalene brachial plexus block in conjunction with shoulder surgery. Methods. A prospective, randomized study was conducted in 45 patients (15 per group) undergoing elective shoulder surgery during general anesthesia. At the end of the surgery, patients received either 10 mL 0.5% bupivacaine (group B) or 5 mg oxycodone and 10 mL 0.5% bupivacaine (group OB) in the subacromial bursa; interscalene plexus blocks were performed preoperative (group IPB). Postoperative analgesia was provided by patient-controlled analgesia, and the amount of intravenous fentanyl used during the total perioperative period was recorded. Postoperative pain was assessed by a visual analog scale. Results. The total fentanyl consumption was lower in groups OB and IPB than in group B, and the difference reached statistical significance for both groups (P = .045 and P = .006, respectively). However, the groups OB and IPB did not differ in respect to their fentanyl requirements (P = 1.000). Visual analog scores for pain were lowest in group IBP during the first 6 postoperative hours. The incidence of adverse effects was similar in all groups; serious adverse effects did not occur. Conclusions. According to the present study, intrabursal oxycodone and bupivacaine offer an acceptable and efficient method for postoperative analgesia after shoulder surgery.     

Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study

BackgroundAlthough continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR.MethodsWe retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h.ResultsTwenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group.ConclusionsPMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively.Level of evidenceLevel III.     

Analgesic effects of low-dose ropivacaine for interscalene brachial plexus block for outpatient shoulder surgery-a dose-finding study

BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block (ISB) with low-dose bupivacaine provides effective postoperative shoulder analgesia in outpatients. The analgesic effect of low-dose ropivacaine for ISB is unknown. METHODS: In this double-blind study, 66 outpatients scheduled to undergo arthroscopic shoulder surgery were randomly assigned to receive an ISB with 10 mL of 0.125%, 0.25%, or 0.5% ropivacaine before surgery. Postoperative verbal pain rating score, analgesic consumption, and the extent of motor and sensory block was assessed for 120 minutes after surgery. RESULTS: The degree of shoulder analgesia was dose dependent. Postoperative pain scores were lowest with 0.5% ropivacaine, and analgesic was not required in the hospital in 70% of the patients who received 0.25% and 0.5% ropivacaine, compared to 30% with 0.125% ropivacaine (P < .03). In the patients who required no analgesic in the hospital, the time to first oral analgesic at home was approximately 10 hours irrespective of ropivacaine concentration. Motor and sensory block distal to the elbow was detected in 25% of the patients in the 0.5% group but none in the 0.125% group. CONCLUSIONS: Interscalene brachial plexus block with low-dose ropivacaine, 10 mL of 0.25% and 0.5%, provides effective long-lasting shoulder analgesia in a majority of patients after arthroscopic surgery.     

Continuous interscalene brachial plexus block for postoperative analgesia following shoulder surgery

BACKGROUND: Severe postoperative pain is a well-known problem following shoulder surgery. This study evaluates the clinical efficacy of continuous interscalene brachial plexus block, patient-controlled analgesia, and morphine (i.v. and i.m.) for postoperative analgesia in this setting. METHODS: Thirty patients, scheduled for acromioplasty during general anesthesia, were randomly allocated to one of three different postoperative pain management groups. Group MO received morphine (5 mg i.m. and 2 mg i.v.) when visual analogue pain score (VAS) > 3, group PL received a continuous interscalene brachial plexus block with bupivacaine (1.25 mg kg-1 + 0.25 mg kg-1 h-1) and group PCA received patient-controlled analgesia with morphine (bolus 1 mg). Postoperative pain relief was assessed (24 h) by VAS, circulatory and respiratory stress parameters (heart rate, systemic arterial pressure and respiratory rate) and stress metabolites (glucose, lactate, glycerol by abdominal subcutaneous microdialysis). RESULTS: Pain relief in the PL group was effective (VAS < 3) and significantly more potent than in groups MO and PCA, except at 16 and 20 h. Lactate was significantly increased in the PL group, glucose was significantly increased in all groups, while glycerol showed a variable pattern. There were no significant stress metabolite differences among groups. VAS showed no statistical correlation with microdialysate, respiratory or circulatory data. CONCLUSION: Successful continuous interscalene brachial plexus block provides very good pain relief following shoulder surgery and is superior to the other methods studied. However, we were unable to demonstrate a correlation between VAS pain scores and stress indicators in metabolic, circulatory and respiratory parameters.     

Ultrasound-guided genicular nerves block vs. local infiltration analgesia for total knee arthroplasty: a randomised controlled non-inferiority trial

Genicular nerves block is a promising technique to treat acute postoperative pain in total knee arthroplasty. Similar to surgeon-administered local infiltration analgesia, it targets sensory branches from the knee capsule, but through a selective ultrasound-guided injection that reduces local anaesthetic dose (150 ml ropivacaine 0.2% with local infiltration analgesia vs. 20 ml with genicular nerves block). This randomised non-inferiority trial compared the analgesic efficacy of genicular nerves block vs. local infiltration analgesia in the first 24 h following total knee arthroplasty. Sixty patients were randomly allocated to receive either ultrasound-guided block of five genicular nerves or local infiltration analgesia. The primary outcome was rest pain numeric rating scale (0–10) at 24 h. Secondary outcomes included pain numeric rating scale (rest and movement) and cumulative opioid consumption during the first 24 h. We analysed 29 patients in the genicular nerves block group and 30 in the local infiltration analgesia group. We found that the median difference (95%CI) in postoperative rest pain at 24 h (non-inferiority criteria, Δ = 1) was −1.0 (−2.0 to 1.0, p < 0.001). Median difference in cumulative opioid consumption was 0.0 mg (−3.0–5.0, p < 0.001) meeting the non-inferiority criteria, Δ = 23 mg. We conclude that genicular nerves block of five nerves provides non-inferior analgesia in the first 24 h following surgery compared with local infiltration analgesia, but with a considerable reduction in the local anaesthetic dose.     

