A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia

Addition of preoperative ultrasound-guided suprascapular nerve block and axillary nerve block to parecoxib is more effective in early postoperative pain control following arthroscopic rotator cuff repair: a prospective randomized controlled study

PURPOSE

The purpose of the study was to prospectively compare the pain intensity and patient-reported outcomes (PROs) following arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only.

METHODS

Sixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n=30) or control group (group C, n=31). Two patients from group C were excluded because of miscommunication. All patients were administered parecoxib 40 mg intravenously prior to induction of anesthesia. In group N, SSNB/ANB were performed after general anesthesia while no nerve block was performed in group C. The pain intensity was compared before the surgery, as well as immediately, 24 hours and 2 weeks after the surgery. PROs, including Oxford shoulder score, University of California-Los Angeles shoulder score and Single Assessment Numeric Evaluation score, were compared before and 6 months after the surgery.

RESULTS

The resting pain numerical rating scale (NRS) was significantly lower in group N (4.9 ± 3.1 vs. 7.6 ± 2.5, p<0.001) immediately after the surgery, but no difference was noted 24 hours after the surgery. The resting pain NRS 2 weeks after the surgery was significantly lower in group N (1.4 ± 1.6 vs. 2.7 ± 2.7, p=0.03), but the movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after the surgery in both groups, but there was no difference between the 2 groups.

CONCLUSION

Addition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after the surgery.

LEVEL OF EVIDENCE

Level 2 prospective randomized controlled trial.

General anesthesia versus combined interscalene nerve/superficial cervical plexus block in arthroscopic rotator cuff repair: A randomized prospective control trial

BACKGROUND

In this study, interscalene brachial plexus block (ISB) with superficial cervical plexus block added and general anesthesia (GA) application were evaluated in terms of intraoperative hemodynamics, operative time and postoperative analgesia need in patients who underwent rotator cuff tear repair.

METHODS

70 patients aged between 18 and 75 years were included in this prospective study. Arthroscopic rotator cuff tear repair surgery was performed in all patients. The patients were randomized into 2 groups, namely Group ISB who received a combination of superficial cervical plexus block added to the Interscalene Nerve Block, and Group GA, for those who received GA. Duration of operation, waiting times, intraoperative hemodynamic data, postoperative visual analog scale (VAS), analgesic requirement, as well as patient and surgeon satisfaction levels, were compared between the 2 groups.

RESULTS

While VAS values at the post-anesthesia care unit were lower in ISB group at 2 and 24 hours (P < .05), there was no significant difference between VAS values measured at 6th and 12th hours (P ≥ .05). In the GA group, postoperative morphine and diclofenac consumption was higher, and rescue analgesia was needed earlier (P < .05). The hospital stay was shorter (P < .05), and surgeon and patient satisfaction were higher in the ISB group (P < .05).

CONCLUSION SUBSECTIONS

In rotator cuff tear repair anesthesia, ISB with superficial cervical plexus block provides adequate intraoperative anesthesia, low postoperative VAS level, reduced and deferred consumption of opioids and nonsteroidal anti-inflammatory drugs, higher patient and surgeon satisfaction and early discharge.

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.

Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial

BACKGROUND

While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty.

METHODS

Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block.

RESULTS

The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA.

CONCLUSIONS

LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Does the use of periarticular anesthetic cocktail provide adequate pain control following shoulder arthroplasty?

BACKGROUND

Interscalene nerve block and liposomal bupivacaine have been found to provide adequate pain control following shoulder arthroplasty. We hypothesized that local infiltration of a periarticular cocktail would provide equivalent pain control compared to interscalene nerve block and liposomal bupivacaine.

METHODS

Eighty-seven patients undergoing primary shoulder arthroplasty were treated with local infiltration of a periarticular cocktail (200 mg of 0.5% ropivacaine, 1 mg epinephrine, and 30 mg ketorolac), local infiltration of liposomal bupivacaine, or preoperative interscalene nerve block. The outcomes of the study were postoperative visual analog scale scores, opioid consumption, length of stay, and complications.

