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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Anesthesiol Clin 2024; 42:219-231. [PMID: 38705672 DOI: 10.1016/j.anclin.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Kim SH, Yeo IS, Jang J, Jung HE, Chun YM, Yang HM. Infraspinatus-teres minor (ITM) interfascial block: a novel approach for combined suprascapular and axillary nerve block. Reg Anesth Pain Med 2024; 49:67-72. [PMID: 37491150 DOI: 10.1136/rapm-2023-104738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Combined suprascapular and axillary nerve block could be an analgesic option for shoulder pain control. The current description of this technique requires performing the block procedures at two different sites without consideration for catheter placement. We hypothesized that a single site injection to the interfascial plane between the infraspinatus and teres minor would result in an injectate spread to the suprascapular and axillary nerves. METHODS We performed 10 injections with this approach using 25 mL dye solution in 10 shoulders of five unembalmed cadavers. Also, we described three case reports, two single-injection cases and one catheter-placement case, using this approach in patients with acute postsurgical pain and chronic pain in their shoulder region. RESULTS In cadaveric evaluations, dye spreading to the suprascapular nerves on the infraspinatus fossa and the spinoglenoid notch cephalad and axillary nerves in the quadrilateral space caudally were observed in all injections. In addition, the most posterolateral part of the joint capsule was stained in 8 out of 10 injections. There was no dye spreading on the nerves to the subscapularis or lateral pectoral nerves. Clinically successful analgesia with no adverse events was achieved in all three cases. CONCLUSION Our anatomical and clinical observations demonstrated that an injection to the interfascial plane between the infraspinatus and teres minor consistently achieved injectate spreading to both suprascapular and axillary nerves, which innervate the glenohumeral joint.
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Affiliation(s)
- Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - In-Seung Yeo
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anatomy, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Jaewon Jang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Hyun Eom Jung
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
| | - Hun-Mu Yang
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Department of Anatomy, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seodaemun-gu, Republic of Korea
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Campbell AS, Johnson CD, O'Connor S. Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery. Anesthesiol Res Pract 2023; 2023:9962595. [PMID: 37727810 PMCID: PMC10506885 DOI: 10.1155/2023/9962595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023] Open
Abstract
Peripheral nerve blocks are an increasingly common method of providing postoperative analgesia for shoulder surgeries. However, the standard technique, the interscalene block (ISB), inevitably causes hemidiaphragmatic paresis (HDP), secondary to phrenic nerve palsy. This can cause morbidity in patients with preexisting respiratory compromise, prompting investigation into alternative "phrenic-sparing" nerve blocks. The aim of this review was to give an overview of these blocks and critically evaluate the current literature to determine if any are suitable replacements for ISB. The incidence of HDP and analgesic efficacy were considered. We queried four electronic databases and one register. Twenty-eight original articles were selected for review. The use of ultrasound guidance, lower volumes of local anaesthetic (LA), and injection 4 mm outside the brachial plexus fascia reduced HDP incidence for the ISB; however, no single modification did so sufficiently. While the anterior suprascapular nerve block (SSNB) showed comparable analgesic effects to the ISB, HDP prevalence was also high. The posterior SSNB produced consistently low HDP incidences but also inferior analgesia to ISB, except when combined with an infraclavicular brachial plexus block. The superior trunk block (STB) provided equivalent analgesia to the ISB while reducing HDP incidence, but not significantly. Lower LA volumes consistently led to lower HDP incidence across all blocks, likely due to a reduced ability to spread to the phrenic nerve. Further investigation into the minimum effective volumes of the extrafascial ISB, anterior SSNB, STB, and combined posterior SSNB with infraclavicular block is warranted to determine if any of these blocks can successfully balance HDP prevention with analgesic efficacy.
