The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence

Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study

PURPOSE

To assess the effects of intravenous tranexamic acid (TXA) on visual clarity at various surgical stages and the correlation between the severity of synovitis and bursitis and the grade of visual clarity in patients undergoing arthroscopic shoulder surgery under an interscalene brachial plexus block.

METHODS

This double-blind, randomized controlled study included patients undergoing arthroscopic rotator cuff repair. The TXA group underwent injection of a 100-mL mixture of 1,000 mg of TXA and normal saline solution intravenously whereas the control group was administered the same volume of normal saline solution at 10 minutes preoperatively. Visual clarity was rated according to a 3-grade visual clarity scoring system from grade 1 (clear) to grade 3 (poor) at 4 surgical stages (I, intra-articular soft-tissue procedures including synovectomy; II, acromioplasty; III, bursectomy; and IV, greater tuberoplasty). The primary outcome was arthroscopic visual clarity. The secondary outcomes were medications administered for hemodynamic stability, length of hospital stay, and thromboembolic events.

RESULTS

Altogether, 63 patients were included in the study; they were divided into the TXA group, comprising 32 patients, and the control group, comprising 31 patients. The TXA group showed significantly better visual clarity than the control group (median [interquartile range], 1 [1-2] vs 2 [1-2]; P = .027) during stage I but not during stages II through IV. Spearman correlation analysis revealed a significant correlation between synovitis and visual clarity grade during synovectomy (correlation coefficient, 0.393; P = .001) but not between bursitis and visual clarity grade during bursectomy. Deep vein thrombosis and pulmonary embolism did not occur in either group.

CONCLUSIONS

Intravenous TXA can improve visual clarity during intra-articular soft-tissue procedures, including synovectomy. However, it does not have a significant effect during acromioplasty, bursectomy, and greater tuberoplasty. TXA can be used to improve visual clarity in patients with suspected severe synovitis.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Surgeon-administered intraoperative brachial plexus block for open shoulder surgery - a novel and safe technique

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

Efficacy of surgeon-directed suprascapular and axillary nerve blocks in shoulder arthroscopy: a 3-arm prospective randomized controlled trial

Background

The use of regional anesthesia in shoulder arthroscopy improves perioperative pain control, thereby reducing the need for opioids and their recognized side effects. Occasionally one type of block is not suitable for a patient's anatomy or comorbidities or requires a specially trained anesthetist to safely perform. The primary aim of this study is to compare the efficacy of 3 different nerve blocks for pain management in patients undergoing shoulder arthroscopy.

Methods

A 3-arm, blinded, randomized controlled trial in patients undergoing elective, unilateral shoulder arthroscopic procedures between August 2018 and November 2020 was conducted at a single center. One hundred and thirty participants were randomized into 1 of 3 regional anesthesia techniques. The first group received an ultrasound-guided interscalene block performed by an anesthetist (US + ISB). The second group received an ultrasound-guided suprascapular nerve block and an axillary nerve block by an anesthetist (US + SSANB). The final group received a suprascapular nerve block without ultrasound and an axillary nerve block under arthroscopic guidance by an orthopedic surgeon (A + SSANB). Intraoperative pain response, analgesia requirements, and side effects were recorded. Visual analogue pain scores and opioid doses were recorded in the Post Anaesthesia Care Unit (PACU) and daily for 8 days following the procedure.

Results

Twelve patients withdrew from the study after randomization, leaving 39 participants in US + ISB, 40 in US + SSANB, and 39 in A + SSANB. The US + ISB group required significantly lower intraoperative opioid doses than US + SSANB and A + SSANB (P < .001) and postoperatively in PACU (P < .001). After discharge from hospital, there were no differences between all groups in daily analgesia requirements (P = .063). There was significantly more nerve complications with 6 patient-reported complications in the US + ISB group (P = .02). There were no reported differences in satisfaction rates between groups (P = .41); however, the A + SSANB group was more likely to report a wish to not have a regional anesthetic again (P = .04).

Conclusion

The US + ISB group required lower opioid doses perioperatively; however, there was no difference between groups after discharge from PACU. The analgesia requirements between the US + SSANB and A + SSANB were similar intraoperatively and postoperatively. A surgeon-administered SSANB may be a viable alternative when an experienced regional anesthetist is not available.

Prevalence, management, and outcomes of nerve injury after shoulder arthroplasty: a case-control study and review of the literature

Background

Neurologic injury is a rare and potentially devastating complication of shoulder arthroplasty. Patients typically present with a mixed plexopathy or mononeuropathy, most commonly affecting the axillary and radial nerves. Given the paucity of studies available on the topic, our goal was to elucidate the prevalence of nerve injury after shoulder arthroplasty and to describe the treatment course and outcomes of neurologic injuries.

Methods

This is a retrospective case-control study performed at a single, urban, academic institution. Consecutive patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) by a single surgeon from 2014 to 2020 were reviewed, and patients with a documented nerve injury were identified. A control group of patients without nerve injury were selected in a 2:1 ratio controlling for age and procedure type (TSA vs. RSA; primary vs. revision). Data collected included demographics, comorbidities as per the Charlson Comorbidity Index, radiographic evaluations, surgical and implant details, patient-reported outcome measures, and perioperative complications.

