Low volume proximal suprascapular nerve block after arthroscopic shoulder surgery - A randomised, controlled trial

BACKGROUND

A proximal suprascapular nerve block has been suggested as an alternative to an interscalene brachial plexus block after arthroscopic shoulder surgery. The aim of this randomised controlled trial was to compare the analgesic and opioid-sparing effect of a low volume proximal suprascapular nerve block with placebo in patients with moderate-to-severe pain after arthroscopic shoulder surgery.

METHODS

Patients with a VAS score equal to or above 50 during the first postoperative hour after planned arthroscopic shoulder surgery were included in the study. They were randomised to an ultrasound-guided proximal suprascapular nerve block with either 5 ml ropivacaine 7.5 mg/ml or 5 ml isotonic NaCl. Primary outcome was change in VAS score at rest from baseline to 30 min after the block procedure (T30). Secondary outcomes included total morphine consumption from 0-6 h after block procedure.

RESULTS

There was a significant difference in mean VAS reductions at T30 between the two groups favouring the ropivacaine group (-50.2 vs -26.8, p < .001). Total intravenous morphine consumption from 0-6 h after block procedure was significantly lower in the ropivacaine group compared to the placebo group (8.5 mg vs 18.5 mg, p < .01).

CONCLUSION

In this study, a proximal suprascapular nerve block with only 5 ml ropivacaine resulted in a substantial pain reduction and opioid-sparing effect in patients with VAS of 50 or more after arthroscopic shoulder surgery.

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.

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).

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.].

Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery

Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients. The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context. They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The most important of these include limiting local anesthetic dose and injection volume and performing the injection further away from the C5–C6 nerve roots. Targeting peripheral nerves supplying the shoulder, such as the suprascapular and axillary nerves, may be an effective alternative to brachial plexus blockade in selected patients. The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article.

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.

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.

Ultrasound guided distal peripheral nerve block of the upper limb: A technical review

Upper extremity surgery is commonly performed under regional anesthesia. The advent of ultrasonography has made performing upper extremity nerve blocks relatively easy with a high degree of reliability. The proximal approaches to brachial plexus block such as supraclavicular plexus block, infraclavicular plexus block, or the axillary block are favored for the most surgical procedures of distal upper extremity. Ultrasound guidance has however made distal nerve blocks of the upper limb a technically feasible, safe and efficacious option. In recent years, there has thus been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery. In this article, we review the technical aspects of performing the distal blocks of the upper extremity and highlight some of the clinical aspects of their usage.

Ultrasound-guided continuous interscalene block: the influence of local anesthetic background delivery method on postoperative analgesia after shoulder surgery: a randomized trial

BACKGROUND

Automated bolus delivery has recently been shown to reduce local anesthetic consumption and improve analgesia, compared with continuous infusion, in continuous sciatic and epidural block. However, there are few data on the influence of local anesthetic delivery method on local anesthetic consumption following interscalene blockade. This randomized, double-blind trial was designed to determine whether hourly automated perineural boluses (4 mL) of local anesthesia delivered with patient-controlled pro re nata (PRN, on demand) boluses would result in a reduction in total local anesthesia consumption during continuous interscalene blockade after shoulder surgery compared with continuous perineural infusion (4 mL/h) plus patient-controlled PRN boluses.

METHODS

One hundred one patients undergoing major shoulder surgery under general anesthesia with ultrasound-guided continuous interscalene block were randomly assigned to receive 0.2% ropivacaine via interscalene end-hole catheter either by continuous infusion 4 mL/h (n = 50) or as automated bolus 4 mL/h (n = 51). Both delivery methods were combined with 5 mL PRN boluses of 0.2% ropivacaine with a lockout time of 30 minutes. Postoperative number of PRN boluses, 24- and 48-hour local anesthetic consumption, pain scores, rescue analgesia (morphine), and adverse events were recorded.