RESULTS

A total of 30 patients receiving local infiltration of a periarticular cocktail, 26 receiving liposomal bupivacaine, and 31 receiving interscalene nerve block were included in the study. Patients who received local infiltration of a periarticular cocktail had a significantly lower mean visual analog scale when compared to interscalene nerve block and liposomal bupivacaine on postoperative day 0 (2.5 versus 4.0 versus 4.8, P = 0.001 and P < 0.001). Pain scores between postoperative day 0-3 were lower in patients who received local infiltration of a periarticular cocktail, but not significantly. Patients who received local infiltration of a periarticular cocktail required significantly less opioids than the interscalene nerve block group on postoperative day 0 (P < 0.001).

DISCUSSION

A decrease in early postoperative pain and opioid consumption was found with local infiltration of a periarticular cocktail when compared with interscalene nerve block and liposomal bupivacaine after shoulder arthroplasty.Level of evidence: Level II.

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.

Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background

Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB).

Hypothesis

We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3.

Results

The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001).

Conclusion

VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.

Single-Shot Liposomal Bupivacaine Reduces Postoperative Narcotic Use Following Outpatient Rotator Cuff Repair: A Prospective, Double-Blinded, Randomized Controlled Trial

BACKGROUND

Liposomal bupivacaine (LB) theoretically is longer-acting compared with conventional bupivacaine. The purpose of this study was to compare conventional bupivacaine combined with dexamethasone (control group), LB combined with conventional bupivacaine (LB group), and LB combined with dexamethasone and conventional bupivacaine (LBD group) in a perineural interscalene nerve block during ambulatory arthroscopic rotator cuff repair to determine if LB decreased postoperative narcotic consumption and pain. The effect of supplemental dexamethasone on prolonging the analgesic effect of LB was also assessed.

METHODS

This was a prospective, double-blinded, randomized controlled trial of 76 consecutive patients who underwent outpatient arthroscopic rotator cuff repair. Patients were randomized into the 3 interscalene-block treatment groups: control group (n = 26), LB group (n = 24), and LBD group (n = 26). Outcome measures included pain measured with a visual analog scale (VAS; 0 to 10) and narcotic consumption measured in oral morphine milligram equivalents (MME). Both were measured daily on postoperative day 0 through postoperative day 4.

RESULTS

Generalized estimating equation modeling revealed that narcotic consumption across all time points (postoperative days 0 to 4) was significantly lower in the LB group compared with the control group (mean difference, -8.5 MME; 95% confidence interval, -15.4 to -1.6; p = 0.015). Narcotic consumption was significantly higher in the control group on postoperative days 2 and 3 compared with the LB group (p = 0.004 and p = 0.02, respectively) and the LBD group (p = 0.01 and p = 0.003, respectively). There was no difference in narcotic consumption between the LBD and LB groups on any postoperative day. VAS pain scores in all groups were similar across all postoperative days.

CONCLUSIONS

Among patients undergoing outpatient arthroscopic rotator cuff repair, the addition of LB to conventional bupivacaine in interscalene nerve blocks appeared to be effective in controlling postoperative pain. Because LB with and without dexamethasone decreased postoperative narcotic use, LB should be considered for use in preoperative interscalene nerve blocks to reduce the reliance on narcotics for pain management.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Dexamethasone added to levobupivacaine prolongs the duration of interscalene brachial plexus block and decreases rebound pain after arthroscopic rotator cuff repair

BACKGROUND

It has been reported that the addition of dexamethasone to interscalene brachial plexus block (ISBPB) prolongs the duration of the block effect. However, there have been no studies focusing on the effects of dexamethasone on rebound pain after the block effect has worn off. The aim of this study was to investigate the effect on postoperative pain when dexamethasone was added to ISBPB for arthroscopic rotator cuff repair (ARCR).