Results

Of 923 patients, 33 (3.6%) sustained an iatrogenic nerve injury: 10 (2.1%) after TSA, 23 (5.0%) after RSA, and 3 (7.8%) after revision arthroplasty. Axillary mononeuropathy was most common (42%), followed by brachial plexopathies (18%). There was no significant difference in age, sex, race, body mass index, and preoperative diagnoses between groups. Patients with nerve injury had fewer comorbidities (Charlson Comorbidity Index <3, 33 vs. 65%, P<.001). Patients with nerve injury had higher rates of cervical spine pathology (15 vs. 6%; P = .15) and increased postoperative lateralization (8.9 mm [7.2] vs. 5.5 mm [7.3]; P<.06). The majority (91%) were managed with observation alone. Three (9%) underwent an additional procedure: carpal tunnel release (1, 3%), ulnar nerve decompression (1, 3%), and ulnar nerve transposition (1, 3%) for peripheral compressive neuropathies. At the final follow-up, 19 (57%) nerves fully recovered, and 14 (43%) showed mild residual sensorimotor dysfunction. The mean time to first sign of recovery and ultimate recovery were 11 (7.2) and 36 (23.5) weeks, respectively. At the final follow-up, patients with nerve injury performed worse on patient-reported outcomes, including visual analog score pain (2.2 vs. 1.0, P<.001), American Shoulder and Elbow Surgeons score (67.8 vs. 84.8, P<.001), and Single Assessment Numeric Evaluation scores (62 vs. 77, P = .009).

Discussion

Nerve injury after shoulder arthroplasty is rare, occurring in 3.6% of our patient population. Axillary mononeuropathy and brachial plexopathies are the most common. Most patients can be managed expectantly with observation and will recover at least partial nerve function, although clinical outcomes remain inferior to those without nerve complication.

Combined distal median nerve block and local anesthesia with lidocaine:epinephrine for carpal tunnel release

Aim

Evaluating patient comfort during full awake local anesthesia in carpal tunnel release surgery, without tourniquet use, by using epinephrine to obtain a completely dry surgical field.

Methods

We included into the study 41 patients who underwent carpal tunnel syndrome surgery under full awake combined anesthesia, using a 9-point questionnaire. Pain and anxiety in all patients were evaluated through a Wang-Baker 0–5 scale. The injection solution consisted of 0.1cc of epinephrine and 10cc of 1% lidocaine (1:100.000); 5cc were used for local cutaneous anesthesia, and 5cc were used for distal median nerve block. All patients underwent a classic, open carpal tunnel release.

Results

Anxiety scores during anesthesia and the post-operative period did not show a statistically significant difference (p > 0.01), with keeping their levels at low perception scores (average score of 1.68 ± 0.38 CI 95%, with a modal value of 2, compared to an average of 0.78 ± 0.29 CI 95% with a modal value of 0). Similar results were obtained for pain scores during anesthesia (1.73 ± 0.48 CI 95% with a most frequent modal score of 1). Our results also showed that the effects of combined anesthesia in carpal tunnel release surgery persisted well into the 6-hour post-operative moment, pain scores remaining low, statistically significant similar to recorded values during the anesthesia moment (p > 0.01), at an average of 2.29 ± 0.5 CI 95% with a modal value of 1. No serious complications were recorded.

Conclusion

Combined distal median nerve block and local anesthesia with epinephrine:lidocaine provides a comfortable option for patients, with minimal risks of complications.

Interscalene Block for Analgesia in Orthopedic Treatment of Shoulder Trauma: Single-Dose Liposomal Bupivacaine versus Perineural Catheter

Background

Interscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery.

Methods

We performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique.

Results

After statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters.

Conclusion

Interscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

Ultrasound-guided interscalene block anesthesia performed by an orthopedic surgeon: a study of 1322 cases of shoulder surgery

Background

Interscalene blocks are becoming increasingly common for shoulder surgeries. This study primarily aimed to demonstrate the efficacy and complications and the secondarily to investigate the anesthesia-related time and patient satisfaction of an ultrasound-guided interscalene block performed by an orthopedic surgeon.

Methods

We retrospectively reviewed the medical records of 1322 consecutive patients (arthroscopic, 1225 cases; open, 97 cases) with a mean age of 64.2 years, who underwent shoulder surgery (arthroscopic or opensurgery) under an ultrasound-guided interscalene block performed by an orthopedic surgeon at a single institution between December 2012 and December 2019. We investigated patient satisfaction, block success rates, and complications and also compared the anesthesia-related time of an interscalene block with that of general anesthesia (428 cases, arthroscopic, 257 cases; open, 171 cases) for shoulder surgery with patients in the beach chair position during the same period. Difference between total anesthesia time and surgical time was defined as anesthesia-related time.