RESULTS

There were no significant differences in either the number of PRN ropivacaine boluses or total 48 hour local anesthetic consumption between the groups (18.5 [11-25.2] PRN boluses in the continuous infusion group vs 17 [8.5-29] PRN boluses in the automated bolus group). Postoperative pain was similar in both groups; on day 2, the median average pain score was 4 (2-6) in the continuous infusion group versus 3 (2-5) in the automated bolus group (P = 0.54). Nor were any statistically significant intergroup differences observed with respect to morphine rescue, incidence of adverse events, or patient satisfaction.

CONCLUSIONS

In continuous interscalene blockade under ultrasound guidance after shoulder surgery, automated boluses of local anesthetic combined with PRN boluses did not provide any reduction in local anesthetic consumption or rescue analgesia, compared with continuous infusion combined with PRN boluses.

A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty

OBJECTIVES

Proximal and distal (mid-thigh) ultrasound-guided continuous adductor canal block techniques have been described but not yet compared, and infusion benefits or side effects may be determined by catheter location. We hypothesized that proximal placement will result in faster onset of saphenous nerve anesthesia, without additional motor block, compared to a distal technique.

METHODS

Preoperatively, patients receiving an ultrasound-guided nonstimulating adductor canal catheter for knee arthroplasty were randomly assigned to either proximal or distal insertion. A local anesthetic bolus was administered via the catheter after successful placement. The primary outcome was the time to achieve complete sensory anesthesia in the saphenous nerve distribution. Secondary outcomes included procedural time, procedure-related pain and complications, postoperative pain, opioid consumption, and motor weakness.

RESULTS

Proximal insertion (n = 23) took a median (10th-90th percentiles) of 12.0 (3.0-21.0) minutes versus 6.0 (3.0-21.0) minutes for distal insertion (n = 21; P= .106) to anesthetize the medial calf. Only 10 of 25 (40%) and 10 of 24 (42%) patients in the proximal and distal groups, respectively, developed anesthesia at both the medial calf and top of the patella (P= .978). Bolus-induced motor weakness occurred in 19 of 25 (76%) and 16 of 24 (67%) patients in the proximal and distal groups (P = .529). Ten of 24 patients (42%) in the distal group required intravenous morphine postoperatively, compared to 2 of 24 (8%) in the proximal group (P = .008), but there were no differences in other secondary outcomes.

CONCLUSIONS

Continuous adductor canal blocks can be performed reliably at both proximal and distal locations. The proximal approach may offer minor analgesic and logistic advantages without an increase in motor block.

A triple-masked, randomized controlled trial comparing ultrasound-guided brachial plexus and distal peripheral nerve block anesthesia for outpatient hand surgery

Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia. Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery. Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength, P = 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery, P = 0.012. Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block.

Adjuvant dexamethasone for bupivacaine sciatic and ankle blocks: results from 2 randomized placebo-controlled trials

BACKGROUND AND OBJECTIVES

Dexamethasone as a local anesthetic adjuvant has been shown to prolong the time to first postoperative pain and improve postoperative analgesia following upper-limb brachial plexus block. However, the lack of systemically administered dexamethasone in controls makes interpretation of previous studies difficult. We performed 2 prospective, randomized, double-blind, placebo-controlled trials to test whether the addition of dexamethasone 8 mg to bupivacaine for sciatic and ankle blocks prolongs block duration, improving postoperative analgesia.

METHODS

One hundred twenty-six patients presenting for elective foot/ankle surgery under sciatic (n = 66) or ankle blocks (n = 60) received 30 mL bupivacaine 0.5% + dexamethasone 8 mg or saline 2 mL. Alternate solutions were administered by intramuscular injection into the ipsilateral thigh. Outcomes assessed at 24 and 48 hours included pain onset, numerically rated pain, and supplementary tramadol consumption.

RESULTS

For the sciatic study, fewer dexamethasone group patients experienced pain at 24 hours (13% vs 47%, P = 0.01), an effect supported by multiple post hoc analyses for pain from 20 to 34 hours. No benefit existed at 48 hours or at any time for the ankle block. For each study, pain-free survival curves for the first 48 hours were not significantly different between groups. Pooled analysis of the 2 individual studies further supported the absence of a significant dexamethasone effect: hazard ratio (0.81; 95% confidence interval, 0.58-1.53; P = 0.94). For both studies, there were no differences between groups for all other study outcomes including worst and average pain, the requirement for tramadol, and patient satisfaction.

