Ipsilateral shoulder pain after thoracotomy surgery

Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

Effect of Upper Arm Position Changes on the Occurrence of Ipsilateral Shoulder Pain After Single-Operator Port Thoracoscopy

Background

The aim of this study was to explore the factors associated with the occurrence of ISP after VATS to reduce the incidence of ISP and improve patients' quality of life.

Methods

The data of patients were collected between June 2020 and August 2020 in the Department of Lung Cancer Surgery, Tianjin Medical University General Hospital. The angle of upper arm was measured intraoperatively. The patient's postoperative shoulder function was quantified using the Constant-Murley shoulder function rating score. The proportional hazards model was applied to identify multiple influence factors.

Results

A total of 140 eligible patients met criteria. At postoperative day 3, only the age influenced patients' shoulder pain. At postoperative day 14, univariate and multivariate logistic regression analyses showed that age (odds ratio [OR]: 1.098 [1.046-1.152]; P < 0.001) and upper arm Angle A (OR: 1.064 [1.011-1.121]; P = 0.018) were independent risk factors for low shoulder function scores. However, height was its protective factor (OR: 0.923 [0.871-0.977]; P = 0.006). At postoperative day 42, univariate and multivariate logistic regression analyses showed that age (OR: 1.079 [1.036-1.124]; P < 0.001) was a risk factor for low shoulder function scores, and height (OR: 0.933 [0.886-0.983]; P = 0.009) was its protective factor. In contrast, upper arm Angle B was not statistically associated with low shoulder function scores (P>0.05). In addition, the reduction in ipsilateral Shoulder scores after surgery was higher in patients with more than 113° of angle A (P = 0.025).

Conclusion

ISP was closely related to the angle of anterior flexion of the upper arm on the patient's operative side intraoperatively. The increase in the degree of postoperative shoulder injury is more pronounced for an anterior flexion angle of >113°. Therefore, we recommend that the angle of anterior flexion of the upper extremity should be <113° intraoperatively.

Phrenic nerve block on severe post-hepatectomy shoulder pain: A randomized, double-blind, placebo-controlled, pilot study

BACKGROUND

Severe shoulder pain occurs frequently after surgery close to the diaphragm, potentially caused by referred pain via the ipsilateral phrenic nerve. We aimed to assess the analgesic effect of an ultrasound-guided phrenic nerve block on moderate to severe right-sided shoulder pain after open partial hepatectomy.

METHODS

This was a randomized, double-blind, placebo-controlled, pilot study, comparing ultrasound-guided phrenic nerve block (ropivacaine 0.75 mg/mL) versus placebo (isotonic sodium chloride 0.9 mg/mL) on severe post-hepatectomy shoulder pain (NRS ≥6). Pre- and postoperative spirometry and arterial blood gas analyses were used to assess respiratory function. Subjects with chronic lung disease were excluded. Unfortunately, due to lack of funding, the trial was ended prematurely and therefore presented as a pilot study.

RESULTS

One hundred and one subjects were screened for eligibility; 14 subjects were randomized, and two subjects were later excluded; thus, 12 subjects were analyzed with six in each group. A statistically significant difference in reduction in median pain intensity between groups was observed 15 minutes after phrenic nerve block ("ropivacaine first" ΔNRS: -6.0 [-6.0 to -3.0] vs. "saline first" ΔNRS: 0 [-6.0 to 1.0], P = .026). Spirometry results and arterial blood gas analyses were not clinically impacted by the block.

CONCLUSIONS

Postoperative phrenic nerve block significantly reduced severe post-hepatectomy shoulder pain. Larger studies are warranted to confirm the lack of clinically relevant block-related impairment of respiratory function.

Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial

Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS).

Efficacy of Phrenic Nerve Catheter in Ipsilateral Shoulder Pain After Thoracic Surgery

The mechanism of ipsilateral shoulder pain (ISP) after thoracic surgery remains unexplained definitively in the literature. Regional techniques targeting specific nerves more precisely will provide practitioners with a better understanding of the pain source. We report the case of a 51-year-old woman who underwent robotic-assisted plication of the right hemidiaphragm. ISP was adequately managed using a low-volume infusion through a continuous phrenic nerve block in addition to a thoracic epidural for her chest pain. ISP after thoracic surgery likely originates from diaphragm manipulation. Phrenic nerve blockade is a successful strategy that does not worsen subjective dyspnea in this setting.

