Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study

Is It the Surgery or the Block? Incidence, Risk Factors, and Outcome of Nerve Injury following Upper Extremity Surgery

Although numerous studies have addressed the topic of postoperative nerve injury, debate continues to exist on its exact incidence, risk factors, etiology, and functional outcome. The aim of this study is to investigate the incidence of nerve injury and to identify patient, anesthetic, and surgical factors pertaining to perioperative nerve injury. Also, long-term nerve injury outcomes were assessed in terms of functionality.

Methods

A total of 297 patients, scheduled for elective distal upper extremity surgery, were prospectively included. At various time points, patients were screened for new onset nerve injury by means of clinical examination and questionnaires (including the Quick Disabilities of the Arm, Shoulder and Hand functionality measure).

Results

New nerve injury was diagnosed in 14 patients [4.7% (95% CI, 2.8-7.8)], but no causative risk factors were identified. The exact origin of nerve injury is suspected to be surgical in 11 cases. At 4 years postoperatively, 5 of the 14 patients with nerve injury (36%) were still symptomatic and had reduced functionality relative to preoperative status.

Conclusions

This study demonstrates an incidence of all cause nerve injury of 4.7%. No specific patient, anesthetic, or surgical risk factors are identified and, importantly, patients who received regional anesthesia are not at more risk of nerve injury than those who received general anesthesia. The exact origin of nerve injury is very difficult to determine, but is suspected to be caused by direct surgical trauma in most cases. Four years following the nerve injury, approximately 40% of the patients with new onset nerve injury have reduced functionality.

Mini-invasive methods of treatment of diabetic foot pain

Neuropathic pain occurs with diabetic polyneuropathy more often than with all polyneuropathies of another etiology. Because the cause of pain can rarely be cured, treatment is usually symptomatic. Neuropathic pain is usually poorly controlled by analgesics. Management of neuropathic pain is started with conservative pharmacotherapy before invasive pain management is applied. Although there are many drugs that can be used in patients with diabetic pain syndrome, pain syndrome can not be surely stoped with monotherapy. In addition, the patient may not tolerate the full therapeutic dose of the drug. All this dictates the need for combination therapy. It is believed that regional anesthesia as an independent type of analgesia or a component of combined anesthesia is the method of choice for the elderly and senile patients. The main reasons for this choice, when comparing regional anesthesia with narcosis, are less stressful response of the organism, absence of depression of the central nervous system, stable reliable analgesia with complete blockade of nociceptive reflexes with the provision of adequate muscle relaxation, prevention of neurovegetative reactions, which ultimately helps to reduce the incidence of postoperative complications and mortality. Clinicians have accumulated considerable experience demonstrating the need for regional analgesia in the management of diabetic foot pain.

Incidence of clinically evident isolated axillary nerve injury in 869 primary anatomic and reverse total shoulder arthroplasties without routine identification of the axillary nerve

Background

It has been suggested that, during primary shoulder arthroplasty, surgeons should identify the axillary nerve through direct visualization, palpation, or the “tug test” to prevent iatrogenic nerve injury. Our goal was to document the rate of isolated axillary nerve injury (IANI) in patients who had undergone primary anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) without routine identification of the axillary nerve.

Methods

Data on 869 cases of primary shoulder arthroplasty (338 TSAs and 531 RTSAs) performed by 1 surgeon between 2003 and 2017 were reviewed. Neither the tug test nor identification of the axillary nerve through palpation or visualization was used in any case. The primary outcome was new IANI documented within 3 months after arthroplasty. The frequency of IANI was summarized using point estimates and 95% confidence intervals (CIs).

Results

Six cases met the criteria for IANI. The overall incidence of IANI was 0.7% (95% CI, 0.3%-1.4%). The incidence of IANI was 0.3% (95% CI, 0%-1.6%) after TSA and 0.9% (95% CI, 0.3%-2.1%) after RTSA. All IANIs were cases of neurapraxia, and all patients had experienced complete neurologic recovery at last follow-up.

Conclusion

Complete, permanent IANI resulting from direct surgical trauma during primary shoulder arthroplasty can be avoided without using the tug test or routine identification of the nerve. A low incidence of partial temporary IANI can be expected, which may be related to indirect traction injuries.

The Ultrasound Anatomy of Nerves in the Interscalene Groove: Can We Reliably Distinguish the Nerve Structures for Needle Placement During Nerve Blocks?

In the interscalene groove, nerve structures are in close proximity and may not be visible as separate structures, increasing the risk of insertion of the needle tip within the epineurium. We evaluated whether experienced regional anesthesiologists can distinguish between nerve elements lying in close proximity on ultrasound images.Brachial plexus elements from 4 nonpreserved cadavers were arranged in a water bath. Ultrasound images of the nerve roots and trunks were taken. Regional anesthesiologists and residents were asked whether they could distinguish the nerves as 2 separate structures and if they could identify a pair of nerve roots versus a single trunk.Attending anesthesiologists reported the ability to discriminate 2 nerve structures when a 2-mm space was arranged between them in 54% of images; however, when in direct contact, this recognition was significantly lower. The residents reported a higher ability to discriminate the 2 nerves in all scenarios. In addition, the attending anesthesiologists successfully identified paired nerve roots versus nerve trunks in 70% of the images, significantly higher than chance (P = 0.01), whereas the fraction of correct resident responses was not significantly different from guessing.When nerves were placed in close proximity, experienced regional anesthesiologists had difficulty identifying them as separate structures and were incorrect nearly one-third of the time in discriminating 2 closely positioned roots versus a nerve trunk. This underscores the importance of cautious needle insertion into the interscalene groove, where nerve elements are often juxtaposed one to another.