CONCLUSIONS

Substitution of systemic dexamethasone for perineural dexamethasone during bupivacaine sciatic and ankle blocks had only a minor analgesic enhancing effect. Given recent animal studies showing dexamethasone neurotoxicity, the perineural route for dexamethasone administration requires reevaluation.

Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs

The use of local anesthetics to reduce acute postoperative pain has a long history, but recent reports have not been systematically reviewed. In addition, the need to include only those clinical studies that meet minimum standards for randomization and blinding must be adhered to. In this review, we have applied stringent clinical study design standards to identify publications on the use of perioperative local anesthetics. We first examined several types of peripheral nerve blocks, covering a variety of surgical procedures, and second, we examined the effects of intentionally administered IV local anesthetic (lidocaine) for suppression of postoperative pain. Thirdly, we have examined publications in which vascular concentrations of local anesthetics were measured at different times after peripheral nerve block procedures, noting the incidence when those levels reached ones achieved during intentional IV administration. Importantly, the very large number of studies using neuraxial blockade techniques (epidural, spinal) has not been included in this review but will be dealt with separately in a later review. The overall results showed a strongly positive effect of local anesthetics, by either route, for suppressing postoperative pain scores and analgesic (opiate) consumption. In only a few situations were the effects equivocal. Enhanced effectiveness with the addition of adjuvants was not uniformly apparent. The differential benefits between drug delivery before, during, or immediately after a surgical procedure are not obvious, and a general conclusion is that the significant antihyperalgesic effects occur when the local anesthetic is present during the acute postoperative period, and its presence during surgery is not essential for this action.

Does motor block related to long-acting brachial plexus block cause patient dissatisfaction after minor wrist and hand surgery? A randomized observer-blinded trial

BACKGROUND

Patient dissatisfaction has been previously associated with motor block in shoulder surgery patients receiving brachial plexus block. For elective minor wrist and hand surgery, we tested whether a regional block accelerating the early return of upper extremity motor function would improve patient satisfaction compared with a long-acting proximal brachial plexus block.

METHODS

A total of 177 patients having elective 'minor' wrist and hand surgery under awake regional block randomly received adrenalized infraclavicular lidocaine 2% 10 ml+ropivacaine 0.75% 20 ml ('long acting', n=90), or adrenalized infraclavicular lidocaine 1.5% 30 ml+long-acting distal median, radial, and ulnar nerve blocks selected according to the anticipated area of postoperative pain ('short acting', n=87). A blinded observer questioned patients on day 1 for numerically rated (0-10) subjective outcomes.

RESULTS

With 95% power, there was no evidence for a 1-point satisfaction shift in the short acting group: satisfaction was similarly high for both groups [median (inter-quartile range)=10 (8-10) vs 10 (8-10), P=0.71], and also demonstrated strong evidence for equivalence [mean difference (95% confidence interval)=-0.18 (-0.70 to 0.35)]. There was no difference between the groups for weakness- or numbness-related dissatisfaction (low for both groups), or for numerically rated or time to first pain. Surgical anaesthesia success was similar between the groups (short acting, 97% vs 93%, P=0.50), although more patients in the short acting group had surgery initiated in ≤25 min (P=0.03).

CONCLUSIONS

Patient satisfaction is not improved after elective minor wrist and hand surgery with a regional block accelerating the early return of motor function. For this surgery, motor block related to a long-acting brachial plexus block does not appear to cause patient dissatisfaction. Clinical Trial Registration number. ACTRN12610000749000, https://www.anzctr.org.au/registry/trial_review.aspx?ID=335931.

Continuous femoral nerve blocks: decreasing local anesthetic concentration to minimize quadriceps femoris weakness

BACKGROUND

Whether decreasing the local anesthetic concentration during a continuous femoral nerve block results in less quadriceps weakness remains unknown.