Results

Approximately 98.3% of patients were satisfied with an interscalene block, and the block success rate on the first attempt was 99.9%. Total complication incidence was 2.3%, with no recorded life-threatening complications. Anesthesia-related times were significantly shorter in the interscalene block group than those in the general anesthesia group (45 ± 14 min vs. 100 ± 26 min, P < .001).

Conclusion

An ultrasound-guided interscalene block performed by an orthopedic surgeon for shoulder surgery is effective and safe, requires less time, and has a high patient acceptance rate, making it a feasible and alternative to the block performed by anesthesiologists.

Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials

This systematic review aimed to compare the analgesic effectiveness and complications rates for anterior suprascapular nerve blocks (ASSB) compared to interscalene brachial plexus blocks (ISB) for arthroscopic and outpatient shoulder surgery. Only randomized controlled trials (RCTs) comparing the ASSB versus ISB in the context of arthroscopic shoulder surgery were eligible for inclusion. The primary outcomes included pain scores (Numeric Rating Scale of 0 to 10) up to 24 h postoperatively and analgesic consumption. Secondary outcomes included block complications. Meta-analysis was performed using random-effects modeling and result certainty was determined using the GRADEpro tool. Six RCTs (709 patients) were included for analysis. ISB displayed a statistically significant reduction in pain scores by 0.40 (95%CI = 0.36 to 0.45; p < 0.00001) but not morphine equivalent consumption (mean difference = 0.74 mg; 95%CI = - 0.18 to 1.66 mg; I² = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24 h were not significantly different. There was no difference in respiratory events postblock. ASSB demonstrated a significantly lower incidence of Horner's syndrome (relative risk (RR) = 0.17; 95%CI = 0.08 to 0.39; p < 0.00001; high certainty), voice hoarseness (RR = 0.24; 95%CI = 0.10 to 0.57; p < 0.00001; high certainty) and impaired respiratory function (p < 0.00001). The ASSB could be considered an appropriate analgesic option for arthroscopic shoulder surgery with potentially fewer complications than the ISB.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair.

Materials and methods

Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant–Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed.

Results

The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant–Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01).

Conclusion

Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials

BACKGROUND

The interscalene brachial plexus block (ISB) is a commonly used nerve block technique for postoperative analgesia in patients undergoing shoulder arthroscopy surgery; however, it is associated with potentially serious complications. The use of suprascapular nerve block (SSNB) has been described as an alternative strategy with fewer reported side effects for shoulder arthroscopy. This review aimed to compare the impact of SSNB and ISB during shoulder arthroscopy surgery.

METHODS

A meta-analysis was conducted to identify relevant randomized controlled trials involving SSNB and ISB during shoulder arthroscopy surgery. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through March 2021.

RESULTS

We identified 1255 patients assessed in 17 randomized controlled trials. Compared with the ISB group, the SSNB group had higher VAS at rest in PACU (P = 0.003), 1 h after operation (P = 0.005), similar pain score 2 h (P = 0.39), 3-4 h (P = 0.32), 6-8 h after operation (P = 0.05), then lower VAS 12 h after operation (P = 0.00006), and again similar VAS 1 day (P = 0.62) and 2 days after operation (P = 0.70). As for the VAS with movement, the SSNB group had higher pain score in PACU (P = 0.03), similar VAS 4-6 h after operation (P = 0.25), then lower pain score 8-12 h after operation (P = 0.01) and again similar VAS 1 day after operation (P = 0.3) compared with the ISB group. No significant difference was found for oral morphine equivalents use at 24 h (P = 0.35), duration of PACU stay (P = 0.65), the rate of patient satisfaction (P = 0.14) as well as the rate of vomiting (P = 0.56), and local tenderness (P = 0.87). However, the SSNB group had lower rate of block-related complications such as Horner syndrome (P < 0.0001), numb (P = 0.002), dyspnea (P = 0.04), and hoarseness (P = 0.04).

CONCLUSION

Our high-level evidence established SSNB as an effective and safe analgesic technique and a clinically attractive alternative to interscalene block with the SSNB'S advantage of similar pain control, morphine use, and less nerve block-related complications during arthroscopic shoulder surgery, especially for severe chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. Given our meta-analysis's relevant possible biases, we required more adequately powered and better-designed RCT studies with long-term follow-up to reach a firmer conclusion.

Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery

»

Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation.

»

While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use.

»

The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures.

»

Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period.

»

Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications.

»

Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.

Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center

PURPOSE

To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.

METHODS

This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges.

RESULTS

A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association.

CONCLUSIONS

Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex.

LEVEL OF EVIDENCE

IV, economic study.

Post-operative pain control following arthroscopic rotator cuff repair: Intravenous acetaminophen versus interscalene brachial plexus block; A prospective randomized study

Background

With the increasing number of patients undergoing arthroscopic rotator cuff repair (ARCR), postoperative pain control in these patients has become an important issue. We investigated and compared post-operative pain relief with intravenous acetaminophen (IA) and interscalene brachial plexus block (IBPB) after ARCR.

Methods

This prospective study involved 66 consecutive patients who underwent ARCR in 2019-2020 at our hospital. Overall, 23 and 43 shoulders were assigned to the IA and IBPB groups, respectively. We evaluated the visual analog scale (VAS) pain scores at rest, during activity, and at night for the first 72 h postoperatively. We compared the results statistically between the groups. A p-value <0.05 was considered statistically significant.