Long-Term Neurological Complications Associated with Surgery and Peripheral Nerve Blockade: Outcomes after 1065 Consecutive Blocks

Peripheral nerve blockade is gaining popularity as an analgesic option for both upper or lower limb surgery. Published evidence supports the improved efficacy of regional techniques when compared to conventional opioid analgesia. The incidence of neurological deficit after surgery associated with peripheral nerve block is unclear. This paper reports on neurological outcomes occurring after 1065 consecutive peripheral nerve blocks over a one-year period from a single institution. All patients receiving peripheral nerve blocks for surgery were prospectively followed for up to 12 months to determine the incidence and probable cause of any persistent neurological deficit. Formal independent neurological review and testing was undertaken as indicated. Thirteen patients reported symptoms that warranted further investigation. A variety of probable causes were identified, with peripheral nerve block being implicated in two cases (one resolved at nine months and one remaining persistent). Overall incidence of block-related neuropathy was 0.22%.

Persistent postoperative neuropathy is a rare but serious complication of surgery associated with peripheral nerve block. Formal follow-up of all such blocks is recommended to assess causality and allow for early intervention.

'SCALD-ED' Block: Superficial Cutaneous Anesthesia in a Lateral Leg Distribution within the Emergency Department - A Case Series

BACKGROUND

In the midst of a nationwide opioid epidemic, focus has been placed on identifying and utilizing safe, effective opioid-free analgesic alternatives. Lower-extremity peripheral nerve blockades are common and often involve both motor and sensory anesthesia, resulting in leg weakness and ambulatory difficulty. The aim of this case report is to describe an ultrasound-guided peripheral nerve block technique (superficial cutaneous anesthesia in a lateral (leg) distribution within the emergency department ['SCALD-ED' block]) that provides motor-sparing, purely sensory anesthesia after a superficial injury to the lateral leg in patients presenting to the emergency department.

DISCUSSION

Two separate patients presenting with lateral leg pain after superficial injury (burn, cellulitis) reported continued breakthrough pain despite a standard analgesic modality of combination acetaminophen and ibuprofen. With the patient placed in prone position for ultrasound-guided access to lower-extremity nerve branches, the lateral sural cutaneous nerve (LSCN) was identified by tracing its pathway from the proximal sciatic nerve to the common peroneal (fibular) nerve to the superficial peroneal (fibular) nerve. Five mL of lidocaine (1%, with epinephrine) was injected along the superficial LSCN route for anesthetic blockade. Temporal assessments of anesthetic effect and pain improvement, and monitoring of motor or ambulatory impairment were conducted at regular intervals to assess the efficacy and feasibility of the blockade. Regional anesthesia along the LSCN sensory distribution was experienced at 7-9 min post blockade. Peak analgesic effect was experienced at 25-29 min. The duration of anesthesia was 120-150 min. A negligible amount of delayed sensory anesthesia was noted along the distal sural nerve distribution. No motor deficit, ambulatory difficulty, or adverse effects were experienced in either patient post blockade.

CONCLUSION

The LSCN is an identifiable target under ultrasound guidance, susceptible to localized, purely sensory blockade of pain from superficial cutaneous lateral leg injuries.

Effects of Intraneural Injection of Dexmedetomidine in Combination With Ropivacaine in Rat Sciatic Nerve Block

BACKGROUND AND OBJECTIVES

Dexmedetomidine is known to have neural protection effect via attenuation of inflammatory responses induced by local anesthetics. We investigated whether intraneural dexmedetomidine is effective for attenuating or preventing neural injury resulting from inadvertent intraneural injection of local anesthetic.

METHODS

Rats were randomly divided, and left sciatic nerve was surgically exposed. The rats received no injection (control group) or intraneural injections of 0.2 mL of normal saline (saline group), 0.2 mL of 0.5% ropivacaine (ropivacaine group), or 0.2 mL of 0.5% ropivacaine and 0.5 μg/kg of dexmedetomidine (ropivacaine plus dexmedetomidine group). Interleukin (IL)-6 and IL-1β messenger RNA (mRNA) levels were detected at 60 minutes after intraneural injection in experiment 1 (5 per group). Sensory and motor functions were assessed until the return of normal sensory and motor functions, and histopathological and ultrastructure analysis were performed at 4 weeks after intraneural injection in experiment 2 (8 per group).

