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Qawasmi F, Best PD, Andryk LM, Grindel SI. Assessment of 2 distinct anatomical landmarks for suprascapular nerve injection: a cadaveric study. J Shoulder Elbow Surg 2023; 32:2376-2381. [PMID: 37178968 DOI: 10.1016/j.jse.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/04/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The suprascapular nerve block (SSNB) is a commonly used procedure for the management of pain in various shoulder pathologies. Both image-guided and landmark-based techniques have been utilized successfully for SSNB, though more consensus is needed regarding the optimal method of administration. This study aims to evaluate the theoretical effectiveness of a SSNB at 2 distinct anatomic landmarks and propose a simple, reliable way of administration for future clinical use. METHODS Fourteen upper extremity cadaveric specimens were randomly assigned to either receive an injection 1 cm medial to the posterior acromioclavicular (AC) joint vertex or 3 cm medial to the posterior AC joint vertex. Each shoulder was injected with a 10 ml methylene blue solution at the assigned location, and gross dissection was performed to evaluate the anatomic diffusion of the dye. The presence of dye was specifically assessed at the suprascapular notch, supraspinatus fossa, and spinoglenoid notch to determine the theoretic analgesic effectiveness of a SSNB at these 2 injection sites. RESULTS Methylene blue diffused to the suprascapular notch in 57.1% of the 1-cm group and 100% of the 3-cm group, the supraspinatus fossa in 71.4% of the 1-cm group and 100% of the 3-cm group, and the spinoglenoid notch in 100% of the 1-cm group and 42.9% of the 3-cm group. CONCLUSION Given its superior coverage at the more proximal sensory branches of the suprascapular nerve, a SSNB injection performed 3 cm medial to the posterior AC joint vertex provides more clinically adequate analgesia than an injection site 1 cm medial to the AC junction. Performing a SSNB injection at this location allows for an effective method of anesthetizing the suprascapular nerve.
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Affiliation(s)
- Feras Qawasmi
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Patrick D Best
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Logan M Andryk
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven I Grindel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Paul RW, Szukics PF, Brutico J, Tjoumakaris FP, Freedman KB. Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e721-e746. [PMID: 35494281 PMCID: PMC9042766 DOI: 10.1016/j.asmr.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Affiliation(s)
- Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Patrick F. Szukics
- Rowan University School of Osteopathic Medicine, Department of Orthopaedic Surgery, Stratford, New Jersey, U.S.A
| | - Joseph Brutico
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
- Address correspondence to Kevin B. Freedman, M.D., Rothman Orthopaedic Institute, Thomas Jefferson University, 825 Old Lancaster Rd., Suite 200, Bryn Mawr, PA, 19010, U.S.A.
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Long J, Liles J, Anakwenze O, Klifto C. Iatrogenic Injury to the Suprascapular Nerve Following Reverse Shoulder Arthroplasty: A Case Report. J Shoulder Elb Arthroplast 2022; 6:24715492221103518. [PMID: 35992510 PMCID: PMC9386855 DOI: 10.1177/24715492221103518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
The location and course of the suprascapular nerve (SSN) to the glenohumeral joint places this nerve at risk when operating around the shoulder. Iatrogenic injury to the suprascapular nerve has been described in several different procedures including, rotator cuff repairs, posterior capsulorraphy, Bankart repairs, SLAP lesion repairs, Latarjet procedures, and shoulder arthroplasty. We present a case of iatrogenic suprascapular nerve injury due to superior glenoid baseplate screw placement following primary reverse shoulder arthroplasty (RSA), a novel approach to diagnosis of nerve injury, and treatment.