Results

VAS scores for night pain in the IBPB group were significantly lower than those in the IA group for the first 24 h postoperatively (p = 0.017). In contrast, the same scores were significantly lower in the IA group than in the IBPB group at 72 h postoperatively (p = 0.024). Other scores were not significantly different between the groups.

Conclusions

IBPB provides superior night pain control during the first 24 h postoperatively, and IA provides superior night pain control at 72 h postoperatively. However, there were no significant differences in other pain scores between the two groups.

Cost Effective Technique of Shoulder Arthroscopy Without the Use of Epinephrine in Irrigation Solution

Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine.

Risk factors for complications and return to the emergency department after interscalene block using liposomal bupivacaine for shoulder surgery

BACKGROUND

Exparel (liposomal bupivacaine) has recently gained favor for use in interscalene regional blocks for shoulder surgery. While effective for pain relief, this does have adverse effects that can lead to postoperative emergency department (ED) visits. This study aimed to identify any patient risk factors that are associated with complications leading to ED return visits owing to interscalene blocks using Exparel before shoulder surgery.

METHODS

A retrospective chart review was performed for all patients undergoing shoulder surgery with an Exparel interscalene block in an 8-month period. For each patient, demographic information, comorbidities, type of block, postoperative complications, ED return visits, and readmissions were recorded. The 5-factor modified Frailty Index score and the Charlson Comorbidity Index score were calculated. Univariate and multivariate logistic regressions were conducted to identify risk factors associated with increased complications and return to the ED.

RESULTS

Overall, 352 patients were included; most patients were men, were aged between 51 and 70 years, and had a body mass index of 25.0-35.0. Postoperative complications related to the Exparel interscalene block occurred in 58 patients (16.5%), including 37 minor complications (10.5%) and 21 major complications (6.0%) that led to return ED visits. Univariate analysis yielded American Society of Anesthesiologists (ASA) score (P = .03) as a significant predictor of minor complications. Multivariate logistic regression analysis yielded ASA score (P = .096; odds ratio, 1.64) as trending toward being a significant risk factor for minor complications. Univariate analysis yielded age (P = .006), ASA score (P = .009), and Charlson Comorbidity Index score (P = .002) as significant predictors of major complications. Multivariate logistic regression analysis yielded ASA score (P = .049; odds ratio, 2.25) as the only significant risk factor for major complications.

CONCLUSION

Surgeons and anesthesiologists should strongly consider a patient's ASA score, in addition to his or her pulmonary and cardiac history, when deciding whether the patient is an appropriate candidate for an interscalene regional block using Exparel for shoulder surgery.

Pulmonary Comorbidities Are Associated with Increased Major Complication Rates Following Indwelling Interscalene Nerve Catheters for Shoulder Arthroplasty

Pulmonary comorbidities and ASA physical status class III and IV can significantly increase the rate of major complications after ISC placement. Patients with an underlying pulmonary comorbidity or lung disease (chronic obstructive pulmonary disease, asthma, or obstructive sleep apnea) have a 2.2-fold increased risk of having any complication and a 2.4-fold increased risk of having a major pulmonary complication compared to those without pulmonary comorbidities. Patients with pulmonary comorbidities may benefit from alternative pain management strategies to avoid complications in the early postoperative period.

Delayed Neurological Recovery After Ultrasound-Guided Brachial Plexus Block: A Case Report

Introduction

Brachial plexus blocks are frequently practiced and safe mode of anaesthsia. Although minor complications may occur, major complications are a rarity. However, we report a rare case of prolonged supraclavicular brachial plexus block which required almost 4 months to recover without a perceivable cause.

Case Presentation

A 22-year-old gentleman posted for open reduction and internal fixation of both forearm bones was administered an ultrasound-guided supraclavicular brachial plexus block. The intra-operative period was uneventful. However, the block persisted for a very prolonged period of time. All perceivable causes were ruled out. A total of 19 weeks was required for the entire block to regress with no residual neurological deficits thereafter.

Conclusion

Although peripheral neuropathies are known complications of peripheral nerve blocks, such a prolonged brachial plexus block is a rare event. The only plausible cause for the patient’s condition could have been the prolonged drug effect; however, it has been rarely documented.

A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair

PURPOSE

Arthroscopic rotator cuff repair is often associated with severe postoperative pain. Various agents, routes, and modes are used for the treatment of postoperative pain with a minimum of side effects. This systematic work was conducted to compare the postoperative effect of subacromial patient-controlled analgesia with intravenous patient-controlled analgesia after an arthroscopic rotator cuff repair surgery.

DESIGN

A systematic review of relevant studies were retrieved from electronic databases and included based on criteria and eligibility.

METHODS

The articles were retrieved from 1997 to 2018 by computerized searches of Scopus, PubMed, and EMBASE using different combinations of search terms, such as shoulder, rotator cuff, analgesic, analgesia, arthroscopic, pain, cuff repair, rotator cuff repair, acromion, and intravenous.