RESULTS

Dexmedetomidine with ropivacaine better enhanced sensory and motor blockade than ropivacaine alone. IL-6 (3.2 ± 1.0 vs 5.9 ± 2.1), IL-1β (1.1 ± 0.1 vs 2.2 ± 0.7) levels, scores of axon and myelinated fiber degeneration (1 [0-2] vs 2 [1-3]), and demyelinated fiber percentages (20.1 ± 10.4 vs 48.3 ± 12.7) were lower in the ropivacaine plus dexmedetomidine group than in the ropivacaine group. No animals showed any signs of permanent neurological deficit.

CONCLUSIONS

Intraneural dexmedetomidine has sensory and motor blockade-enhancing effects, anti-inflammatory properties, and protective effects against neural injury. These findings suggest that dexmedetomidine as an adjuvant has beneficial effects in rat when intraneural injection of local anesthetic occurs.

Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade

Background and Objectives

The exact mechanism of peripheral nerve blocks causing/leading to nerve injury remains controversial. Evidence from animal experiments suggests that intrafascicular injection resulting in high injection pressure has the potential to rupture nerve fascicles and may consequently cause permanent nerve injury and neurological deficits. The B-Smart (BS) in-line manometer and the CompuFlo (CF) computerized injection pump technology are two modalities used for monitoring pressure during regional anesthesia. This study sought to explore the accuracy of these two technologies in measuring needle-tip pressures in a simulated environment.

Methods

In seven simulated needle–syringe combinations, the BS and the CF devices were connected in series through a closed system and attached to a digital manometer at the tip of various needles. The pressures were evaluated in three trials per needle-syringe combination. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (F1 Score) were determined for each needle type and overall.

Results

For pressures ≥15 psi and ≥20 psi, respectively, the CF device demonstrated a sensitivity of 100%, 100%; specificity of 96%, 98%; positive predictive value 93%, 93%; and negative predictive value of 100%, 100%. The BS device demonstrated a sensitivity of 60%, 100%; specificity of 99%, 95%; positive predictive value of 96%, 85%; and negative predictive value of 85%, 100%. Accuracy, as measured by the F1 Score, for detecting a pressure of ≥15 psi was 0.96 for the CF and 0.74 for the BS.

Conclusions

Future research is needed to explore in-vivo performance and evaluate whether either of these devices can impact on clinical outcomes.

Updated Retrospective Single-Center Comparative Analysis of Peripheral Nerve Block Complications Using Landmark Peripheral Nerve Stimulation Versus Ultrasound Guidance as a Primary Means of Nerve Localization

OBJECTIVES

The purpose of this study was to perform an updated analysis of complications associated with upper and lower extremity peripheral nerve blocks (PNBs) performed with ultrasound (US) guidance versus the landmark approach.

METHODS

We conducted a single-center retrospective cohort analysis to compare the incidence of PNB complications between the techniques. The primary outcome was local anesthetic systemic toxicity (LAST), whereas the secondary outcomes included short- and long-term nerve injuries. The current query included cases performed between 2012 and 2015. A combined analysis included data extending to 2006. The Statistical examination relied on the χ² test.

RESULTS

During this 4-year period, we performed 7789 US-guided and 498 landmark-guided blocks with no statistically significant difference in the incidence of nerve injury or LAST between the groups. Our 10-year analysis, however, revealed a significant increase (P < .01) in the rate of LAST with the landmark technique: 7 of 5932 versus 0 of 16,858 cases. The combined data also revealed a significant increase (P < .01) in short-term injuries associated with the landmark approach (30 of 5932 versus 33 of 16,858) but no significant difference in the incidence of long-term injuries.

CONCLUSIONS

Our analysis supports a conclusion that the use of US guidance during PNBs leads to a significant reduction in the incidence of LAST, adding to growing evidence from similar investigations. The impact of US on the incidence of nerve injuries remains unclear, considering that the nature of transient deficits is thought to be multifactorial, and the frequency of lasting injuries did not differ significantly in this study.

Dry Catheter Technique in Shoulder Arthroplasty

Introduction

Interscalene regional anesthesia is effective for pain management but is not without complications. To determine whether postoperative neurologic findings were related to the surgery versus the regional catheter, we developed the dry catheter technique where patients could be examined after the surgery prior to dosing the catheter. The purpose of the study was to assess the utility of the dry catheter block in recognizing neurological deficits associated with regional anesthesia.

Methods

An interscalene catheter was placed but not started. After the surgery, a neurovascular examination was performed. If the examination was normal, the regional anesthesia was started. Throughout the patient’s hospitalization, pain levels were collected.

Results

A total of 125 shoulders were studied. There were 9 postoperative nerve-related complications. The patients experienced the most pain relief in the first 12 hours.

Conclusion

The dry catheter technique allows differentiation between complications associated with regional anesthesia versus those associated with the surgery. Although interscalene anesthesia provided effective pain control, we stopped using it because we felt its complication rate was too high.

Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons

The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].

Interscalene brachial plexus bolus block versus patient-controlled interscalene indwelling catheter analgesia for the first 48 hours after arthroscopic rotator cuff repair

BACKGROUND

We sought to compare the efficacy of interscalene brachial plexus bolus blockade (IBPBB) and patient-controlled interscalene indwelling catheter analgesia (PCIA) for postoperative pain management within 48 hours postoperatively in patients undergoing arthroscopic rotator cuff repairs (ARCR).