METHODS

In this multicenter, single-blinded, and randomized controlled study, 54 patients (33 males, 21 females) who received ARCR were randomly assigned to group L (ISBPB with 20 cc of 0.25% levobupivacaine; 21 patients) or group LD (ISBPB with 20 cc of 0.25% levobupivacaine + 3.3 mg dexamethasone; 33 patients). The primary outcome was the visual analog scale (VAS) for pain after the block effect had worn off. Secondary outcomes were the duration of analgesia, the time to the first request for additional analgesic, the number of additional doses of analgesic, and complications.

RESULTS

The VAS scores on postoperative days 0 and 1 were significantly lower in group LD than group L (P = .005, .035). This indicated that the rebound pain was relieved in group LD. After postoperative day 1, there was no significant difference in VAS score (P = .43 and .19 for days 2 and 3, respectively). The duration of analgesia was significantly longer in group LD than group L (P < .001). The time to the first request for additional analgesic was significantly longer in group LD than group L (P < .001). The number of additional doses of analgesic was significantly lower in group LD (P < .001).

CONCLUSION

In ARCR, the addition of dexamethasone to levobupivacaine not only prolongs the duration of ISBPB but also relieves rebound pain after the block effect wears off.

Combination Preemptive Peripheral Nerve Block in Limb Surgery. A Prospective Study

Background and objectives: Patients often suffer from moderate to severe pain during the early recovery period in orthopedic surgery. We investigated the impact of a single-shot preoperative peripheral nerve block (PNB) on post-anesthesia recovery parameters and interleukin (IL)-6 level during limb surgery. Materials and Methods: A prospective randomized controlled study was conducted, and patients scheduled for limb surgery were recruited. Sixty patients were randomly assigned to either the PNB group or control group, who received morphine as a primary analgesic. The peak verbal numeric rating scale (NRS) score in the post-anesthesia care unit (PACU) was evaluated as a primary outcome. We also recorded rescue analgesics requirement and wake-up time from anesthesia in the PACU. In addition, the change of plasma IL-6 level after incision was measured. Results: Fifty-two patients completed the study, 27 and 25 cases in the PNB and control group, respectively. Preemptive PNB significantly reduced peak NRS score in the PACU compared to control group. Lower rescue analgesics requirement and rapid wake-up from anesthesia were also noted in PNB group. The IL-6 concentration increased less in the PNB group at 2 h after incision. Conclusions: Preemptive PNB attenuates IL-6 expression 2 h after incision and improves pain management in the PACU. PNB was considered as an essential part of pain management in limb surgery.

Randomized trial protocol of interscalene nerve block vs liposomal bupivacaine injection after total shoulder arthroplasty

BACKGROUND

The possibility of local infiltration analgesia (LIA) replacing interscalene blockade (ISB) as an integral component of a multimodal clinical pathway for total shoulder arthroplasty (TSA) needs to be further investigated. We thus further designed a randomized controlled study to compare LIA with ISB in the treatment of TSA.

METHODS

This blinded and randomised study was performed after approval of the institutional review board in the first affiliated hospital of Jinan University. The included patients were all aged over 18 years and underwent shoulder arthroplasty because of osteoarthritis of the shoulder. Subjects were randomized into 2 groups as follows: LIA or ISB. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery. Secondary outcomes included pain scores, length of hospital stay, complication, and satisfaction score. P value < .05 was considered statistically significant.

RESULTS

For the present trial, we hypothesized that there would be no difference in pain score levels and opioid medication use throughout admission.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5640).

Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis

BACKGROUND

Interscalene block (ISB) is the acute pain management technique of choice for shoulder surgery, but its undesirable respiratory side effects have prompted seeking alternatives. Supraclavicular block (SCB) is proposed as an ISB alternative, but evidence of comparative analgesic and respiratory-sparing effects is inconsistent. We compared the analgesic and respiratory effects of SCB and ISB for shoulder surgery.

