|Year : 2016 | Volume
| Issue : 4 | Page : 536-541
Postoperative analgesia for arthroscopic shoulder surgery: comparison between ultrasound-guided interscalene block and combined suprascapular and axillary nerve blocks
Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||03-Dec-2015|
|Date of Acceptance||25-Apr-2016|
|Date of Web Publication||12-Jan-2017|
20 Taksem Al-Awkaf, Presidential Palace Street, Al-Sawah, Cairo, 11646
Source of Support: None, Conflict of Interest: None
Arthroscopic shoulder surgery is often associated with severe postoperative pain that is often significant enough to interfere with initial recovery and rehabilitation − the pain that can be difficult to manage without large-dose opioids. Opioids can cause nausea, vomiting, sedation, and/or failure to control pain. Supplementing general anesthesia with a regional nerve block might improve the quality of postoperative pain relief. The use of interscalene blockade (ISB) is gaining popularity, but it is associated with infrequent but potentially serious complications. Combined suprascapular nerve block and axillary nerve block (SSNB+ANB) can offer a safe alternative to ISB.
This study was designed to compare between ISB and SSNB+ANB in arthroscopic shoulder surgery as regards postoperative analgesia
Patients and methods
Sixty American Society of Anesthesiologist physical status I and II patients, aged between 18 and 40 years, scheduled for arthroscopic shoulder surgery were randomized to receive ISB or SSNB+ANB. After performing the blocks, general anesthesia was standardized in all groups. All the patients in the two groups were compared as regards postoperative pain assessed by the visual analog scale score at postanesthesia care unit, 4, 6, 12, and 24 h, occurrence of complications, and patient’s satisfaction.
In the postoperative period, there were no statistically significant differences between the two groups as regards visual analog scale and analgesic requirements. Complications such as Horner’s syndrome, hoarseness of voice, major weakness of the upper arm, and dyspnea were recorded in the ISB group.
For certain procedures of shoulder arthroscopic surgery, SSNB+ANB is a safe and effective alternative to ISB as postoperative analgesia.
Keywords: arthroscopic shoulder surgery, axillary nerve block, interscalene block, suprascapular nerve block
|How to cite this article:|
Waleed A. Postoperative analgesia for arthroscopic shoulder surgery: comparison between ultrasound-guided interscalene block and combined suprascapular and axillary nerve blocks. Ain-Shams J Anaesthesiol 2016;9:536-41
|How to cite this URL:|
Waleed A. Postoperative analgesia for arthroscopic shoulder surgery: comparison between ultrasound-guided interscalene block and combined suprascapular and axillary nerve blocks. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Sep 23];9:536-41. Available from: http://www.asja.eg.net/text.asp?2016/9/4/536/198260
| Background|| |
Severe intraoperative and postoperative pain associated with arthroscopic shoulder surgery has high incidence reaching up to 45%; it is often significant enough to interfere with initial recovery and rehabilitation . This pain is difficult to manage without large-dose opioids.
Opioids have many adverse effects including nausea, vomiting, sedation, and/or failure to control pain. Adding regional nerve block to general anesthesia (GA) may improve the quality of postoperative pain relief . The use of interscalene block (ISB) for postoperative pain relief is gaining popularity; this block is associated with infrequent but potentially serious complications such as diaphragmatic paralysis, hoarseness of voice, Horner’s syndrome, and pneumothorax. These may be because of inadvertent injection of local anesthetic into the cerebrospinal fluid, the epidural space, or the vertebral artery. Its associated side effects are more common because of unpredictable spread of local anesthetic to important adjacent structures such as the phrenic and vagus nerves and the stellate ganglion. ISB is associated with transient postoperative neurological complications .
Combined suprascapular nerve block and axillary nerve block (SSNB+ANB) can offer a safe alternative to ISB. Many studies have evaluated the efficacy of SSNB to determine intraoperative and postoperative pain relief in patients undergoing shoulder arthroscopy under GA .
The brachial plexus supplies all the motor and most of the sensory functions of the shoulder . The terminal branches of the brachial plexus that supply the majority of the shoulder innervation are the SSN and AN. Suprascapular nerve arises from the superior trunk of the brachial plexus, C5–C6, and possibly C4; it descends posteriorly, passing through the scapular notch, innervating the supraspinatus and infraspinatus muscles. The axillary nerve originates from C5–C6 nerve roots, with occasional contribution from C4. It is derived from the posterior cord of the brachial plexus, and it crosses the anteroinferior aspect of the subscapularis muscle where it crosses posteriorly through the quadrilateral space and divides into two trunks: anterior and posterior.
The anterior portion of the glenohumeral articular capsule, the subscapular muscles, and the acromioclavicular articulation are not supplied by SSNB+ANB.
The aim of this randomized, controlled study was to compare between ISB and SSNB+ANB in arthroscopic shoulder surgery as regards postoperative analgesia, patient satisfaction, and incidence of complications.
| Patients and methods|| |
After obtaining approval from Ain Shams University Hospital Ethics Committee, 60 American Society of Anesthesiologist physical status I and II patients, aged between 18 and 40 years, scheduled for arthroscopic shoulder surgery were included in this prospective, randomized controlled study. Randomization of patients was performed using sealed envelope design. The study was conducted from June 2014 to May 2015.