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Affiliation(s)
- Aaron S. Campbell
- Centre for Biomedical Sciences Education, Queen's University, Belfast BT9 7AA, UK
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Lee BH, Qiao WP, McCracken S, Singleton MN, Goman M. Regional Anesthesia Techniques for Shoulder Surgery in High-Risk Pulmonary Patients. J Clin Med 2023; 12:jcm12103483. [PMID: 37240589 DOI: 10.3390/jcm12103483] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/01/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Patients with pre-existing pulmonary conditions are at risk for experiencing perioperative complications and increased morbidity. General anesthesia has historically been used for shoulder surgery, though regional anesthesia techniques are increasingly used to provide anesthesia and improved pain control after surgery. Relative to regional anesthesia, patients who undergo general anesthesia may be more prone to risks of barotrauma, postoperative hypoxemia, and pneumonia. High-risk pulmonary patients, in particular, may be exposed to these risks of general anesthesia. Traditional regional anesthesia techniques for shoulder surgery are associated with high rates of phrenic nerve paralysis which significantly impairs pulmonary function. Newer regional anesthesia techniques have been developed, however, that provide effective analgesia and surgical anesthesia while having much lower rates of phrenic nerve paralysis, thereby preserving pulmonary function.
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Affiliation(s)
- Bradley H Lee
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - William P Qiao
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Stephen McCracken
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Michael N Singleton
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mikhail Goman
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10021, USA
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Boekel P, Brereton SG, Doma K, Grant A, Kippin A, Wilkinson M, Morse L. Efficacy of surgeon-directed suprascapular and axillary nerve blocks in shoulder arthroscopy: a 3-arm prospective randomized controlled trial. JSES Int 2023; 7:307-315. [PMID: 36911772 PMCID: PMC9998877 DOI: 10.1016/j.jseint.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Pamela Boekel
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
- Mater Health Services North Queensland, Pimlico, Townsville, Queensland, Australia
- Department of Orthopaedic Surgery, Townsville University Hospital, James Cook, University, Townsville, Queensland, Australia
- Corresponding author: Pamela Boekel, MBBS (Hons), MSc, FRACS (Orth), Orthopaedic Research Institute of Queensland, 7 Turner St, Pimlico, Queensland, Australia 4812.
| | - Sarah G. Brereton
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
- Mater Health Services North Queensland, Pimlico, Townsville, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Kenji Doma
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
- Department of Sports and Exercise Science, James Cook University, Townsville, Queensland, Australia
| | - Andrea Grant
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
| | - Alex Kippin
- Mater Health Services North Queensland, Pimlico, Townsville, Queensland, Australia
- Department of Orthopaedic Surgery, Townsville University Hospital, James Cook, University, Townsville, Queensland, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
- Department of Orthopaedic Surgery, Royal Hobart Hospital and Calvary Care, University of Tasmania, Hobart, Tasmania, Australia
| | - Levi Morse
- Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, Australia
- Mater Health Services North Queensland, Pimlico, Townsville, Queensland, Australia
- Department of Orthopaedic Surgery, Townsville University Hospital, James Cook, University, Townsville, Queensland, Australia
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Kang R, Ko JS. Recent updates on interscalene brachial plexus block for shoulder surgery. Anesth Pain Med (Seoul) 2023; 18:5-10. [PMID: 36746896 PMCID: PMC9902626 DOI: 10.17085/apm.22254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Interscalene brachial plexus block (ISBPB) provides optimal analgesia for shoulder surgery. However, several limitations still exist, including the short duration of analgesia, rebound pain, a high incidence of unilateral diaphragmatic paresis, and potential risk of nerve damage, prompting the search for alternative techniques. Many alternatives to ISBPB have been studied to alleviate these concerns, and clinicians should choose an appropriate option based on the patient's condition. In this mini-review, we aimed to present recent updates on ISBPB while discussing our clinical experiences in shoulder surgery.