METHODS

Trials comparing ISB to SCB for shoulder surgery were sought. We decided a priori that SCB would be an acceptable alternative if it were noninferior for (1) postoperative 24-hour cumulative oral morphine equivalent consumption (primary outcome, noninferiority margin Δ = -25 mg) and (2) postoperative pain (secondary outcome, noninferiority margin Δ = 4.0 cm·hour); and superior for (3) postblock respiratory dysfunction (primary outcome). Opioid-related side effects and block-related complications were also evaluated.

RESULTS

Fifteen studies (1065 patients) were analyzed. In single-injection blocks, SCB was noninferior to ISB for 24-hour morphine consumption (mean difference for SCB-ISB, MD [95% confidence interval {CI}] = -3.11 mg [-9.42 to 3.19], Δ = -25 mg); it was also noninferior for 24-hour pain scores (MD = 0.78 cm·hour [0.07-1.49], Δ = 4.0 cm·hour); and decreased the odds of respiratory dysfunction (odds ratio [OR] [95% CI] = 0.08 [0.01-0.68]). Similarly, in continuous blocks, SCB was noninferior to ISB for 24-hour morphine consumption (MD = 0.46 mg [-6.08 to 5.15], Δ = -25 mg), and decreased the odds of respiratory dysfunction (OR = 0.22 [0.08-0.57]). SCB also decreased odds of minor block-related complications (OR = 0.36 [0.20-0.68] and OR = 0.25 [0.15-0.41] for single-injection and continuous blocks, respectively). Consequently, the null joint-hypothesis was rejected, and SCB can be considered an acceptable alternative to ISB.

CONCLUSIONS

For acute pain control following shoulder surgery, high-quality evidence indicates that SCB can be used as an effective ISB alternative. SCB is noninferior for postoperative opioid consumption and acute pain, and it reduces the odds of postblock respiratory dysfunction.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant)

INTRODUCTION

Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain.

METHODS

This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat.

DISCUSSION

This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.

TRIAL REGISTRATION NUMBER

NCT03691922; Recruited Date of registration: October 2, 2018.

Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal

INTRODUCTION

Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included.

RESULTS

Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia.

CONCLUSIONS

This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.

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.

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.].

Advances in Experimental Medicine and Biology: Intrafascicular Local Anesthetic Injection Damages Peripheral Nerve-Induced Neuropathic Pain

Peripheral nerve blockade (PNB) is advantageous for patients undergoing surgery to decrease the perioperative opioid consumptions and enhance recovery after surgery.Inadvertent local anesthetic (LA) administration into nerve fiber intrafascicularly easily results in unrecognized nerve injury. Using nerve block guidance either by ultrasound, electrical nerve stimulator, or using pressure devices does not prevent nerve damage, even though most of the nerve injury is transiently. The incidence of neurologic symptoms or neuropathy is in the range of 0.02-2.2%, and no significant difference of postoperative neurologic symptoms is found as compared with using ultrasound or guided nerve stimulator technique. However, intrafascicular lidocaine brought about macrophage migration into the damaged fascicle, Schwann cell proliferation, increased intensity of myelin basic protein, and shorten withdrawal time to mechanical stimuli. In dorsal root ganglion (DRG), intrafascicular LA injection increased the activated transcriptional factor 3 (ATF-3) and downregulated Nav1.8 (Nav1.8). In spinal dorsal horn (SDH), the microglia and astrocytes located in SDH were activated and proliferated after intrafascicular LA injection and returned to baseline gradually at the end of the month. This is a kind of neuropathic pain, so low injection pressure should be maintained, the correct needle bevel used, nerve stimulator or ultrasound guidance applied, and careful and deliberately slow injection employed as important parts of the injection technique to prevent intrafascicular LA administration-induced neuropathic pain.