Postoperative Pain Management and the Incidence of Ipsilateral Shoulder Pain After Thoracic Surgery at an Australian Tertiary-Care Hospital: A Prospective Audit

OBJECTIVES

Ipsilateral shoulder pain (ISP) is a common but variably occurring (42%-85%) complication after thoracic surgery. Multiple potential treatments, including upper limb blocks, intrapleural local anaesthetic infiltration, and systemic opioids, have undergone trials, with limited efficacy. Phrenic nerve infiltration is a potential intervention that may prevent ISP. The aim of this study was to assess the incidence and severity of ISP after thoracic surgery at the authors' institution, where phrenic nerve infiltration is commonly used.

DESIGN

Observational cohort study.

SETTING

A single- center study in a tertiary referral center in Brisbane, Australia.

PARTICIPANTS

This study comprised all adult patients undergoing thoracic surgery at a tertiary- care referral center from May to July 2018.

MEASUREMENTS AND MAIN RESULTS

Surgical procedures were divided into open thoracotomy, video-assisted thoracic surgery (VATS) and VATS-guided mini-thoracotomy. The primary outcome was a comparison of incidence of ISP among the 3 types of surgical procedures. Data were analyzed using Stata (StataCorp), with significance testing by Kruskal-Wallis equality of populations rank test. A p value of < 0.05 was deemed significant. Sixty thoracic surgeries were performed during the audit period. Nineteen patients had thoracotomies performed for lobectomy or pneumonectomy, all of whom received phrenic nerve infiltration. The incidence of moderate-to-severe ipsilateral shoulder pain among the thoracoctomy cohort was 15.8% (3/19). Of the 36 VATS procedures audited, 7 patients (19.4%) received infiltration of their phrenic nerve, none of whom reported postoperative ISP. Of the remaining twenty-nine patients who did not receive phrenic nerve infiltration, there were 4 cases of moderate-to-severe ipsilateral shoulder pain (11.1%). Four of the 5 patients (80%) who underwent VATS-guided mini-thoracotomies received phrenic nerve infiltration intraoperatively. Three patients reported moderate-to-severe ISP and of these 3 patients, 2 patients had phrenic nerve infiltration, and 1 patient did not receive infiltration. Overall, there were no statistically significant differences in rest or dynamic pain scores across the surgical groups at any time point. Mann-Whitney test revealed that the participants with ISP were significantly older than those without ISP (p = 0.006). However, there were no significant differences in sex or body mass index between those with and without ISP.

CONCLUSION

The authors observed a lower (15.8%) incidence of moderate-to-severe ISP among their thoracotomy patients than reported in prior literature. Injection of local anesthetic into the phrenic nerve fat pad at the level of the diaphragm appeared to be an effective and safe surgical intervention that may eliminate a significant cause of ISP. None of the VATS patients who received phrenic nerve infiltration experienced ISP. Postoperative pain in VATS is expected to be reduced by avoiding the use of a rib spreader, severing of the intercostal nerves, and division of muscle tissue, which may account for the lower observed rates of ISP in the VATS cohort who did not receive phrenic nerve infiltration. Further randomized controlled trials are warranted to establish if patients undergoing various VATS procedures benefit from this intervention.

A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy

Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.

The effect of interscalene block on ipsilateral shoulder pain and pulmonary function in patients undergoing lung lobectomy: A randomized controlled trial

BACKGROUND

Postoperative ipsilateral shoulder pain occurs in 37% to 68% of patients undergoing a thoracotomy. We examined whether interscalene brachial plexus block using a lower concentration of local anesthetic would reduce the incidence of post-thoracotomy ipsilateral shoulder pain with assessment of pulmonary function in patients who underwent a lung lobectomy.

METHODS

Forty-four patients who underwent a lung lobectomy were randomly assigned to either the control or the interscalene block group. Single-shot interscalene block on the surgical site side was performed using ropivacaine 0.25% 10 mL including dexamethasone 5 mg under ultrasound guidance in the interscalene block group. Lobectomy and continuous paravertebral block were performed under general anesthesia. The presence of ipsilateral shoulder pain and postoperative adverse events were assessed. Pulmonary function tests were performed preoperatively, the day after surgery, and the day after removing the chest tube.