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Affiliation(s)
- Jason Long
- Duke University Department of Orthopaedic Surgery, Duke University Medical Center, Department of Orthopaedic Surgery, Box 3000, Durham NC, 27710, USA
| | - Jordan Liles
- Duke University Department of Orthopaedic Surgery, Duke University Medical Center, Department of Orthopaedic Surgery, Box 3000, Durham NC, 27710, USA
| | - Oke Anakwenze
- Duke University Department of Orthopaedic Surgery, Duke University Medical Center, Department of Orthopaedic Surgery, Box 3000, Durham NC, 27710, USA
| | - Christopher Klifto
- Duke University Department of Orthopaedic Surgery, Duke University Medical Center, Department of Orthopaedic Surgery, Box 3000, Durham NC, 27710, USA
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Ko SH, Park SH, Jang SM, Lee KJ, Kim KH, Jeon YD. Multimodal nerve injection provides noninferior analgesic efficacy compared with interscalene nerve block after arthroscopic rotator cuff repair. J Orthop Surg (Hong Kong) 2021; 29:23094990211027974. [PMID: 34278884 DOI: 10.1177/23094990211027974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This randomized noninferiority trial aimed to evaluate whether combined suprascapular, axillary nerve, and the articular branch of lateral pectoral nerve block (3NB) is noninferior to interscalene nerve block (ISB) for pain control after arthroscopic rotator cuff repair (ASRCR). MATERIALS AND METHODS Eighty-five patients undergoing ASRCR were randomized to either 3NB (n = 43) or ISB (n = 42) group. We used 5 and 15 ml of 0.2% ropivacaine for each nerve in the 3NB and ISB groups, respectively. The primary outcome was the visual analog scale (VAS) pain score at 4 h postoperatively measured assessed on an 11-point scale (ranging from 0 = no pain to 10 = worst pain) that was analyzed using noninferiority testing. The secondary outcome was VAS pain scores in the recovery room and at 8, 12, 24, 36, 48, and 72 h postoperatively. Rebound pain, IV-PCA usage during 48 h, dyspnea, muscle weakness, and satisfaction were evaluated. RESULTS Regarding the primary outcome, the mean difference in VAS pain scores between the 3NB (2.5 ± 1.6) and ISB (2.2 ± 2.3) groups at 4 h postoperatively was 0.3, with a 95% confidence interval (CI) of -0.56 to 1.11. The upper limit of 95% CI is lower than the noninferiority margin of 1.3 (p < 0.001). At all other time points, except in the recovery room, 3NB showed noninferior to ISB. Rebound pain, IV-PCA usage during the second 24 h, and muscle weakness were lower in the 3NB group (all p < 0.005). The satisfaction was similar in both groups (p = 0.815). CONCLUSION Combined 3NB is noninferior to ISB in terms of pain control after ASRCR; and is associated with low levels of rebound pain, IV-PCA usage, and muscle weakness. LEVEL OF EVIDENCE Randomized controlled trial, Level I.
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Affiliation(s)
- Sang Hun Ko
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Se Hun Park
- Department of Anesthesia and Pain Medicine, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Seong Min Jang
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Kyung Joo Lee
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Kwang Ho Kim
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Young Dae Jeon
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
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Choi H, Roh K, Joo M, Hong SH. Continuous suprascapular nerve block compared with single-shot interscalene brachial plexus block for pain control after arthroscopic rotator cuff repair. Clinics (Sao Paulo) 2020; 75:e2026. [PMID: 33206761 PMCID: PMC7603171 DOI: 10.6061/clinics/2020/e2026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/21/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES We compared the analgesic efficacy of a continuous suprascapular nerve block (C-SSNB) and a single-shot interscalene brachial plexus block (S-ISNB) for postoperative pain management in patients undergoing arthroscopic rotator cuff repair. METHODS A total of 118 patients undergoing arthroscopic rotator cuff repair were randomly allocated to the S-ISNB or C-SSNB groups. Postoperative pain was assessed using the visual analog scale (VAS) at 1, 2, 6, 12, and 24 h postoperatively. Supplemental analgesic use was recorded as total equianalgesic fentanyl consumption. RESULTS The C-SSNB group showed significantly higher VAS scores at 0-1 h and 1-2 h after the surgery than the S-ISNB group (4.9±2.2 versus 2.3±2.2; p<0.0001 and 4.8±2.1 versus 2.4±2.3; p<0.0001, respectively). The C-SSNB group showed significantly lower VAS scores at 6-12 h after the surgery than the S-ISNB group (4.1±1.8 versus. 5.0±2.5; p=0.031). The C-SSNB group required significantly higher doses of total equianalgesic fentanyl in the post-anesthesia care unit than the S-ISNB group (53.66±44.95 versus 5.93±18.25; p<0.0001). Total equianalgesic fentanyl in the ward and total equianalgesic fentanyl throughout the hospital period were similar between the groups (145.99±152.60 versus 206.13±178.79; p=0.052 and 199.72±165.50 versus 212.15±180.09; p=0.697, respectively). CONCLUSION C-SSNB was more effective than S-ISNB at 6-12 h after the surgery for postoperative analgesia after arthroscopic rotator cuff repair.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Kyungmoon Roh