Suprascapular and Interscalene Nerve Block for Shoulder Surgery

Background

Interscalene block provides optimal shoulder surgery analgesia, but concerns over its associated risks have prompted the search for alternatives. Suprascapular block was recently proposed as an interscalene block alternative, but evidence of its comparative analgesic effect is conflicting. This meta-analysis compares the analgesic effect and safety of suprascapular block versus interscalene block for shoulder surgery.

Methods

Databases were searched for randomized trials comparing interscalene block with suprascapular block for shoulder surgery. Postoperative 24-h cumulative oral morphine consumption and the difference in the area under curve for pooled rest pain scores were designated as primary outcomes. Analgesic and safety outcomes, particularly block-related and respiratory complications, were evaluated as secondary outcomes. Results were pooled using random-effects modeling.

Results

Data from 16 studies (1,152 patients) were analyzed. Interscalene block and suprascapular block were not different in 24-h morphine consumption. The difference in area under the curve of pain scores for the 24-h interval favored interscalene block by 1.1 cm/h, but this difference was not clinically important. Compared with suprascapular block, interscalene block reduced postoperative pain but not opioid consumption during recovery room stay by a weighted mean difference (95% CI) of 1.5 cm (0.6 to 2.5 cm; P &lt; 0.0001). Pain scores were not different at any other time. In contrast, suprascapular block reduced the odds of block-related and respiratory complications.

Conclusions

This review suggests that there are no clinically meaningful analgesic differences between suprascapular block and interscalene block except for interscalene block providing better pain control during recovery room stay; however, suprascapular block has fewer side effects. These findings suggest that suprascapular block may be considered an effective and safe interscalene block alternative for shoulder surgery.

Comparison of liposomal bupivacaine infiltration versus interscalene nerve block for pain control in total shoulder arthroplasty: A meta-analysis of randomized control trails

BACKGROUND

This meta-analysis aimed to compare the efficiency and safety of liposomal bupivacaine infiltration and interscalene nerve block for pain control after total shoulder arthroplasty.

METHODS

A systematic search was performed in Medline (1966 to May 2017), PubMed (1966 to May 2017), Embase (1980 to May 2017), ScienceDirect (1985 to May 2017) and the Cochrane Library. Only randomized controlled trials (RCTs) were included. Reported surgical outcomes, including visual analogue scale (VAS) scores, opioid consumption, length of stay, and postoperative adverse effects including the risk of nausea and vomiting. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Four RCTs including 510 patients met the inclusion criteria. The present meta-analysis indicated that there were no significant differences between groups in terms of VAS score at 12 hours (standard mean difference [SMD] = 0.272, 95% CI: -0.150 to 0.695, P = .207), 24 hours (SMD = -0.056, 95% CI: -0.458 to 0.346, P = 0.785), and 48 hours (SMD = 0.183, 95% CI: -0.148 to 0.513, P = .278). Liposomal bupivacaine infiltration groups required an equivalent amount of opioids at postoperative 12 hours (SMD = -0.039, 95% CI: -0.222 to 0.143, P = .672), 24 hours (SMD = 0.046, 95% CI: -0.136 to 0.228, P = .618) and 48 hours (SMD = -0.025, 95% CI: -0.207 to 0.157, P = .785).

CONCLUSION

Liposomal bupivacaine infiltration provides equivalent postoperative pain control compared with interscalene nerve block following total shoulder arthroplasty. Both of them can reduce the consumption of opioids without severe adverse effects. More high-quality RCTs with long follow-up period are necessary for proper comparisons of the efficacy and safety of liposomal bupivacaine infiltration with interscalene nerve block.

Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To compare the effects of a single-dose interscalene block and general anesthesia (SISB/GA) with the effects of GA only in the early postoperative period after arthroscopic rotator cuff repair by evaluating subjective pain visual analog scale scores and objective pain-related stress biomarkers.