FINDINGS

A total of 10 articles were included in this study from the initial search of 778 records. Compared with subacromial procedure, the intravenous procedure helps in reducing the postoperative pain but with more side effects.

CONCLUSIONS

This study described that the direct continuous infusion of anesthetic under subacromial analgesic pump showed a greater pain relief with less side effects compared with intravenous infusion for arthroscopic rotator cuff repair.

Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty

Background

Optimal modalities for pain control in shoulder arthroplasty are not yet established. Although regional nerve blockade has been a well-accepted modality, complications and rebound pain have led some surgeons to seek other pain control modalities. Local injection of anesthetics has recently gained popularity in joint arthroplasty. The purpose of this study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade.

Methods

A total of 314 patients underwent TSA and were administered general anesthesia with either a local injection mixture (local infiltration anesthesia [LIA], n = 161) or peripheral nerve block (PNB, n = 144). Patient charts were retrospectively reviewed for postoperative pain scores, 24-hour opioid consumption, and 90-day postoperative complications.

Results

Immediate postoperative pain scores were not significantly different between groups (P = .94). The LIA group demonstrated a trend toward lower pain scores at 24 hours postoperatively (P = .10). Opioid consumption during the first 24 hours following surgery was significantly reduced in the LIA group compared with the PNB group (P < .0001). There was a trend toward fewer postoperative nerve and cardiopulmonary complications in the LIA group than the PNB group (P = .22 and P = .40, respectively)

Conclusion

Periarticular local injection mixtures provide comparable pain control to regional nerve blocks while reducing opioid use and postoperative complications following TSA. Local injection of a multimodal anesthetic solution is a viable option for pain management in TSA.

A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty

BACKGROUND

The ideal analgesic modality for total shoulder arthroplasty (TSA) remains controversial. We hypothesized that a multimodal analgesic pathway incorporating continuous interscalene blockade (ISB) provides better analgesic efficacy than both single-injection ISB and local infiltration analgesia.

METHODS

This single-center, parallel, unblinded, randomized clinical trial evaluated 129 adults undergoing primary TSA. Patients were allocated to single-injection ISB, continuous ISB, or local infiltration analgesia. The primary outcome was the Overall Benefit of Analgesia Score (range, 0 [best] to 28 [worst]) on postoperative day 1. Additional outcomes included pain scores, opioid consumption, quality of life, and postoperative complications in the first 24 hours, at 3 months, and at 1 year.

RESULTS

We analyzed 125 patients (42 with single-injection ISB, 41 with continuous ISB, and 42 with local infiltration analgesia). The Overall Benefit of Analgesia Score was significantly improved in the continuous group (median [25th percentile, 75th percentile], 0 [0, 2]) compared with the single-injection group (2 [1, 4]; P = .002) and local infiltration analgesia group (3 [2, 4]; P < .001). Pain scores were significantly lower in the continuous group compared with the local infiltration analgesia group (P < .001 for all time points) and after 12 hours from ward arrival compared with the single-injection group (median [25th percentile, 75th percentile], 1.0 [0.0, 2.8] vs. 2.5 [0.0, 4.0]; P = .016). After postanesthesia recovery discharge, opioid consumption (oral morphine equivalents) was significantly lower in the continuous group (median [25th percentile, 75th percentile], 7.5 mg [0.0, 25.0 mg]) than in the local infiltration analgesia group (30 mg [15.0, 52.5 mg]; P < .001) and single-injection group (17.6 mg [7.5, 45.5 mg]; P = .010). No differences were found across groups for complications, 3-month outcomes, and 1-year outcomes.

CONCLUSION

Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after TSA.

A comparison of continuous interscalene block versus general anesthesia alone on the functional outcomes of the patients undergoing arthroscopic rotator cuff repair

PURPOSE

The aim of this prospective and randomized study was to compare the effects of general anesthesia to the combination of general anesthesia and continuous interscalene block on postoperative pain and functional outcomes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included a total of 85 patients aged 45-74 years, who were scheduled for elective arthroscopic rotator cuff repair. One group consists of patients who underwent only general anesthesia (GA, N = 43), and the other group consists of patients who underwent a combination of continuous interscalene brachial plexus block and general anesthesia (CISB + GA, N = 42). Pain levels of the patients were evaluated postoperatively by a visual analog scale. Shoulder function was evaluated preoperatively and postoperatively using the Constant score.

RESULTS

Patients in the CISB + GA group had lower postoperative visual analog scores and less additional analgesic needs during the early postoperative period than those in the GA group. Constant scores of the patients in the CISB + GA group at postoperative week 6 were higher than those in the GA group. Evaluation of the functional outcomes at 6 months postoperatively showed that there were no significant differences between the two groups.

CONCLUSION

Although CISB significantly improved postoperative pain control and early (in the first 6 weeks) functional outcomes following arthroscopic rotator cuff repair, there was no significant difference between the CISB group and CISB + GA group at 6 months.

LEVEL OF EVIDENCE

Level II, Randomized Controlled Trial, Treatment Study.