Exclusion criteria included allergy to local anesthetic; patients with a history of neurological, psychiatric, or cardiopulmonary disease; patients with a history of diabetic neuropathy or bleeding tendency; and those with a BMI greater than 35 kg/m2.
Informed written consents were obtained from all patients who were recruited for the study in preoperative visit at least 1 day before surgery; the study protocol was explained to each patient who received information about how to use a visual analog scale (VAS) that consisted of an unmarked 100 mm line, with 0 mm representing no pain and 100 mm representing the worst pain imaginable.
Patients were divided into two groups: the ISB group and the SSNB+ANB group. The ISB group comprised 30 patients who received ISB while the patient was in the supine position with the head facing away from the side to be blocked. Scanning with a 38 mm broadband linear ultrasound probe GE Healthcare, LOGIQ C3 Premium (GE Healthcare, Wauwatosa, Wisconsin, USA) was started just below the level of the cricoid cartilage medial to the sternocleidomastoid muscle; the skin was disinfected and the transducer was positioned in the transverse plane to identify the carotid artery. Once the artery was identified, the transducer was moved slightly laterally across the neck to identify the scalene muscles and the brachial plexus that is present between the anterior and middle scalene muscles. The needle was then inserted in-plane toward the brachial plexus, in a lateral-to-medial direction. After a careful aspiration, 20 ml of levobupivacaine 0.25% was injected.
The SSNB+ANB group comprised 30 patients who received SSNB+ANB.
The patient was in the sitting position with the arm in full adduction.
Suprascapular nerve block
After cleaning the skin with an antiseptic solution, an ultrasound probe was put in sagittal orientation at the superior medial border of the scapula to identify the pleura and then moved laterally; when it was parallel to the spine of the scapula, the transducer was moved cephalad and the suprascapular fossa was identified, and then the transducer was moved lateral to locate the suprascapular notch. The suprascapular nerve was a round hyperechoic structure beneath the transverse scapular ligament in the scapular notch. The needle was inserted along the longitudinal axis of the ultrasound beam, and 10 ml of levobupivacaine 0.25% was injected.
Axillary nerve block
After cleaning the skin with an antiseptic solution, the ultrasound probe was put to image the posterior surface of the humerus in its long-axis and short-axis views of the circumflex artery and the axillary nerve, and 10 ml of levobupivacaine 0.25% was injected on the posterior surface of the humerus.
After performing the blocks, GA was standardized in all groups using propofol 2 mg/kg and fentanyl 1 µg/kg. Tracheal intubation was facilitated using cisatracurium 0.15 mg/kg; maintenance of anesthesia was with 50 : 50% O2 and air with isoflurane, and cisatracurium. Heart rate and blood pressure were measured on arrival in the operating room and every 5 min after blockade until the end of surgery. Blood pressure and/or heart rate more than 30% from baseline was considered a failed block, and patients received another dose of fentanyl and were excluded from the study. Postoperatively, all patients received ketorolac 30 mg intravenously every 12 h and morphine 5 mg intramuscularly when the VAS score for pain exceeded 30 mm, as rescue analgesia.
Postoperative pain was measured using mean VAS score in both groups at postanesthesia care unit (PACU), at 4, 6, 12, and 24 h. Postoperative complications either related to technique of nerve block (pain with needle insertion, dyspnea, hoarseness of voice, Horner’s syndrome, major weakness of upper arm) or use of opioids [postoperative nausea and vomiting (PONV)] are measured as the number of patients and percent. Patients’ satisfaction was categorized as poor, fair, good, or excellent and measured also as the number of patients and percent.
Before starting the study, a power analysis was performed to determine the minimal acceptable number of patients in each group based on the weakness of the upper arm score. The minimal sample number was 26 patients for each group with a two-sided type one error of 0.05 and study power at 90%, and thus the group number was increased to 30 to compensate for any possible dropouts. Data were collected, coded, and analyzed using SPSS version 12.0 computer software (SPSS Inc., Chicago, Illinois, USA). Numerical variables were presented as mean±SD, whereas categorical variables were presented as the number of cases and percent. Comparisons of numerical variables were performed with unpaired Student’s ‘t’ test, whereas comparisons of categorical variables were performed by χ2-test. The probability of error at 0.05 was considered significant.
| Results|| |
There were no statistically significant differences between the two groups as regards age, height, weight, sex, American Society of Anesthesiologist physical status, and duration of surgery ([Table 1]).
Postoperative pain assessment showed no statistically significant differences between the two groups of the study as regards the VAS ([Table 2] and [Figure 1]).
|Figure 1: Comparison between the two studied groups as regards VAS. PACU, postanesthesia care unit; VAS, visual analog scale.|
Click here to view
In the current study, VAS remained less than 30 mm until the sixth hour postoperatively.