METHODS

Patients refractory to conservative treatment of the affected shoulder were enrolled in this prospective, randomized endpoint study. Patients diagnosed with a rotator cuff tear (1-4 cm) based on magnetic resonance imaging were included. Exclusion criteria were small (<1 cm) and massive (>4 cm) rotator cuff tears. Thirty-one patients each were randomized into the SISB/GA and GA treatment groups. Preoperative pain scores were measured at 6:00 AM on the day of surgery, measured again at 1 and 6 hours postoperatively, and then every 6 hours until 3 days postoperatively. Blood sampling was performed to evaluate the stress biomarkers insulin, dehydroepiandrosterone sulfate, and fibrinogen preoperatively at 6:00 AM on the day of surgery and postoperatively at 18, 42, and 66 hours (6:00 AM on postoperative days 1-3).

RESULTS

Pain scores were significantly decreased in the SISB/GA group (2.50 ± 0.94) versus the GA group (3.82 ± 1.31) on the day of surgery (P < .001), and especially at 6 hours postoperatively (SISB/GA: 2.42 ± 1.43; GA: 4.23 ± 2.17; P < .001). Insulin was decreased significantly in the SISB/GA group (10.55 ± 7.92 μU/mL) versus the GA group (20.39 ± 25.60 μU/mL) at 42 hours postoperatively (P = .048). There was no significant change in dehydroepiandrosterone sulfate or fibrinogen over time (P > .05).

CONCLUSIONS

After arthroscopic rotator cuff repair, an SISB effectively relieved pain on the day of surgery without any complications. In addition, insulin levels were significantly reduced at 42 hours postoperatively.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial

BACKGROUND

On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block.

METHODS

A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2.

RESULTS

There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups.

CONCLUSIONS

There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

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.

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Particulate-steroid betamethasone added to ropivacaine in interscalene brachial plexus block for arthroscopic rotator cuff repair improves postoperative analgesia

Background

Dexamethasone added to local anesthetic for brachial plexus block improves postoperative pain after arthroscopic rotator cuff repair, as compared with the use of local anesthetic alone. Dexamethasone is present in non-particulate form in local anesthetic solution, while betamethasone is partially present in particulate form. The particulate betamethasone gradually decays and is expected to cause its longer-lasting effect. This study investigated the postoperative analgesic effect of betamethasone added to ropivacaine for brachial plexus block in patients who underwent arthroscopic rotator cuff repair.

Methods

This was a prospective, randomized, triple-blind study of 44 patients undergoing arthroscopic rotator cuff repair surgery. Ultrasound-guided interscalene brachial plexus block, involving 20 mL of 0.375 % ropivacaine (group R) or 19 mL of 0.375 % ropivacaine with 4 mg (1 mL) of betamethasone (group BR), was administered and surgery was performed under general anesthesia. After surgery, the pain score was recorded at 12 h after surgery, and on the first, second, and seventh postoperative day. Analgesia duration, offset time of motor block, frequency of rescue analgesic administration, postoperative nausea/vomiting, and sleep disturbance during the night after surgery were recorded. The numerical values were expressed as median [interquartile range]. P values < 0.05 were considered statistically significant.

Results

The duration of analgesia was significantly prolonged in group BR (group BR: 19.1 h [16.6, 20.9 h], group R: 13.3 h [11.6, 16.5 h], p < 0.001). The pain scores at 12 h after surgery and on the first and seventh day after surgery were significantly lower in group BR than in group R. The duration of motor block was significantly prolonged in group BR. The frequency of rescue analgesic administration and the sleep disturbance rate were significantly lower in group BR. There was no difference in postoperative nausea/vomiting between the two groups.

Conclusions

Betamethasone added to local anesthetic in interscalene brachial plexus block improved postoperative pain after arthroscopic rotator cuff repair, and betamethasone prolonged the duration of analgesia by almost 6 h.

Trial registration

University Hospital Medical Information Network Center Clinical Trials Registration System (UMIN000012899).

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0251-9) contains supplementary material, which is available to authorized users.