METHODS

Patients undergoing ARCR were randomized into 3 groups by postoperative analgesia method. The IBPBB group received a mixed solution of 16 mL of 0.75% ropivacaine and 4 mL of 2% lidocaine as a bolus postoperatively. The PCIA group received a 10-mL bolus solution of 0.75% ropivacaine (4 mL) and 5% dextrose water (6 mL) just after the operation and continuous infusion of this solution. The control received only meperidine as needed, 12.5 mg, intravenously. Visual analog scale (VAS) pain scores were evaluated for the first 48 hours postoperatively.

RESULTS

For the first 2 hours postoperatively, VAS scores in the IBPBB group were significantly lower than in the PCIA group and control group, but at 12 and 24 hours postoperatively, VAS scores of the IBPBB group were significantly higher than the PCIA group (P < .05). At 48 hours postoperatively, there was no significant difference in VAS scores among the 3 groups (P = .169). The method of analgesia was the only factor affecting pain scores at 24 hours postoperatively (P < .05).

CONCLUSIONS

IBPBB provided effective immediate postoperative analgesia until 6 hours postoperatively. Especially until postoperative 2 hours, the VAS pain score was less than 1 point in the IBPBB group; however, there was significant rebound pain at 12 hours after surgery. During the first 24 hours postoperatively, PCIA reduced postoperative pain without rebound pain. Surgeons should choose methods for control of postoperative pain considering the advantages and disadvantages of each analgesic method.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Complications After Multiple-Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone

BACKGROUND

Single or combined multiple-site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks.

METHODS

Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later.

RESULTS

Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients' last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks.

CONCLUSION

There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple-site blocks did not increase the rate of neurologic complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Distal Mononeuropathy Before and After Arthroscopic Rotator Cuff Repair: A Prospective Investigation

PURPOSE

The purpose of this study was to characterize the occurrence of distal mononeuropathy (DMN) in patients before and after arthroscopic rotator cuff repair (RCR) as well as resolution of the symptoms.

METHODS

One hundred one patients over the age of 18 undergoing arthroscopic RCR +/- concurrent procedures completed a questionnaire regarding the presence of a symptomatic DMN. Patients with history of diabetic neuropathy, cervical radiculopathy, brachial plexopathy, or Spurling sign were excluded. All patients underwent physical examination to determine the characteristics and location of symptoms. Postoperatively, patients underwent repeat examination at 2, 6, and 12 weeks.

RESULTS

Preoperatively, 19% (19/101) of RCR patients described DMN symptoms (9 median nerve symptoms, 5 ulnar nerve symptoms, 4 nonspecific symptoms, one with both ulnar and median nerve symptoms). Ninety percent (17/19) patients with preoperative DMN symptoms described resolution within the final 12 weeks of follow-up. A portion of previously asymptomatic RCR patients (12/82) developed new DMN symptoms (6 nonspecific symptoms, 3 ulnar nerve symptoms, 2 median nerve symptoms, one radial sensory nerve symptoms) postoperatively, with 92% (11/12) having resolution by the final 12-week follow-up. At the final 12 weeks, 3 RCR patients had DMN symptoms with 2 of those 3 patients having their symptoms existing preoperatively.

CONCLUSIONS

This study supports the hypothesis that DMN can be a preexisting finding in patients undergoing arthroscopic RCR. Similarly, it is common for patients undergoing arthroscopic RCR to develop new DMN symptoms following their procedure. Regardless, there is good evidence to show that a large majority of both groups of patients will go on to have resolution of their symptoms.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Peripheral nerve blocks of the pelvic limb in dogs: A retrospective clinical study

Objective: To evaluate the success rate and complications of lumbar plexus (LP) and femoral nerve (FN) blocks, each combined with a sciatic nerve (SN) block, in dogs undergoing pelvic limb orthopaedic surgery.

Design: Retrospective clinical study.

Procedure: The intra-operative and postoperative clinical records of dogs that underwent orthopaedic surgery of the pelvic limb were reviewed. Dogs were divided into two groups according to the analgesic technique used during surgery: dogs that received a peripheral nerve block (group PNB) and dogs in which opioid analgesia alone was used (group C).

Results: The PNB and C groups included 265 and 31 dogs, respectively. Complete statistical analysis was performed in 115/265 dogs of PNB group. The overall success rate of the PNB performed was 77% (89/115): 76% (72/95) and 85% (17/20) for LP-SN and FN-SN blocks, respectively. In group PNB, the prevalence of intra-operative hypotension was 7.8% (9/115). Only one (out of 95 [1.05%]) LP-SN block manifested transient postoperative bilateral pelvic limb paralysis. None of the 265 dogs in group PNB manifested neurological complications at six weeks postoperatively.

Conclusion: The success rate and the absence of neurological complications obtained support the use of LP-SN and FN-SN for loco-regional anaesthesia and analgesia in dogs undergoing orthopaedic surgery of the pelvic limb.