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Affiliation(s)
| | - Justin Sangwook Ko
- Corresponding author: Justin Sangwook Ko, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-2454 Fax: 82-2-3410-0361 E-mail:
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7
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Steen-Hansen C, Madsen MH, Lange KHW, Lundstrøm LH, Rothe C. Single injection combined suprascapular and axillary nerve block: A randomised controlled non-inferiority trial in healthy volunteers. Acta Anaesthesiol Scand 2023; 67:104-111. [PMID: 36069505 DOI: 10.1111/aas.14147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/07/2022] [Accepted: 09/01/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND A shoulder block without lung affection is desirable. In this study, we compared a low versus a high volume of a modified supraclavicular brachial plexus block. We hypothesised that a low volume of local anaesthetic would provide non-inferior block success rate with better preserved lung function. METHODS Healthy volunteers were randomised to receive ultrasound guided 5 or 20 ml ropivacaine 0.5% at the departure of the suprascapular nerve from the brachial plexus. Primary outcome was successful shoulder block-defined as cutaneous sensory affection of the axillary nerve and motor affection of the suprascapular nerve (>50% reduction in external rotation force measured with dynamometry). We used a non-inferiority margin of 20%. Secondary outcome was change in lung function measured with spirometry. RESULTS Thirteen of 16 (81.3%; 95% confidence interval [CI] 57.0% to 93.4%) in the 5 ml group and 15 of 16 (93.8%; 95% CI 71.7% to 98.9%) in the 20 ml group had successful shoulder block (p = .6). The ratio of the event rates of the 20 ml (standard) and 5 ml (intervention) groups was (15/16)/(13/16) = 0.937/0.813 = 1.15 (95% CI 0.88 to 1.51). All mean reductions in lung function parameters were non-significantly lower in the 5 ml group compared with the 20 ml group. CONCLUSION For our primary outcome, the 95% CI of the difference of event ratio included the non-inferiority margin. We are therefore unable to conclude that 5 ml LA is non-inferior to 20 ml LA with respect to block success rate.
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Affiliation(s)
- Christian Steen-Hansen
- Department of Anaesthesiology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel H Madsen
- Department of Anaesthesiology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kai H W Lange
- Department of Anaesthesiology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Rothe
- Department of Anaesthesiology, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Clin Sports Med 2022; 41:219-231. [PMID: 35300836 DOI: 10.1016/j.csm.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Liu C, Cheng L, Du B, Cheng S, Jiang Y, Tan X, Qian K. The analgesic efficacy of pregabalin for shoulder arthroscopy: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26695. [PMID: 34559094 PMCID: PMC8462647 DOI: 10.1097/md.0000000000026695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 06/19/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The efficacy of pregabalin for pain management of shoulder arthroscopy remains controversial. We conduct this meta-analysis to explore the influence of pregabalin versus placebo on the postoperative pain intensity of shoulder arthroscopy. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through November 2019 for randomized controlled trials assessing the effect of pregabalin versus placebo on pain control of shoulder arthroscopy. This meta-analysis was performed using the random-effect model. RESULTS Three randomized controlled trials were included in the meta-analysis. Overall, compared with control group for shoulder arthroscopy, pregabalin remarkably decreased pain scores at 0 to 1 hour (Std. MD = -0.57; 95% CI = -1.04 to -0.09; P = .02) and 12 hours (Std. MD = -0.37; 95% CI = -0.72 to -0.02; P = .04), as well as analgesic consumption (Std. MD = -1.84; 95% CI = -2.24 to -1.44; P < .00001), but showed no notable influence on pain scores at 24 hours (Std. MD = -0.54; 95% CI = -1.47 to 0.38; P = .25), nausea or vomiting (RR = 0.84; 95% CI = 0.53-1.33; P = .45), dizziness (RR = 1.14; 95% CI = 0.89-1.47; P = .30). CONCLUSIONS Pregabalin may benefit to pain control after shoulder arthroscopy.
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Affiliation(s)
- Chunhong Liu
- Department of Anesthesiology, People's Hospital of Chongqing Banan District
| | - Ling Cheng
- Department of Hepatological Surgery, The People's Hospital of Kaizhou District, Chongqing, China
| | - Bo Du
- Department of Anesthesiology, People's Hospital of Chongqing Banan District
| | - Shuang Cheng
- Department of Surgery, The TCM Hospital of Kaizhou District, Chongqing, China
| | - Yangming Jiang
- Department of Hepatological Surgery, The People's Hospital of Kaizhou District, Chongqing, China
| | - Xiaohong Tan
- Department of Hepatological Surgery, The People's Hospital of Kaizhou District, Chongqing, China
| | - Ke Qian
- Department of Anesthesiology, People's Hospital of Chongqing Banan District
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González-Arnay E, Galluccio F, Pérez-Santos I, Merlano-Castellanos S, Bañón-Boulet E, Jiménez-Sánchez L, Rivier-Julien C, Barrueco-Fernández M, Olea MS, Yamak-Altinpulluk E, Teles AS, Fajardo-Pérez M. Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder. Ann Anat 2021; 239:151814. [PMID: 34536540 DOI: 10.1016/j.aanat.2021.151814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.