Efficacy of interscalene block combined with multimodal pain control for postoperative analgesia after rotator cuff repair

PURPOSE

The aim of the study reported here was to compare the efficacy and safety of postoperative analgesia provided by interscalene block with multimodal pain control (IB-MPC) versus that provided by multimodal pain control (MPC) alone after arthroscopic rotator cuff repair.

METHODS

Sixty consecutive patients were assigned to either the IB-MPC group (30 patients) or the MPC group (30 patients). Visual analogue scale (VAS) pain scores before surgery and through day 5 after surgery, consumption of rescue analgesic, adverse effects and complications were evaluated.

RESULTS

Mean VAS pain scores immediately after surgery and on days 1 through 5 after surgery were 3.9 ± 2.6, 4.4 ± 1.5, 3.4 ± 1.3, 2.7 ± 1.3, 2.4 ± 1.2, and 2.0 ± 1.0, respectively, in the IB-MPC group and 6.2 ± 1.8, 4.1 ± 1.7, 3.2 ± 1.9, 2.7 ± 1.4, 2.5 ± 1.3, and 2.0 ± 1.2, respectively, in the MPC group. The IB-MPC group had significantly lower VAS pain score immediately after surgery than the MPC group did (P < 0.001). There were no statistically significant differences regarding consumption of rescue analgesic or adverse effects between the two groups (n.s.). In the IB-MPC group, complications related to interscalene block included tingling of the hand in three patients and numbness of the neck and ear in two. However, these symptoms resolved spontaneously within a few days. No patients had major complications related to interscalene block.

CONCLUSIONS

IB-MPC achieved better pain control immediately after surgery than MPC alone, without major complications related to interscalene block. It is an effective and safe method for providing postoperative analgesia after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Prospective Comparative Study, Prognosis Study, Level II.

Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN)

BACKGROUND AND OBJECTIVES

A practice advisory on regional anesthesia in children in 2008, published in this journal, supported the placement of regional blocks in children under general anesthesia (GA). Interscalene brachial plexus (IS) blocks were specifically excluded, based on case reports (level 3 evidence) of injury, which occurred predominantly in heavily sedated or anesthetized adult patients. Apart from case reports, there is a paucity of data that explore the safety of IS blocks placed in patients under GA, and the level of evidence available on which to base recommendations is limited.

METHODS

Querying the database of the Pediatric Regional Anesthesia Network (PRAN), we report on the incidence of postoperative neurological symptoms, local anesthetic systemic toxicity, and other reported adverse events in children receiving IS blocks under GA or sedated.

RESULTS

A total of 518 interscalene blocks were performed, 390 under GA and 123 with the patient sedated or awake (5 cases had missing status); 472 of these were single injection, and 46 involved the placement of infusion catheters. Eighty-eight percent of blocks were placed with ultrasound guidance, 7.7% with no location device, and 2.5% with a nerve stimulator. No local anesthetic systemic toxicity, postoperative neurological symptoms, cardiovascular complications, or dural puncture was reported in this cohort. There were 1 vascular puncture and 1 postoperative infection. These negative results are compatible with 0 to 7.7/1000 events for each of these complications for IS blocks placed under GA. There was no paralysis, motor block, or sensory deficit beyond the expected block duration time.

CONCLUSIONS

Analyzing interscalene blocks in children placed under GA, we identified no serious adverse events. The upper limit of the confidence interval for these events is similar to that in awake or sedated adults receiving IS blocks. Based on these prospectively collected data, placement of IS blocks under GA in children is no less safe than placement in awake adults, calling into question the American Society of Regional Anesthesia and Pain Medicine advisory proscribing GA during IS block in pediatric patients.

[Hypoglossal nerve neuropraxia after shoulder hemiarthroplasty]

We report a case of hypoglossal nerve damage after shoulder hemiarthroplasty with the patient in "beach chair" position, performed with general anesthesia with orotracheal intubation, and without complications. An ultrasound-guided interscalene block was previously performed in an alert patient. After the intervention, the patient showed clinical symptomatology compatible with paralysis of the right hypoglossal nerve that completely disappeared after 4 weeks. Mechanisms such as hyperextension of the neck during intubation, endotracheal tube cuff pressure, excessive hyperextension, or head lateralization during surgery have been described as causes of this neurological damage. We discuss the causes, the associated factors and suggest preventive measures.