Liposomal Bupivacaine Mixture Has Similar Pain Relief and Significantly Fewer Complications at Less Cost Compared to Indwelling Interscalene Catheter in Total Shoulder Arthroplasty

BACKGROUND

The efficacy and costs of indwelling interscalene catheter (ISC) and liposomal bupivacaine (LBC), with and without adjunctive medications, in patients with primary shoulder arthroplasty are a source of current debate.

METHODS

In 214 arthroplasties, 156 patients had ISC and 58 had LBC injections that were mixed with morphine, ketorolac, and 0.5% bupivacaine with epinephrine. Charts were reviewed for visual analog scale pain scores, oral morphine equivalent (OME) usage, major complications, and costs.

RESULTS

Visual analog scale scores were not significantly different at 24 hours or at 2, 6, and 12 weeks. Average OME consumption at 24 hours was significantly more with LBC, but was not significantly different at 12 weeks. Relative risk of a major complication was nearly 4 times higher with ISC than with LBC. The average cost for the LBC mixture was $289.04, and for ISC, including equipment and anesthesia fees, was $1559.42.

CONCLUSION

The intraoperative LBC mixture provided equivalent pain relief with significantly fewer major complications and at markedly lower cost than ISC. LBC required almost twice as much OME to attain the same level of pain relief at 24 hours, but there was no significant difference in the cumulative amount of outpatient narcotic use.

Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block

Postoperative pain control is a significant concern after total shoulder arthroplasty. Injectable periarticular liposomal bupivacaine, which has been found to decrease opioid use after orthopedic procedures, has been proposed as a viable alternative to regional anesthesia. This study compared the efficacy of liposomal bupivacaine vs interscalene block among patients undergoing total shoulder arthroplasty. A retrospective review was conducted of 79 patients who underwent anatomic total shoulder arthroplasty performed by a single surgeon between January 2013 and April 2015. Patient demographics, in-hospital Numeric Pain Rating Scale (NPRS) score obtained at 12-hour intervals, length of stay, and total in-hospital morphine equivalents in both the bupivacaine (n=25) and block (n=44) groups were recorded. Differences in length of stay, morphine equivalents, and age were assessed with Wilcoxon tests. Sex differences were assessed with the chi-square test. Repeated measures analysis with least square means was used to assess longitudinal changes in NPRS scores. No significant differences were found between groups for sex (P=.89), age (P=.81), American Society of Anesthesiologists classification (P=.50), preoperative opioid use (P=.41), length of stay (P=.32), or morphine equivalents (P=.71). The average NPRS score in the first 12 hours was 3.01 for the bupivacaine group and 4.41 for the interscalene block group (P=.25). By 48 hours postoperatively, average NPRS scores were similar (P=.93) for the 2 groups, 4.90 for the bupivacaine group and 4.19 for the interscalene block group. The findings for this cohort of patients undergoing anatomic total shoulder arthroplasty showed no significant difference for pain scores, postoperative narcotic use, or length of stay with injectable liposomal bupivacaine vs interscalene block. [Orthopedics. 2017; 40(5):e806-e811.].

Pain Management After Outpatient Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction.

PURPOSE

This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery.

STUDY DESIGN

Systematic review.

METHODS

We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures.

RESULTS

A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction.

CONCLUSION

On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.

Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation: A lesson why we should use low concentrated local anesthetics for continuous blocks

RATIONALE

Recurrent laryngeal nerve block is an uncommon complication that can occur after an interscalene brachial plexus block (ISB), which may lead to vocal cord palsy or paresis. However, if the recurrent laryngeal nerve is blocked in patients with a preexisting contralateral vocal cord palsy following neck surgery, this may lead to devastating acute respiratory failure. Thus, ISB is contraindicated in patients with contralateral vocal cord lesion. To the best of our knowledge, there are no reports of bilateral vocal cord paresis, which occurred after a continuous ISB and endotracheal intubation in a patient with no history of vocal cord injury or surgery of the neck.

PATIENT CONCERNS

A 59 year old woman was planned for open acromioplasty and rotator cuff repair under general anesthesia. General anesthesia was induced following an ISB using 0.2% ropivacaine and catheter insertion for postoperative pain control.

DIAGNOSES

While recovering in the postanesthesia care unit (PACU), however, the patient complained of a sore throat and hoarseness without respiratory insufficiency. On the morning of the first postoperative day, she still complained of mild dyspnea, dysphonia, and slight aspiration. She was subsequently diagnosed with bilateral vocal cord paresis following an endoscopic laryngoscopy examination.

INTERVENTIONS

The continuous ISB catheter was immediately removed and the dyspnea and hoarseness symptoms improved, although mild aspiration during drinking water was still present.

OUTCOMES

On the 4th postoperative day, a laryngoscopy examination revealed that the right vocal cord movement had returned to normal but that the left vocal cord paresis still remained.

LESSONS

When ISB is planned, a detailed history-taking and examination of the airway are essential for patient safety and we recommend that any local anesthetics be carefully injected under ultrasound guidance. We also recommend the use of low concentration of local anesthetics to avoid possible paralysis of the vocal cord.

Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay

BACKGROUND

Brachial plexus block has been associated with improved pain control and decreased length of stay in patients undergoing upper extremity arthroplasty. Continuous delivery is associated with a shorter length of stay; however, comparisons to single-shot delivery in this setting are scarce. As the paradigm shifts to outpatient arthroplasty in the era of bundled payments, there exists a strong impetus to identify the most effective mode of analgesia associated with the least risk to patients.

METHODS

This is a retrospective review of 697 patients undergoing upper extremity arthroplasty comparing the rate of complications and incidence of potential barriers to discharge and length of stay of patients receiving continuous vs. single-shot perineural brachial plexus block.

RESULTS

No difference was observed in the complication rate between indwelling (n = 63 [12%]) and single-shot groups (n = 30 [17%]; P = .137). The majority of complications were pulmonary, 72% attributable to oxygen desaturation. The indwelling catheter group had 1.61 times higher odds (95% confidence interval, 1.07-2.42; P = .023) of exhibiting any potential barrier to discharge and exhibited a longer length of stay (P = .002).

CONCLUSION

There was no demonstrated disparity in the rate of complications associated with single-shot vs. continuous brachial plexus block. However, the continuous indwelling catheter was associated with an increased incidence of potential barriers to discharge and an increased length of stay compared with patients receiving single-shot regional anesthesia.

Suprascapular block associated with supraclavicular block: An alternative to isolated interscalene block for analgesia in shoulder instability surgery?

BACKGROUND

Interscalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. However, this technique has side effects and potentially serious complications. The aim of this study was to compare the combinations of ultrasound-guided suprascapular (SSB) associated with supraclavicular nerve block (SCB) and ultrasound-guided ISB for postoperative analgesia after shoulder instability surgery.

METHODS

Sixty ASA physical status I-II patients scheduled to undergo shoulder instability surgery were included. Two groups: (i) the SSB+SCB group (n=30) in which the patients received a combination of US-guided SSB (15mL of bupivacaine 0.25%) and US-guided SCB (15mL of bupivacaine 0.25%) and (ii) the ISB group (n=30) in which the patients received US-guided ISB with 30mL of bupivacaine 0.25%. General anesthesia was administered to all patients. During the first 24h, the variables assessed were time to administer the anesthesia, duration of the analgesia, onset and duration of motor and sensory blockade, opioid consumption, cardiovascular stability, complications, and patient satisfaction.

RESULTS

Anesthesia induction took more time for the SSB+SCB group than for the ISB group. However, the onset time of motor and sensory blockade was similar in the two groups. Statistical analysis of the visual analog postoperative pain scoring at H0, H6, H12, and H24 showed nonsignificant differences between the groups. Analgesia, the first request for morphine, and total morphine consumption during the first 24h was similar in both groups. No complication was recorded in the SSB+SCB group. However, phrenic nerve block occurred in all patients in the ISB group.

CONCLUSION

US-guided SCB combined with US-guided SSB was as effective as ISB for postoperative analgesia after shoulder instability surgery without decreasing potential side effects.

TRIAL REGISTRATION

NCT identifier: NCT02397330.

Complex regional pain syndrome: a recent update

Complex regional pain syndrome (CRPS) is a debilitating condition affecting the limbs that can be induced by surgery or trauma. This condition can complicate recovery and impair one’s functional and psychological well-being. The wide variety of terminology loosely used to describe CRPS in the past has led to misdiagnosis of this condition, resulting in poor evidence-base regarding the treatment modalities available and their impact. The aim of this review is to report on the recent progress in the understanding of the epidemiology, pathophysiology and treatment of CRPS and to discuss novel approaches in treating this condition.

Effect of Dexmedetomidine as an Adjuvant to 0.75% Ropivacaine in Interscalene Brachial Plexus Block Using Nerve Stimulator: A Prospective, Randomized Double-blind Study

BACKGROUND

Ropivacaine, a newer local anesthetic (LA), has been increasingly used nowadays in different concentrations for peripheral nerve blocks. It has lesser cardiac toxicity and higher safety margin when compared to bupivacaine. Dexmedetomidine, a novel α₂ agonist, is widely used as adjuvant to LA in peripheral nerve blocks to decrease the time of onset and increase the duration of the block. In this study, we evaluated the effect of dexmedetomidine as an adjuvant with 0.75% ropivacaine for interscalene brachial plexus block using nerve stimulator.

AIM

This study aims to know the effect of using dexmedetomidine as an adjuvant to 0.75% ropivacaine in interscalene brachial plexuses block using nerve stimulator.

SETTINGS AND DESIGNS

Sixty patients scheduled for elective orthopedic surgery of the upper limb under interscalene block were considered in this prospective randomized controlled double-blind study. The study population was randomly divided into two groups with thirty patients in each group by using computerized randomization.

MATERIALS AND METHODS

Group R received 30 ml of 0.75% ropivacaine with 0.5 ml normal saline and Group RD received 30 ml of 0.75% ropivacaine with 50 μg of dexmedetomidine. The onset of sensory and motor blocks, duration of sensory and motor block, and patient satisfaction score were observed.