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Mina Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
- *Corresponding author. E-mail:
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Kay J, Memon M, Hu T, Simunovic N, Duong A, Paul J, Athwal G, Ayeni OR. Suprascapular Nerve Blockade for Postoperative Pain Control After Arthroscopic Shoulder Surgery: A Systematic Review and Meta-analysis. Orthop J Sports Med 2018; 6:2325967118815859. [PMID: 30627589 PMCID: PMC6311591 DOI: 10.1177/2325967118815859] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Regional nerve blocks are commonly used to manage postoperative pain after arthroscopic shoulder procedures. The interscalene brachial plexus block (ISB) is commonly used; however, because of the reported side effects of ISB, the use of a suprascapular nerve block (SSNB) has been described as an alternative strategy with fewer reported side effects. Purpose: To examine the efficacy of SSNB for pain control after shoulder arthroscopy compared with ISB as well as anesthesia without a nerve block. Study Design: Systematic review; Level of evidence, 1. Methods: Three databases (PubMed, MEDLINE, and EMBASE) were searched on April 20, 2018, to systematically identify and screen the literature for randomized controlled trials (RCTs). A meta-analysis of standard mean differences (SMDs) was performed to pool the estimated effects of the nerve blocks. Results: The search identified 14 RCTs that included 1382 patients, with a mean age of 54 years (SD, 13 years). The mean follow-up time was 3 days (range, 24 hours to 6 weeks). Postoperative pain control was significantly more effective in the SSNB groups compared with the control groups within 1 hour (SMD, –0.76; 95% CI, –1.45 to –0.07; P = .03) and 4 to 6 hours (SMD, –0.81; 95% CI, –1.53 to –0.09; P = .03) postoperatively. However, pain control was significantly less effective in the SSNB groups compared with ISB within 1 hour (SMD, 0.87; 95% CI, 0.28 to 1.46; P = .004). No major complications were noted in the SSNB groups, and minor complications such as hoarseness and prolonged motor block were significantly less common for SSNB compared with ISB. Conclusion: Although not more efficacious than ISB in terms of pain control for patients undergoing shoulder arthroscopy, SSNB provides significantly improved pain control in comparison with analgesia without a nerve block. Moreover, few major and minor complications are associated with SSNB reported across the literature.
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Affiliation(s)
- Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Muzammil Memon
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Duong
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - George Athwal
- Roth McFarlane Hand and Upper Limb Center, St Joseph's Health Care, University of Western Ontario, London, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Abstract
In the past 30 years, the use of ultrasonography in the field of orthopaedics has evolved. As ultrasonography has been refined, smaller machines with higher fidelity and better transducers have become available at a lower cost. Diagnostic and therapeutic applications of ultrasonography in the shoulder and elbow have expanded imaging options and provided alternatives to surgical management. Ultrasonography is a dynamic tool that affords immediate diagnostic assessment for clinical correlation and can be used for serial examinations and image guidance during therapeutic procedures. This imaging modality is highly reliable and accurate and may limit the need for costly imaging referrals, particularly in geographic areas where advanced imaging is not readily available. However, clinical expertise is paramount for ultrasonography, which is an operator-dependent modality. Ultrasonography is an effective educational resource; therefore, the curriculum in orthopaedic residency training programs should include education on this modality as the use of ultrasonography increases among orthopaedic surgeons.