METHODS

Preoperatively, bilateral femoral perineural catheters were inserted in subjects undergoing bilateral knee arthroplasty (n = 36) at a single clinical center. Postoperatively, right-sided catheters were randomly assigned to receive perineural ropivacaine of either 0.1% (basal 12 ml/h; bolus 4 ml) or 0.4% (basal 3 ml/h; bolus 1 ml), with the left catheter receiving the alternative concentration/rate in an observer- and subject-masked fashion. The primary endpoint was the maximum voluntary isometric contraction of the quadriceps femoris muscles the morning of postoperative day 2. Equivalence of treatments would be concluded if the 95% CI for the difference fell within the interval -20%-20%. Secondary endpoints included active knee extension, passive knee flexion, tolerance to cutaneous electrical current applied over the distal quadriceps tendon, dynamic pain scores, opioid requirements, and ropivacaine consumption.

RESULTS

Quadriceps maximum voluntary isometric contraction for limbs receiving 0.1% ropivacaine was a mean (SD) of 13 (8) N · m, versus 12 (8) N · m for limbs receiving 0.4% [intrasubject difference of 3 (40) percentage points; 95% CI -10-17; P = 0.63]. Because the 95% CI fell within prespecified tolerances, we conclude that the effect of the two concentrations were equivalent. Similarly, there were no statistically significant differences in secondary endpoints.

CONCLUSIONS

For continuous femoral nerve blocks, we found no evidence that local anesthetic concentration and volume influence block characteristics, suggesting that local anesthetic dose (mass) is the primary determinant of perineural infusion effects.

The role of regional anaesthesia techniques in the management of acute pain

Regional anaesthesia and analgesia techniques are used to effectively manage acute pain after a variety of surgeries. With the rapid growth of ultrasound-guided procedures, anaesthetists are re-examining regional anaesthesia and analgesia and their roles in pain management. In this evolving field previous published data may not reflect current practice. Therefore, a narrative review of recent literature was undertaken to establish the current utility and efficacy of regional anaesthesia and analgesia for the management of acute pain following surgery. Only prospective randomised controlled trials published between March 2009 and March 2011 with outcome measures of analgesia efficacy were included. Sixty-five randomised controlled trials were identified involving 4841 patients. Regional techniques for the management of knee (26%), abdominal (26%) and shoulder (14%) surgery were most frequently studied. The review provides further evidence that regional anaesthesia and analgesia can offer excellent analgesia with acceptable side-effects for the management of postsurgical pain. In addition, the results of this review support the use of ultrasound guidance when performing regional techniques and continuous catheter techniques to prolong analgesia.

A clinical comparison of continuous interscalene brachial plexus block with different basal infusion rates of 0.2% ropivacaine for shoulder surgery

Background

A continuous interscalene brachial plexus block is a highly effective postoperative analgesic modality after shoulder surgery. However, there is no consensus regarding the optimal basal infusion rate of ropivacaine for a continuous interscalene brachial plexus block. A prospective, double blind study was performed to compare two different basal rates of 0.2% ropivacaine for a continuous interscalene brachial plexus block after shoulder surgery.

Methods

Sixty-two patients receiving shoulder surgery under an interscalene brachial plexus block were included. The continuous interscalene brachial plexus block was performed using a modified lateral technique with 30 ml of 0.5% ropivacaine. Surgery was carried out under an interscalene brachial plexus block or general anesthesia. After surgery, the patients were divided randomly into two groups containing 32 each. During the first 48 h after surgery, groups R8 and R6 received a continuous infusion of 0.2% ropivacaine at 8 ml/h and 6 ml/h, respectively. The pain scores at rest and on movement, supplemental analgesia, motor block, adverse events and patient's satisfaction were recorded.

Results

The pain scores, supplemental analgesia, motor block, adverse events and patient's satisfaction were similar in the two groups.

Conclusions

When providing continuous interscalene brachial plexus block after shoulder surgery, 0.2% ropivacaine at a basal rate of 8 ml/h or 6 ml/h produces similar clinical efficacy. Therefore, decreasing the basal rate of CISB is more appropriate considering the toxicity of local anesthetics.