RESULTS

Both the groups were comparable in demographic characteristics. The onset of the sensory and motor block is earlier and statistically significant in Group RD (P < 0.05) when compared to Group R. The duration of sensory and motor blockade were significantly prolonged in Group RD (P < 0.0001).

CONCLUSION

Addition of dexmedetomidine to 0.75% ropivacaine in interscalene brachial plexus block significantly shortened the time of onset of the block and prolongs the duration sensory and motor blockade.

Brachial Plexus Blockade Causes Subclinical Neuropathy: A Prospective Observational Study

Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.

Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: a prospective randomized trial

HYPOTHESIS

Our hypothesis was that in patients undergoing shoulder arthroplasty, a prospective randomized trial would find no significant differences in average daily pain scores of those treated with interscalene nerve block (INB) vs. local liposomal bupivacaine (LB).

METHODS

Sixty patients undergoing primary shoulder arthroplasty were assessed for eligibility. Study arms included either intraoperative local infiltration of LB (20 mL bupivacaine/20 mL saline) or preoperative INB, with a primary outcome of postoperative average daily visual analog scale scores for 4 days. Secondary outcomes assessed included opioid consumption, length of stay, and complications. Randomization was by a computerized algorithm. Only the observer was blinded to the intervention.

RESULTS

Three patients were excluded, all before randomization. A total of 57 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups.

CONCLUSION

An increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day. After the day of surgery, there were no significant differences found in any variables. These findings suggest that LB provides similar overall pain relief as INB, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery.

Mixed neuropathy presenting clinically as an anterior interosseous nerve palsy following shoulder arthroscopy: a report of four cases

BACKGROUND

Anterior interosseous nerve (AIN) palsies can arise spontaneously or be attributed to one of many causes. We present 4 cases, the largest series to date, in which a mixed peripheral neuropathy presented primarily as an AIN palsy following ipsilateral shoulder arthroscopy. In this report, we detail the patient's presenting symptoms, describe our management of the complication, and provide hypotheses for the mechanism behind the complication.

METHODS

Four different surgeons performed the initial arthroscopic surgeries, but the senior author in all cases managed follow-up and treatment of the neuropathy. All patients were informed and agreed to have their cases published.

RESULTS

All four patients experienced significant recovery, although 2 of 4 required AIN decompression and exploration because of failure to improve with conservative management.

CONCLUSION

Whereas variables such as position, index surgical procedure, and use of regional anesthesia varied among our patients, the one constant was the fluid extravasation from the arthroscopy itself, and for this reason we believe that if there is one singular cause to explain all of these neuropathies, it would be increased pressure in the upper arm and forearm from fluid extravasation in patients with at-risk anatomy. Outside of prevention, recognizing this complication and providing appropriate intervention or referral to a surgeon capable of appropriate intervention are important for any surgeon performing shoulder arthroscopies.

Subscapularis function after total shoulder arthroplasty: electromyography, ultrasound, and clinical correlation

BACKGROUND

The literature lacks electromyographic (EMG) examination of subscapularis function in the postoperative period after total shoulder arthroplasty (TSA). The primary purpose of this study was to document EMG activity of the subscapularis after TSA and to correlate it with clinical and ultrasound findings.

METHODS

The study included 30 patients who were at least 1 year (average, 2.1 years) from surgery, status post TSA approached through a standard subscapularis tenotomy. Patients returned for a physical examination, ultrasound evaluation, and EMG evaluation. Patients also completed postoperative surveys: the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and the 12-Item Short Form Health Survey.

RESULTS

The American Shoulder and Elbow Surgeons, Simple Shoulder Test, and physical 12-Item Short Form Health Survey scores improved from preoperatively to postoperatively, respectively, 45.3 to 76.8 (P = .0002), 3.9 to 9.0 (P < .0001), and 33.9 to 42.8 (P = .017). Six patients had a positive lift-off test result, and the belly-press test result was negative in all patients. Two patients had a subscapularis rupture on ultrasound. The postoperative EMG finding was normal in 15 patients; in the other 15 patients, there was evidence of chronic denervation with reinnervation changes: 30% subscapularis, 27% infraspinatus, 20% supraspinatus, 20% teres minor, and 13% rhomboids.

CONCLUSIONS

This is the first study using a comparison EMG evaluation to document subscapularis function after TSA. EMG evaluation showed that active denervation of the subscapularis was not evident in any patient at least 1 year after TSA. However, in half of the patients, there was evidence of chronicdenervation and reinnervation changes across 5 muscle groups. We theorize that surgical exposure, traction, and the use of interscalene regional anesthesia may contribute to these unexpected EMG results.

Localization of the brachial plexus: Sonography versus anatomic landmarks

PURPOSE

Interscalene brachial plexus blocks are performed for perioperative management of surgeries involving the shoulder. Historically, these procedures employed anatomic landmarks (AL) to determine the location of the brachial plexus as it passes between the anterior and middle scalene muscles in the neck. In this study, we compared the actual location of the brachial plexus as found with sonography (US) to the anticipated location using AL.