Total Spinal Anesthesia Following an Interscalene Block Treated with Intravenous Lipid Emulsion

Total spinal anesthesia following interscalene block is a rare and life-threatening complication of regional anesthesia. A 56-year-old woman underwent an uncomplicated left shoulder bone spur removal under general anesthesia with an interscalene nerve block at an outpatient surgical center. Subsequently, she developed bilateral mydriasis, paralysis of all extremities, and respiratory arrest. She was intubated and transferred to the emergency department (ED) where she was given intravenous lipid emulsion (ILE) with complete recovery of neurological function. ILE therapy may be considered as a rescue treatment in addition to supportive therapy for total spinal anesthesia.

Local infiltration analgesia versus interscalene nerve block for postoperative pain control after shoulder arthroplasty: a prospective, randomized, comparative noninferiority study involving 99 patients

BACKGROUND

The aim of this study was to compare the efficacy of local infiltration analgesia (LIA) and interscalene nerve block (ISB) for early postoperative pain control after total shoulder arthroplasty (TSA). The hypothesis was that LIA is not inferior to ISB.

METHODS

A prospective, randomized controlled study was performed in 2014-2016. All patients who underwent TSA for shoulder osteoarthritis were included. Patients in the ISB group received a continuous infusion of 0.2% ropivacaine by perineural catheter for 48 hours. The surgeon injected 110 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and 0.5 mg of epinephrine before TSA in the LIA group and inserted a catheter into the glenohumeral joint. The next morning, 10 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and epinephrine were injected through the catheter, which was then removed. The primary outcome was the mean shoulder pain score for the 48-hour postoperative period on a numerical scale (0-10). The secondary outcomes were postoperative opioid requirements, complications, and shoulder function at the 1-month follow-up visit. The sample size was calculated for a noninferiority study.

RESULTS

The study included 99 patients (50 LIA and 49 ISB patients) with a mean age of 72 ± 9.6 years. Although no significant difference in the mean pain score was found between the 2 groups for the 48-hour postoperative period (1.4 ± 0.9 for LIA vs 1.7 ± 1 for ISB, P = .19), the LIA group had significantly less severe pain (P = .003) and less opioid consumption (P = .01) in the recovery room. No complications occurred. A negative but nonsignificant correlation was found between postoperative pain and Constant score at the 1-month follow-up.

CONCLUSION

LIA is not less effective than ISB for early postoperative pain control after TSA.

Ultrasound Guidance Enhances the Efficiency of Brachial Plexus Block and Ameliorates the Vascular Injury Compared with Nerve Stimulator Guidance in Hand Surgery Patients

Background: Nerve stimulation guidance and ultrasound guidance are two major methods that have been widely accepted and applied in axillary brachial plexus block. However, the differences between the effects of these two types of guidance still need to be further elucidated for clinical usage. Materials and Methods: Overall, 208 patients undergoing elective upper limb surgeries and receiving axillary brachial plexus block were recruited in our study. The patients were randomly assigned to receive either ultrasound guidance (group U, n = 112) or nerve stimulation (group N, n = 96). Pinprick test was performed for assessing the sensory blockades. The pain was evaluated by visual analog scale (VAS). Reactive oxygen species (ROS) levels were measured by dichloro-dihydro-fluorescein diacetate staining and serum levels of nitric oxide (NO), nitric oxide synthases (NOS), tumor necrosis factor (TNF)-α, and monocyte chemoattractant protein 1 (MCP1) were evaluated by ELISA. Results: Ultrasound guidance significantly enhanced the quality of the sensory blockade and reduced the VAS scores when compared with the nerve stimulator guidance. In addition, the production of ROS, NO, NOS, TNF-α, and MCP-1 were significantly alleviated by ultrasound guidance. Conclusion: Ultrasound-guided brachial plexus block relieves pain during operation, provides higher success rates in the nerve block, causes less vascular damage and results in lower levels of inflammatory cytokines secretion when compared with neurostimulator-directed brachial plexus blockage.

Suprascapular Nerve Blockade for Postoperative Pain Control After Arthroscopic Shoulder Surgery: A Systematic Review and Meta-analysis

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.

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.].

Pain Management Strategies in Shoulder Arthroplasty

Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between patients, surgeon, and anesthetist. A multimodal approach with preemptive medication, regional blockade, local anesthetics, and a combination of acetaminophen, nonsteroidal antiinflammatory drugs, tramadol, and gabapentinoids postoperatively leads to pain control and patient satisfaction. Assessment of patients' expectations constitutes a vital aspect of the preoperative patient evaluation. Educating and psychologically preparing patients reduces postoperative pain. Patients with anxiety and depression, preoperative narcotic use, and medical comorbidities are at an increased risk for suboptimal pain control. Minimizing narcotic use decreases opioid-related adverse effects and facilitates productive rehabilitation efforts.

Neurologic complications of shoulder joint replacement

BACKGROUND

Little attention has been given to neurologic complications after shoulder joint replacement (SJR). Previously thought to occur infrequently, it is likely that many are not clinically recognized, and they can result in postoperative morbidity and impair the patient's recovery. The purpose of this study was to document the prevalence of nerve complications after SJR, to identify the nerves involved, and to define patient outcomes.