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Ko SH, Cho SD, Lee CC, Choi JK, Kim HW, Park SJ, Bae MH, Cha JR. Comparison of Arthroscopically Guided Suprascapular Nerve Block and Blinded Axillary Nerve Block vs. Blinded Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Clin Orthop Surg 2017; 9:340-347. [PMID: 28861202 PMCID: PMC5567030 DOI: 10.4055/cios.2017.9.3.340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 05/05/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the results of arthroscopically guided suprascapular nerve block (SSNB) and blinded axillary nerve block with those of blinded SSNB in terms of postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. METHODS Forty patients who underwent arthroscopic rotator cuff repair for medium-sized full thickness rotator cuff tears were included in this study. Among them, 20 patients were randomly assigned to group 1 and preemptively underwent blinded SSNB and axillary nerve block of 10 mL 0.25% ropivacaine and received arthroscopically guided SSNB with 10 mL of 0.25% ropivacaine. The other 20 patients were assigned to group 2 and received blinded SSNB with 10 mL of 0.25% ropivacaine. Visual analog scale (VAS) score for pain and patient satisfaction score were assessed 4, 8, 12, 24, 36, and 48 hours postoperatively. RESULTS The mean VAS score for pain was significantly lower 4, 8, 12, 24, 36, and 48 hours postoperatively in group 1 (group 1 vs. group 2; 5.2 vs. 7.4, 4.1 vs. 6.1, 3.0 vs. 5.1, 2.1 vs. 4.2, 0.9 vs. 3.9, and 1.3 vs. 3.3, respectively). The mean patient satisfaction score was significantly higher at postoperative 4, 8, 12, 24, 36, and 48 hours in group 1 (group 1 vs. group 2; 6.7 vs. 3.9, 7.4 vs. 5.1, 8.8 vs. 5.9, 9.2 vs. 6.7, 9.5 vs. 6.9, and 9.0 vs. 7.2, respectively). CONCLUSIONS Arthroscopically guided SSNB and blinded axillary nerve block in arthroscopic rotator cuff repair for medium-sized rotator cuff tears provided more improvement in VAS for pain and greater patient satisfaction in the first 48 postoperative hours than blinded SSNB.
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Affiliation(s)
- Sang Hun Ko
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Do Cho
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chae Chil Lee
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jang Kyu Choi
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Han Wook Kim
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seon Jae Park
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Mun Hee Bae
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae Ryong Cha
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Moon SH, Ko KP, Baek SI, Lee S. Ultrasonography and Ultrasound-guided Interventions of the Shoulder. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.3.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. Cochrane Database Syst Rev 2015; 2015:CD006459. [PMID: 26361135 PMCID: PMC6465072 DOI: 10.1002/14651858.cd006459.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014. OBJECTIVES The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks SEARCH METHODS In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies. MAIN RESULTS We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block. AUTHORS' CONCLUSIONS There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety ResearchPointer Court 1, Ashton RoadLancasterUKLA1 1RP
| | - Anastasia Price
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterUK
| | - Kevin J Walker
- Ayr HospitalDepartment of AnaestheticsDalmellington RoadAyrAyrshireUKKA6 6DX
| | - Ken McGrattan
- Royal Preston HospitalDepartment of AnaestheticsSharoe Green Lane NorthFulwoodPreston, LancashireUKPR2 9HT
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterUK
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Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26361135 DOI: 10.1002/14651858.cd006459.pub3.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Peripheral nerve blocks can be performed using ultrasound guidance. It is not yet clear whether this method of nerve location has benefits over other existing methods. This review was originally published in 2009 and was updated in 2014. OBJECTIVES The objective of this review was to assess whether the use of ultrasound to guide peripheral nerve blockade has any advantages over other methods of peripheral nerve location. Specifically, we have asked whether the use of ultrasound guidance:1. improves success rates and effectiveness of regional anaesthetic blocks, by increasing the number of blocks that are assessed as adequate2. reduces the complications, such as cardiorespiratory arrest, pneumothorax or vascular puncture, associated with the performance of regional anaesthetic blocks SEARCH METHODS In the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (July 2008 to August 2014); EMBASE (July 2008 to August 2014); ISI Web of Science (2008 to April 2013); CINAHL (July 2014); and LILACS (July 2008 to August 2014). We completed forward and backward citation and clinical trials register searches.The original search was to July 2008. We reran the search in May 2015. We have added 11 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate them into the formal review findings during future review updates. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing ultrasound-guided peripheral nerve block of the upper and lower limbs, alone or combined, with at least one other method of nerve location. In the 2014 update, we excluded studies that had given general anaesthetic, spinal, epidural or other nerve blocks to all participants, as well as those measuring the minimum effective dose of anaesthetic drug. This resulted in the exclusion of five studies from the original review. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We used standard Cochrane methodological procedures, including an assessment of risk of bias and degree of practitioner experience for all studies. MAIN RESULTS We included 32 RCTs with 2844 adult participants. Twenty-six assessed upper-limb and six assessed lower-limb blocks. Seventeen compared ultrasound with peripheral nerve stimulation (PNS), and nine compared ultrasound combined with nerve stimulation (US + NS) against PNS alone. Two studies compared ultrasound with anatomical landmark technique, one with a transarterial approach, and three were three-arm designs that included US, US + PNS and PNS.There were variations in the quality of evidence, with a lack of detail in many of the studies to judge whether randomization, allocation concealment and blinding of outcome assessors was sufficient. It was not possible to blind practitioners and there was therefore a high risk of performance bias across all studies, leading us to downgrade the evidence for study limitations using GRADE. There was insufficient detail on the experience and expertise of practitioners and whether experience was equivalent between intervention and control.We performed meta-analysis for our main outcomes. We found that ultrasound guidance produces superior peripheral nerve block success rates, with more blocks being assessed as sufficient for surgery following sensory or motor testing (Mantel-Haenszel (M-H) odds ratio (OR), fixed-effect 2.94 (95% confidence interval (CI) 2.14 to 4.04); 1346 participants), and fewer blocks requiring supplementation or conversion to general anaesthetic (M-H OR, fixed-effect 0.28 (95% CI 0.20 to 0.39); 1807 participants) compared with the use of PNS, anatomical landmark techniques or a transarterial approach. We were not concerned by risks of indirectness, imprecision or inconsistency for these outcomes and used GRADE to assess these outcomes as being of moderate quality. Results were similarly advantageous for studies comparing US + PNS with NS alone for the above outcomes (M-H OR, fixed-effect 3.33 (95% CI 2.13 to 5.20); 719 participants, and M-H OR, fixed-effect 0.34 (95% CI 0.21 to 0.56); 712 participants respectively). There were lower incidences of paraesthesia in both the ultrasound comparison groups (M-H OR, fixed-effect 0.42 (95% CI 0.23 to 0.76); 471 participants, and M-H OR, fixed-effect 0.97 (95% CI 0.30 to 3.12); 178 participants respectively) and lower incidences of vascular puncture in both groups (M-H OR, fixed-effect 0.19 (95% CI 0.07 to 0.57); 387 participants, and M-H OR, fixed-effect 0.22 (95% CI 0.05 to 0.90); 143 participants). There were fewer studies for these outcomes and we therefore downgraded both for imprecision and paraesthesia for potential publication bias. This gave an overall GRADE assessment of very low and low for these two outcomes respectively. Our analysis showed that it took less time to perform nerve blocks in the ultrasound group (mean difference (MD), IV, fixed-effect -1.06 (95% CI -1.41 to -0.72); 690 participants) but more time to perform the block when ultrasound was combined with a PNS technique (MD, IV, fixed-effect 0.76 (95% CI 0.55 to 0.98); 587 participants). With high levels of unexplained statistical heterogeneity, we graded this outcome as very low quality. We did not combine data for other outcomes as study results had been reported using differing scales or with a combination of mean and median data, but our interpretation of individual study data favoured ultrasound for a reduction in other minor complications and reduction in onset time of block and number of attempts to perform block. AUTHORS' CONCLUSIONS There is evidence that peripheral nerve blocks performed by ultrasound guidance alone, or in combination with PNS, are superior in terms of improved sensory and motor block, reduced need for supplementation and fewer minor complications reported. Using ultrasound alone shortens performance time when compared with nerve stimulation, but when used in combination with PNS it increases performance time.We were unable to determine whether these findings reflect the use of ultrasound in experienced hands and it was beyond the scope of this review to consider the learning curve associated with peripheral nerve blocks by ultrasound technique compared with other methods.