METHODS

The location of the brachial plexus was evaluated using US and AL in 96 subjects. The distance between the two locations was measured. A multivariate analysis of variance was used to determine the significance of the difference and a 2 × 2 analysis of variance was used to compare differences in gender, height, and body mass index.

RESULTS

The brachial plexus was located on average 1.8 cm inferior (p = 0.0001) and 0.2 cm lateral (p = 0.09) to the location determined with AL. A significant difference was also associated with gender (p = 0.03), but not with height or body mass index.

CONCLUSIONS

US is a reliable method that accurately pinpoints the roots of the brachial plexus. The brachial plexus is often located inferior to the location anticipated using AL. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:411-415, 2016.

Traction injury of the brachial plexus confused with nerve injury due to interscalene brachial block: A case report

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The confusing factor of regional block in shoulder surgery when neurologic damage appears after surgery.

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The importance of intraoperative head and neck position checking in long procedures.

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The beach-chair position as a possible factor that predisposes to brachial plexus traction injury.

Introduction

Shoulder surgery is often performed with the patient in the so called “beach-chair position” with elevation of the upper part of the body. The anesthetic procedure can be general anesthesia and/or regional block, usually interscalenic brachial plexus block. We present a case of brachial plexus palsy with a possible mechanism of traction based on the electromyographic and clinical findings, although a possible contribution of nerve block cannot be excluded.

Presentation of the case

We present a case of a 62 year-old female, that suffered from shoulder fracture-dislocation. Open reduction and internal fixation were performed in the so-called “beach-chair” position, under combined general-regional anesthesia. In the postoperative period complete motor brachial plexus palsy appeared, with neuropathic pain. Conservative treatment included analgesic drugs, neuromodulators, B-vitamin complex and physiotherapy. Spontaneous recovery appeared at 11 months.

Discusion

in shoulder surgery, there may be complications related to both anesthetic technique and patient positioning/surgical maneuvers. Regional block often acts as a confusing factor when neurologic damage appears after surgery. Intraoperative maneuvers may cause eventual traction of the brachial plexus, and may be favored by the fixed position of the head using the accessory of the operating table in the beach-chair position.

Conclusion

When postoperative brachial plexus palsy appears, nerve block is a confusing factor that tends to be attributed as the cause of palsy by the orthopedic surgeon. The beach chair position may predispose brachial plexus traction injury. The head and neck position should be regularly checked during long procedures, as intraoperative maneuvers may cause eventual traction of the brachial plexus.

Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis

BACKGROUND

Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery.

METHODS

We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed.

RESULTS

A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results.

CONCLUSIONS

ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.

Effect of dexamethasone in low volume supraclavicular brachial plexus block: A double-blinded randomized clinical study

BACKGROUND AND AIMS

With the use of ultrasound, a minimal effective volume of 20 ml has been described for supraclavicular brachial plexus block. However achieving a long duration of analgesia with this minimal volume remains a challenge. We aimed to determine the effect of dexamethasone on onset and duration of analgesia in low volume supraclavicular brachial plexus block.

MATERIAL AND METHODS

Sixty patients were randomly divided into two groups of 30 each. Group C received saline (2 ml) + 20 ml of 0.5% bupivacaine and Group D received dexamethasone (8 mg) + 20 ml of 0.5% bupivacaine in supraclavicular brachial plexus block. Hemodynamic variables and visual analog scale (VAS) score were noted at regular intervals until 450 min. The onset and duration of sensory and motor block were measured. The incidence of "Halo" around brachial plexus was observed. Student's t-test and Chi-square test were used for statistical analysis.

RESULTS

The onset of sensory and motor block was significantly earlier in dexamethasone group (10.36 ± 1.99 and 12 ± 1.64) minutes compared to control group (12.9 ± 2.23 and 18.03 ± 2.41) minutes. The duration of sensory and motor block was significantly prolonged in dexamethasone group (366 ± 28.11 and 337.33 ± 28.75) minutes compared to control group (242.66 ± 26.38 and 213 ± 26.80) minutes. The VAS score was significantly lower in dexamethasone group after 210 min. "Halo" was present around the brachial plexus in all patients in both the groups.

CONCLUSION

Dexamethasone addition significantly increases the duration of analgesia in patients receiving low volume supraclavicular brachial plexus block. No significant side-effects were seen in patients receiving dexamethasone as an adjunct.

Workup and Management of Persistent Neuralgia following Nerve Block

Neurological injuries following peripheral nerve blocks are a relatively rare yet potentially devastating complication depending on the type of lesion, affected extremity, and duration of symptoms. Medical management continues to be the treatment modality of choice with multimodal nonopioid analgesics as the cornerstone of this therapy. We report the case of a 28-year-old man who developed a clinical common peroneal and lateral sural cutaneous neuropathy following an uncomplicated popliteal sciatic nerve block. Workup with electrodiagnostic studies and magnetic resonance neurography revealed injury to both the femoral and sciatic nerves. Diagnostic studies and potential mechanisms for nerve injury are discussed.