METHODS

This was a retrospective review of 211 SJRs in 202 patients during a 5-year period were included, with 89 male and 122 female patients at an average age of 70 years. All patients underwent a comprehensive analysis of any postoperative nerve complication, including onset, duration, investigation, treatment, and symptom resolution.

RESULTS

Of the 211 SJR procedures, 44 were identified as having sustained a nerve complication (20.9%), with 36 female (81.8%) and 8 male patients (18.2%). Reverse SJR was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved. Most nerve complications were transient and resolved within 6 months. Permanent sequelae and injuries that required secondary surgical intervention were rare.

CONCLUSION

The occurrence of nerve complications after SJR is common, but almost all will fully recover. Most are transient neurapraxias involving the lateral cord of the brachial plexus. Women are more likely to be affected, as are patients who have undergone prior surgery to the affected shoulder. Most are likely to be the result of excessive traction or direct injury to the nerves during glenoid exposure.

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.].

Pre- or postoperative interscalene block and/or general anesthesia for arthroscopic shoulder surgery: a retrospective observational study

PURPOSE

Arthroscopic shoulder surgery can be performed with an interscalene brachial plexus block (ISBPB) alone, ISBPB combined with general anesthesia (GA), or GA alone. Postoperative pain is typically managed with opioids; however, both GA and opioids have adverse effects which can delay discharge. This retrospective study compares the efficacy of four methods of anesthesia management for arthroscopic shoulder surgery.

METHODS

Charts of all patients who underwent shoulder surgery by a single surgeon from 2012-2015 were categorized by analgesic regimen: GA only (n = 177), single-shot ISBPB only (n = 124), or pre- vs postoperative ISBPB combined with GA (ISBPB + GA [n = 72] vs GA + ISBPB [n = 52], respectively). The primary outcome measure was the time to discharge from the postanesthesia care unit (PACU).

RESULTS

Mean (SD) time in the PACU ranged from 70.5 (39.9) min for ISBPB only to 111.2 (56.9) min for GA only. Use of ISBPB in any combination and regardless of timing resulted in significantly reduced PACU time, with a mean drop of 27.2 min (95% confidence interval [CI], 17.3 to 37.2; P < 0.001). The largest mean pairwise difference was between GA only and ISBPB only, with a mean difference of 40.7 min (95% CI, 25.5 to 55.8; P < 0.001). Use of ISBPB also reduced pain upon arrival at the PACU and, in some cases, upon discharge from the PACU (i.e., ISBPB only but not ISBPB + GA compared with GA). An ISBPB (alone or prior to GA) also reduced analgesic requirements.

CONCLUSION

Previously reported benefits of an ISBPB for arthroscopic shoulder surgery are confirmed. Postoperative ISBPBs may also be beneficial for reducing pain and opioid requirements and could be targeted for patients in severe pain upon emergence. A sufficiently powered randomized-controlled trial could determine the relative efficacy, safety, and associated financial implications associated with each method.

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial

BACKGROUND

Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB).

METHODS

This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05.

RESULTS

Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different.

CONCLUSION

Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.

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.

Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery

PURPOSE

The goal of the study was to evaluate the efficacy of additional axillary nerve block (ANB) with suprascapular nerve block (SSNB) and patient-controlled anaesthesia (PCA) with no device assistance after arthroscopic rotator cuff repair. The hypothesis is that patients with intravenous (IV) PCA and the blockade of the two main nerves (SSNB + ANB) experienced lesser pain than patients with IV PCA or IV PCA + SSNB.

METHODS

The 114 patients undergoing arthroscopic rotator cuff repair were allocated randomly to three groups as follows: group I, intravenous PCA pumps (only PCA); group II, IV PCA + SSNB using a blind technique (PCA + SSNB); and group III, IV PCA + SSNB + ANB using a blind technique (PCA + SSNB + ANB). Pain visual analogue scale (VAS) scores were evaluated at 1, 6, 12, 24, 36, and 48 post-operative hours. Furthermore, the degree of pain was compared according to cuff tear size.

RESULTS

The pain VAS score of group III was lower than that of the other two groups and was significantly lower at post-operative hours 1, 6, and 12. In addition, the larger cuff tear tended to be indicative of greater pain. However, all groups experienced rebound pain.

CONCLUSION

PCA + SSNB + ANB using a blind technique is a better pain control method than PCA + SSNB and only PCA during the initial 12 post-operative hours. PCA + SSNB + ANB is a cost-effective, time-saving, and easily performed method for post-operative pain control as an axis of multimodal pain control strategy.

LEVEL OF EVIDENCE

II.

Suprascapular Nerve Block Versus Interscalene Block as Analgesia After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Noninferiority Trial

PURPOSE

To compare the efficacy of suprascapular nerve block (SSB) and interscalene block (ISB) as postoperative analgesia within the first 24 hours after arthroscopic supraspinatus and/or infraspinatus tendon repair.