After 6 h, each of the six patients in the ISB group required a dose of rescue analgesia (in the form of 5 mg morphine intramuscularly), whereas in the SSNB+ANB group eight patients each received the same dose of rescue analgesia with a subsequent decrease in VAS.
A second dose of rescue analgesia was needed in between the 12th and 24th hour postoperatively for eight patients in the ISB group and 10 patients in the SSNB+ANB group ([Table 3]).
Complications were recorded in the ISB group: dyspnea occurred in four patients (13.33%), Horner’s syndrome occurred in five patients (16.67%), hoarseness of voice occurred in two patients (6.67%), major weakness of the upper arm occurred in 16 patients (53.33%), pain during needle entry occurred in three patients (10%), and PONV occurred in two patients (6.7%).
On the other hand, fewer number of complications were recorded in the SSNB+ANB group: pain during needle entry occurred in five patients (16.67%) and PONV occurred in four patients (13.33%) ([Table 4]).
In the current study, no bilateral spread, pneumothorax, or convulsions had been recorded in both groups.
Finally, as regards patient satisfaction, there were no statistically significant differences (P>0.05) between the two groups ([Table 5]).
| Discussion|| |
Pain control is a challenge during shoulder surgery, even when using arthroscopic approaches. Pain is one of the major factors that can influence hospital discharge. By eliminating pain, we can reduce the mean length of hospital stay after GA.
The current clinical study was designed to compare between ISB and SSNB+ANB in arthroscopic shoulder surgery regarding postoperative analgesia, incidence of complications, and patient satisfaction.
In the current study, postoperative pain assessed by the VAS score showed no significant statistical differences between the two groups of the study. We noticed that mean VAS score remained less than 30 mm until the sixth hour postoperatively. After 6 h, six patients in the ISB group and eight patients in the SSNB+ANB group required a dose of rescue analgesia (in the form of 5 mg morphine intramuscularly) with a subsequent decrease in the mean VAS score. A second dose of rescue analgesia was needed in between the 12th and 24th hour postoperatively in eight patients in the ISB group compared with 10 patients in the SSNB+ANB group.
In a study by Lee et al. , the analgesic effect of ISB in comparison with SSNB+ANB was studied in patients under patient-controlled analgesia (PCA) in arthroscopic shoulder surgery. The VAS score of the PCA in the ISB group was significantly lower than that of the PCA in the SSNB+ANB group in the recovery room. At the 16 h postoperative evaluation, significant differences were found between the PCA in the ISB group and PCA in the SSNB+ANB group; however, there were large fluctuations in the results over time in the ISB group and the VAS score of the PCA with SSNB+ANB group was not significantly higher than that of the PCA in the ISB group; such a trend was persistent throughout the evaluation process without time-related fluctuations. In the current study, there were no significant fluctuations in the results of the two groups over time, and they concluded that SSNB+ANB is a good alternative to ISB as a postoperative method of analgesia.
As regards SSNB+ANB, Checcucci et al.  reported a low VAS score especially at 12 and 24 h. Fifteen out of 20 patients reported mild to moderate pain after 6 h postoperatively and were successfully treated with intravenous ketorolac 30 mg.
In another study, assessment of the analgesic effect of ISB, SSNB, and intraarticular local anesthetic after arthroscopic acromioplasty showed that in the PACU and at the 4 h follow-up, significantly less pain on movement was noted in the ISB group when compared with the SSNB group, with no difference in the total paracetamol consumption. However, significantly more patients in the SSNB group received morphine analgesia compared with the ISB group (19 from 30 patients vs. eight from 30 patients); this is mostly because of the lack of ANB .
In a study by Brown et al. , a comparison was made between ISB and GA for shoulder arthroscopy; 5% of patients developed a Horner’s syndrome and 6% complained of hoarseness (recurrent laryngeal nerve block), which was transient and resolved without any subjective complaints.
Another study reported that 33.3% of patients complained of Horner’s syndrome signs. In all these patients, the signs were noticed after ISB by about 30 min, and all patients were free before leaving the PACU. This high percent may be because of the performance of the block without ultrasound guidance .
Another study compared ISB and selective SSNB+ANB, and it was reported that ISB resulted in paralysis of the shoulder girdle, upper arm, and even extended to the forearm and hand, which caused many patients to feel discomfort; in comparison, motor blockade was limited to the posterior rotator cuff muscles and deltoid muscle in selective technique .
Similar to the results of the current study, Singelyn et al.  reported that patient satisfaction in the ISB was 87%. Another study demonstrated that patient satisfaction was 99.06% with the ISB .
In contrast to the current study, Lee et al.  reported that the degree of patient satisfaction of the PCA in the ISB group was significantly higher than that of the PCA in the SSNB+ANB group in the recovery room. In agreement with the current study, at 8, 16, and 24 h postoperative evaluations, degrees of satisfaction between the two groups were not significantly different.
| Conclusion|| |
The use of SSNB+ANB is a safe and effective alternative to ISB as regard postoperative analgesia for certain arthroscopic shoulder surgeries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]