RESULTS

The incidence of ipsilateral shoulder pain was significantly lower in the interscalene block group than in the control group (54.5% vs 14.3%, P = .006) with an overall incidence of 34.9%. Postoperative adverse events were similar between the groups, with no patients presenting symptoms of respiratory difficulty. Significant reductions in pulmonary function were observed in all patients after lobectomy; however, no significant difference in any of the pulmonary function test variables was observed postoperatively between the groups.

CONCLUSIONS

Interscalene block using 10 mL of 0.25% ropivacaine including dexamethasone 5 mg reduced the incidence of post-thoracotomy ipsilateral shoulder pain and did not result in additional impairment of pulmonary function.

The Features and Functions of Neuronal Assemblies: Possible Dependency on Mechanisms beyond Synaptic Transmission

"Neuronal assemblies" are defined here as coalitions within the brain of millions of neurons extending in space up to 1-2 mm, and lasting for hundreds of milliseconds: as such they could potentially link bottom-up, micro-scale with top-down, macro-scale events. The perspective first compares the features in vitro versus in vivo of this underappreciated "meso-scale" level of brain processing, secondly considers the various diverse functions in which assemblies may play a pivotal part, and thirdly analyses whether the surprisingly spatially extensive and prolonged temporal properties of assemblies can be described exclusively in terms of classic synaptic transmission or whether additional, different types of signaling systems are likely to operate. Based on our own voltage-sensitive dye imaging (VSDI) data acquired in vitro we show how restriction to only one signaling process, i.e., synaptic transmission, is unlikely to be adequate for modeling the full profile of assemblies. Based on observations from VSDI with its protracted spatio-temporal scales, we suggest that two other, distinct processes are likely to play a significant role in assembly dynamics: "volume" transmission (the passive diffusion of diverse bioactive transmitters, hormones, and modulators), as well as electrotonic spread via gap junctions. We hypothesize that a combination of all three processes has the greatest potential for deriving a realistic model of assemblies and hence elucidating the various complex brain functions that they may mediate.

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

Postthoracotomy pain management problems

Pain after thoracotomy is very severe, probably the most severe pain experienced after surgery. Thoracic epidural analgesia has greatly improved the pain experience and its consequences and has been considered the standard for pain management after thoracotomy. This view has been challenged recently by the use of paravertebral nerve blocks. Nevertheless, severe ipsilateral shoulder pain and the prevention of the postthoracotomy pain syndrome remain the most important challenges for management of postthoracotomy pain.

Differential dynamics of transient neuronal assemblies in visual compared to auditory cortex

Large-scale, coherent, but highly transient networks of neurons, 'neuronal assemblies', operate over a sub-second time frame. Such assemblies of brain cells need not necessarily respect well-defined anatomical compartmentalisation, but represent an intermediate level of brain organisation between identified brain regions and individual neurons dependent on the activity status of the synaptic connections and axonal projections. To study neuronal assemblies both in slices and in the living brain, optical imaging using voltage-sensitive dyes (VSDI) offers the highest spatial and temporal resolution in real-time. Applying VSDI technique to compare assemblies in visual versus auditory cortices under standardised experimental protocols, we observed no significant variations in the basic parameters of fluorescence signal and assembly size: such results might be predicted from the canonical invariance of cortical structures across modalities. However, further analysis revealed less obvious yet significant differences in the assembly dynamics of the two regions. The neural assemblies spread widely across layers in the two cortices following paired-pulse stimulation of putative layer 4. The respective patterns of activity started to differentiate within a specific time frame (250-300 ms). The signal was predominant near the point of stimulation in the visual cortex, whereas in the auditory cortex the signal was stronger in the superficial layers. This modality-specific divergence in assembly dynamics highlights a previously under-appreciated level of neuronal processing. Additionally, these findings could prompt a new approach to the understanding of how information from different senses, transmitted as action potentials with identical electrochemical characteristics across different cortices, be it visual or auditory, can eventually yield, nonetheless, the qualitatively distinct experiences of seeing or hearing.