Hemidiaphragmatic paralysis following ultrasound-guided anterior vs. posterior suprascapular nerve block: a double-blind,randomised control trial

Interscalene brachial plexus block provides analgesia for shoulder surgery but is associated with hemidiaphragmatic paralysis. Before considering a combined suprascapular and axillary nerve block as an alternative to interscalene brachial plexus block, evaluation of the incidence of diaphragmatic dysfunction according to the approach to the suprascapular nerve is necessary. We randomly allocated 84 patients undergoing arthroscopic shoulder surgery to an anterior or a posterior approach to the suprascapular nerve block combined with an axillary nerve block using 10 ml ropivacaine 0.375% for each nerve. The primary outcome was the incidence of hemidiaphragmatic paralysis diagnosed by ultrasound. Secondary outcomes included: characterisation of the hemidiaphragmatic paralysis over time; numeric rating scale pain scores; oral morphine equivalent consumption; and patient satisfaction. The incidence of hemidiaphragmatic paralysis was 40% (n = 17) vs. 2% (n = 1) in the anterior and posterior groups, respectively (p < 0.001). In one third of patients with hemidiaphragmatic paralysis, it persisted beyond the eighth hour. The median (interquartile range [range]) oral morphine equivalent consumption was significantly higher in the posterior approach when compared with the anterior approach, whether in the recovery area (20 [5–31 (0–60)] mg vs. 7.5 [0–14 (0–52)] mg, respectively; p = 0.004) or during the first 24 h (82 [61–127 (12–360) mg] vs. 58 [30–86 (0–160)] mg, respectively; p = 0.01). Patient satisfaction was comparable between groups (p = 0.6). Compared with the anterior approach, diaphragmatic function is best preserved with the posterior needle approach to the suprascapular nerve block.     

Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block

In this prospective, randomized, blinded study, we assessed the analgesic efficacy of interscalene brachial plexus block (ISB), suprascapular nerve block (SSB), and intraarticular local anesthetic (IA) after arthroscopic acromioplasty. One-hundred-twenty patients were divided into 4 groups of 30. In Group SSB, the block was performed with 10 mL of 0.25% bupivacaine. In Group IA, 20 mL of 0.25% bupivacaine was administered intraarticularly at the end of surgery. In Group ISB, the block was performed with 20 mL of 0.25% bupivacaine. A control group was included for comparison. General anesthesia was administered to all patients. Patients were observed during the first 24 h. Pain scores, supplemental analgesia, satisfaction scores, and side effects were recorded at 4 and 24 h. No significant difference was observed between the IA and control groups. When compared with these groups, Groups SSB and ISB had significantly lower pain scores. At 4-h follow-up, better pain relief on movement was noted in Group ISB than in Group SSB. When compared with controls, a significant reduction in morphine consumption and a better satisfaction score were noted only in Group ISB. We conclude that ISB is the most efficient analgesic technique after arthroscopic acromioplasty. SSN block would be a clinically appropriate alternative.     

Continuous shoulder analgesia via an indwelling axillary brachial plexus catheter

Continuous interscalene brachial plexus blockade can provide anesthesia and analgesia in the shoulder region. Difficulty accessing the interscalene space and premature displacement of interscalene catheters may preclude their use in certain situations. We present two case reports in which a catheter was advanced from the axilla along the brachial plexus sheath to the interscalene space to provide continuous cervicobrachial plexus analgesia. In the first case report, previous neck surgery made the anatomic landmarks for performing an interscalene block very difficult. An epidural catheter was advanced from the axillary brachial plexus sheath to the interscalene space under fluoroscopic guidance. This technique provided both intraoperative analgesia for shoulder surgery as well as 24-hour postoperative analgesia by an infusion of 0.125% bupivacaine. In the second case report, a catheter was inserted in a similar fashion from the axillary to the interscalene space to provide 14 days of continuous analgesia in the management of complex regional pain syndrome. We have found that this technique allows us to secure the catheter more easily than with the traditional interscalene approach and thus prevents premature dislodgment. This approach may be a suitable alternative when either an interscalene or an infraclavicular catheter may not be inserted.     

Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques

Shoulder surgery is well recognised as having the potential to cause severe postoperative pain. The aim of this review is to assess critically the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery. Subacromial/intra‐articular local anaesthetic infiltration appears to perform only marginally better than placebo, and because the technique has been associated with catastrophic chondrolysis, it can no longer be recommended. All single injection nerve blocks are limited by a short effective duration. Suprascapular nerve block reduces postoperative pain and opioid consumption following arthroscopic surgery, but provides inferior analgesia compared with single injection interscalene block. Continuous interscalene block incorporating a basal local anaesthetic infusion and patient controlled boluses is the most effective analgesic technique following both major and minor shoulder surgery. However, interscalene nerve block is an invasive procedure with potentially serious complications and should therefore only be performed by practitioners with appropriate experience.