METHODS

A single-blind, randomized controlled study was performed between 2013 and 2014. The inclusion criteria were arthroscopic supraspinatus and/or infraspinatus tendon repair confirmed intraoperatively, with or without associated procedures, and informed consent. The exclusion criteria were a previously operated shoulder, repair of the subscapularis tendon, and an allergy to local anesthetics. ISB was performed under ultrasound guidance by an anesthesiologist, whereas SSB was performed based on specific anatomic landmarks by a surgeon. The primary evaluation criterion was mean shoulder pain score during the first postoperative 24 hours assessed on a visual analog scale by the patient. The secondary criteria were complications of locoregional anesthesia, the use of analgesics in the recovery room (the first 2 hours) until postoperative day 7, and pain (visual analog scale) during the first week. Forty-four patients were needed for this noninferiority study. An institutional review board approved the study.

RESULTS

Seventy-four patients were randomized, and 59 met the intraoperative inclusion criteria. Six patients were excluded (1 for pneumothorax after ISB, 1 for unsuccessful SSB, and 4 for incomplete questionnaires). None of the patients were lost to follow-up. There was no significant difference between the SSB and ISB groups in mean pain score for the first 24 hours (P = .92) or the first 7 days (P = .05). However, there was significantly less pain in the ISB group in the recovery room (P = .01). Consumption of analgesics was comparable between the groups, but the SSB group took significantly more morphine in the recovery room.

CONCLUSIONS

In this prospective, randomized controlled study, SSB was as effective as ISB for mean pain control within the first 24 hours but ISB was more effective in relieving pain in the recovery room after arthroscopic supraspinatus and/or infraspinatus tendon repair.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

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.

A prospective, randomized and controlled study of interscalene brachial plexus block for arthroscopic shoulder surgery: A comparison of C5 and conventional approach, a CONSORT-compliant article

BACKGROUND

The shoulder area is mainly innervated with the C5 and C6 nerve roots, and interscalene brachial plexus block (ISB) is widely used for postoperative analgesia after shoulder surgery. However, it is associated with adverse effects, such as numbness and weakness in the blocked arm due to an unwanted block of the lower brachial plexus (C7-T1). We hypothesized that the C5 approach during ISB would provide postoperative analgesia while minimizing adverse events after arthroscopic shoulder surgery.

METHODS

A total of 92 patients scheduled for arthroscopic shoulder surgery were enrolled and randomly assigned to 1 of the 3 groups: The control (no ISB, n = 31), conventional ISB (ISB with the conventional approach, n = 31), or C5 ISB (ISB with the C5 approach, n = 30) group. ISB was performed before the induction of anesthesia, and a subacromial catheter was placed in all patients at the end of the surgery. Postoperative pain scores, numbness, and weakness were recorded at 2, 8, and 24 hours after surgery. Oxygen saturation and overall patient satisfaction scores were also assessed at 1 and 48 hour after surgery, respectively.

RESULTS

The pain scores were lower in the conventional ISB group and the C5 ISB group than in the control group at postoperative 2 and 8 hours (P < 0.05). The incidence and degree of numbness and weakness of the blocked arm were significantly lower in the C5 ISB group than in the conventional ISB group (P < 0.05). Oxygen saturation were lower in the conventional ISB group and C5 ISB group than in the control group (P = 0.01). Overall patient satisfaction scores were higher in the C5 ISB group than in the control or conventional ISB group (P < 0.01).

CONCLUSION

The C5 approach for ISB provides analgesia as effectively as the conventional approach following arthroscopic shoulder surgery, with the advantages of minimal numbness and weakness.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety

BACKGROUND

Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure.

HYPOTHESIS

The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period.

PATIENTS AND METHODS

Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients.

RESULTS

Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes.

CONCLUSION

No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery.

LEVEL OF EVIDENCE

III, prospective, comparative, non-randomised study.

Horner's Syndrome after Scalene Block and Carotid Dissection

BACKGROUND

Horner's syndrome refers to the clinical triad of ptosis, miosis, and anhidrosis resulting from disruption of the ocular and facial sympathetic pathways. A myriad of etiologies can lead to Horner's syndrome; awareness of the underlying anatomy can assist physicians in identifying potential causes and initiating appropriate care.

CASE REPORT

Two patients presented to our Nashville-area hospital in 2014. Patient 1 was a 26-year-old man who noticed facial asymmetry one day after an outpatient orthopedic procedure. His symptoms were attributed to his posterior interscalene anesthesia device; with deactivation of this device, the symptoms rapidly resolved. Patient 2 was a 42-year-old man who presented to our emergency department with persistent headache and ptosis over several weeks. Computed tomography angiography revealed ipsilateral carotid dissection and the patient was admitted for further management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The pathologies underlying Horner's syndrome are exceedingly diverse. Although classic teaching often focuses on neoplastic causes, and more specifically Pancoast tumors, neoplasms are discovered only in a small minority of Horner's syndrome cases. Other etiologies include trauma, cervical artery dissection, and infarction. With a better understanding of the pertinent anatomy and array of possible etiologies, emergency physicians may have more success in identifying and treating the causes of Horner's syndrome.