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Affiliation(s)
- Sharon R Lewis
- Patient Safety Research, Royal Lancaster Infirmary, Pointer Court 1, Ashton Road, Lancaster, UK, LA1 1RP
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Lee JJ, Kim DY, Hwang JT, Lee SS, Hwang SM, Kim GH, Jo YG. Effect of ultrasonographically guided axillary nerve block combined with suprascapular nerve block in arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy 2014; 30:906-14. [PMID: 24880194 DOI: 10.1016/j.arthro.2014.03.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 03/11/2014] [Accepted: 03/20/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare the results of ultrasonographically guided axillary nerve block (ANB) combined with suprascapular nerve block (SSNB) with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. METHODS Forty-two patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this study. Among them, 21 patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL 0.75% ropivacaine and ANB with 10 mL saline. Visual analog scale (VAS) pain score, patient satisfaction (SAT), and lateral pain index (LPI) was checked at 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively. RESULTS Group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours compared with group 2 (5.1 < 7.6, 4.4 < 6.3, 3.7 < 5.3, 3.2 < 4.5, 2.7 < 4.0, and 2.7 < 3.4, respectively). A significantly high mean SAT and low mean LPI was observed in group 1 at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (4.9 > 2.4, 5.9 > 3.7, 6.3 > 5.0, 6.8 > 5.7, 7.3 > 6.2, 7.5 > 6.6, and 7.7 > 7.0, respectively), (1.1 < 3.0, 0.8 < 2.5, 0.7 < 2.0, 0.7 < 1.6, 0.6 < 1.3, 0.6 < 1.0, and 0.4 < 0.7, respectively). The frequency of rebound pain decreased in group 1 compared with group 2 (P = .032). In addition, rebound phenomenon showed a correlation with ANB on univariate logistic regression (P = .034; odds ratio, 0.246). CONCLUSIONS Ultrasonographically guided ANB combined with SSNB in arthroscopic rotator cuff repair showed an improved mean VAS in the first 24 hours after surgery compared with SSNB alone. The mean SAT and LPI of the combined blocks were better than those of the single block within the first 36 hours. Ultrasonographically guided ANB combined with SSNB also decreased the rebound phenomenon. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Jae Jun Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Do-Young Kim
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea; Institute for Skeletal Aging and Orthopedic Surgery, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Jung-Taek Hwang
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea; Institute for Skeletal Aging and Orthopedic Surgery, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea.
| | - Sang-Soo Lee
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea; Institute for Skeletal Aging and Orthopedic Surgery, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Sung Mi Hwang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Gi Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Yoon-Geol Jo
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea
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Yamakado K. Efficacy of arthroscopically placed pain catheter adjacent to the suprascapular nerve (continuous arthroscopically assisted suprascapular nerve block) following arthroscopic rotator-cuff repair. Open Access J Sports Med 2014; 5:129-36. [PMID: 24982592 PMCID: PMC4074897 DOI: 10.2147/oajsm.s63345] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Rotator-cuff surgery is well recognized to be a painful procedure. Objectives The purpose of this study was to examine the effectiveness of an arthroscopically placed perineural catheter at the scapular notch to provide a continuous block of the suprascapular nerve (continuous arthroscopically assisted suprascapular nerve block [ca-SSNB]) following arthroscopic rotator-cuff repair (ARCR). Materials and methods This level II, prospective, randomized, controlled trial without postoperative blinding included 40 patients, who had a 48-hour pain pump, with 0.2% ropivacaine infusion and a continuous rate of 3 mL/hour, placed via an arthroscopically placed catheter following ARCR with arthroscopic release of the superior transverse ligament: 21 patients had a ca-SSNB, and 19 patients had a continuous subacromial bursal block (SAB). The visual analog scale (at 6 hours and on the first, second, and third postoperative days) and the total number of additional pain-reduction attempts during the 3 postoperative days were calculated. Results The respective visual analog scale scores (mm) obtained from the ca-SSNB and SAB groups were 62.4 and 67.6 (P=0.73) before surgery, 9.1 and 19.4 (P=0.12) at 6 hours after surgery, 24.4 and 44.6 (P=0.019) on the first postoperative day, 19.4 and 40.4 (P=0.0060) on the second postoperative day, and 18.5 and 27.8 (P=0.21) on the third postoperative day. Total additional pain-reduction attempts recorded for the ca-SSNB and SAB groups during the 3 postoperative days were 0.3 times and 1.2 times (P=0.0020), respectively. Conclusion ca-SSNB was highly effective in controlling postoperative pain after ARCR.
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Affiliation(s)
- Kotaro Yamakado
- Department of Orthopaedics, Fukui General Hospital, Fukui, Japan
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Lubowitz JH, Provencher MT, Poehling GG. Congratulations and condemnations: Level I Evidence prize for femoral tunnel position in ACL reconstruction, and AAOS clinical practice guidelines miss the mark-again. Arthroscopy 2014; 30:2-5. [PMID: 24384269 DOI: 10.1016/j.arthro.2013.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 11/11/2013] [Indexed: 02/02/2023]
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Lubowitz JH, Provencher MT, Poehling GG. Measuring orthopaedic outcome: shoulder outcome measures. Arthroscopy 2013; 29:791-3. [PMID: 23628662 DOI: 10.1016/j.arthro.2013.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 02/02/2023]
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