Shoulder surgeons' perceptions of interscalene nerve blocks and a review of complications rates in the literature

BACKGROUND

Interscalene nerve blocks (ISBs) have been shown to be an effective option for regional anesthesia in shoulder surgery. Our study presents survey results of shoulder surgeons' perceptions of ISBs and a literature summary of complications rates with ISB use.

METHODS

A survey addressing demographics, preferences, treatment patterns, risks/benefits, and patient recommendations regarding the use of ISBs was created. Respondents were also asked whether they would elect an ISB if personally undergoing shoulder surgery, and results of other questions were stratified based on this personal preference. The survey was administered electronically to all members of the American Shoulder and Elbow Surgeons. A literature review of ISB-related complication rates was compiled from 13 studies of shoulder surgery using ISB.

RESULTS

Of all respondents, 58.7% would elect a single-shot ISB, 15.0% would elect a continuous catheter, and 26.3% would not elect the use of an ISB if undergoing shoulder surgery. Respondents from a university hospital were 1.44 times more likely to elect any ISB than respondents from a non-university hospital. Improved post-operative pain control was considered the greatest benefit, whereas persistent neuropathy was considered the greatest risk of ISB use. Of the respondents, 76.1% would recommend use of ISB to their patients undergoing shoulder surgery. Our literature review yielded 13 applicable studies that utilized a total of 6243 ISBs, with data resulting in a 0.35% major complication rate and an 11.32% minor complication rate in patients.

CONCLUSION

The majority of shoulder surgeons surveyed in our study would elect to have a single-shot interscalene nerve block if undergoing shoulder surgery themselves, indicating that ISB use is considered a safe and effective anesthetic option among shoulder surgeon specialists.

Low-dose ropivacaine for supraclavicular brachial plexus block combined with general anesthesia for successful postoperative analgesia: A case series

Background:

Ropivacaine, a long-acting local anesthetic agent, has been used for postoperative analgesia in brachial plexus block (BPB) at high doses. However, use of lower doses would reduce the occurrence of adverse effects.

Methods:

We applied BPB with low-dose ropivacaine (10 mL of 0.375% ropivacaine) after induction of general anesthesia for surgery of the upper extremities in 62 patients at our hospital. Ropivacaine was administered via a fluoroscopy-guided supraclavicular method. Analgesic effects during surgery, visual analog scale pain scores, skin sensation, muscle strength, and postoperative patient satisfaction indices were evaluated.

Results:

Fifty-six patients (90.3%) did not require supplemental analgesics during surgery. The remaining six patients were administered fentanyl due to the insufficient analgesic effects of the nerve block. Some adverse effects, including numbness and delayed motor and sensory recovery of the upper extremities, were observed. The mean postoperative patient-evaluated visual satisfaction scale was 94.1.

Conclusions:

Our results suggest that low-dose ropivacaine is clinically acceptable for BPB under general anesthesia.

[Calcific tendinitis of the shoulder]

Calcific tendinitis of the shoulder is a process involving crystal calcium deposition in the rotator cuff tendons, which mainly affects patients between 30 and 50 years of age. The etiology is still a matter of dispute. The diagnosis is made by history and physical examination with specific attention to radiologic and sonographic evidence of calcific deposits. Patients usually describe specific radiation of the pain to the lateral proximal forearm, with tenderness even at rest and during the night. Nonoperative management including rest, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and shock wave therapy is still the treatment of choice. Nonoperative treatment is successful in up to 90% of patients. When nonsurgical measures fail, surgical removal of the calcific deposit may be indicated. Arthroscopic treatment provides excellent results in more than 90% of patients. The recovery process is very time consuming and may take up to several months in some cases.