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Affiliation(s)
- Emilio González-Arnay
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Division of Pathology, General Hospital of La Palma (HGLP) Buenavista de Arriba s/n PC48713 La Palma, Canary Islands, Spain.; MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Felice Galluccio
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Division of Rheumatology, Medical-geriatric Department, University Hospital AOU Careggi, Largo Piero Palagi, 1, 50139 Florence, Italy.
| | - Isabel Pérez-Santos
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Sebastián Merlano-Castellanos
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Elena Bañón-Boulet
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Lorena Jiménez-Sánchez
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Wellcome Translational Neuroscience Ph.D. Program, Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, Scotland, UK.
| | - Clotilde Rivier-Julien
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Manuel Barrueco-Fernández
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain.
| | - Marilina S Olea
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Hospital Interzonal General Dr. José Penna, Av. Lainez 2401, B8000 Bahía Blanca, Buenos Aires, Argentina.
| | - Ece Yamak-Altinpulluk
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Outcomes Research Anesthesiology Institute Cleveland Clinic, 2049 East 100th Street, Cleveland, OH 44195, USA; Department of Anesthesiology and Reanimation, University of Istambul-cerrahpasa School of Medicine, Cerrahpaşa Campus, Kocamustafapaşa Cad. No:34/E, Istanbul, Turkey; Anaesthesiology Clinical Research Office, Ataturk University, Üniversite Atatürk Üniversitesi Kampüsü, 25030 Yakutiye, Erzurum, Turkey.
| | - Ana S Teles
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Anesthesia, Instituto Português de Oncologia Do Porto Francisco Gentil, R. Dr. António Bernardino de Almeida 62, 4200-072 Porto, Portugal.
| | - Mario Fajardo-Pérez
- MoMaRC Morphological Madrid Research Center, Calle Arzobispo Morcillo, 4, 28029 Madrid, Spain; Department of Anesthesia and Chronic Pain, Móstoles University Hospital, C. Gladiolo, s/n, 28933 Móstoles, Spain.
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11
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Saini S, Rao SM, Agrawal N, Gupta A. Comparison of analgesic efficacy of shoulder block versus interscalene block for postoperative analgesia in arthroscopic shoulder surgeries: A randomised trial. Indian J Anaesth 2021; 65:451-457. [PMID: 34248188 PMCID: PMC8253006 DOI: 10.4103/ija.ija_110_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/04/2021] [Accepted: 05/22/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Arthroscopic orthopaedic surgery may lead to significant postoperative pain. Interscalene block (ISB) is associated with undesirable effects like phrenic nerve palsy. Shoulder block (ShB) is a relatively recent diaphragm sparing alternative for analgesia in these cases. Methods This prospective randomised trial was conducted in 70 adult patients posted for arthroscopic Bankart repair surgery. Patients were randomly assigned into two groups: interscalene block [Group ISB (n = 35): 0.5% bupivacaine 10 ml] or shoulder block [Group ShB (n = 35): 0.5% bupivacaine (suprascapular block 10 ml and axillary block 10 ml)] using ultrasound and nerve stimulator. The primary aim of our study was to compare the ISB with ShB for visual analogue score (VAS) in recovery area (zero hour). Time for block performance, VAS, time to first rescue analgesia, total analgesic requirement, patient satisfaction and complications were recorded. Results VAS was significantly higher in ShB group at 2 and 4 h (P = 0.001 and 0.000) while it was significantly higher in ISB group at 12 h (P = 0.013). The time to first analgesic request was significantly prolonged in ISB group as compared to ShB group (8.22 h vs. 4.69 h; P = 0.002) but total analgesic requirement and patient satisfaction at 24 h were similar. Complications like dyspnoea, ptosis and motor weakness were seen only with ISB group. Conclusion Both ShB and ISB blocks have similar efficacy in terms of postoperative pain scores, cumulative analgesic requirements and patient satisfaction. However, considering the various undesirable effects associated with ISB, like phrenic nerve blockade, prolonged upper limb weakness and the occurrence of rebound pain, shoulder block may be preferred for arthroscopic shoulder surgeries.
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Affiliation(s)
- Suman Saini
- Anaesthesiology and Intensive Care, VMMC and Safdarjung Hospital, New Delhi, India
| | - Shruti Mahesh Rao
- Anaesthesiology and Intensive Care, VMMC and Safdarjung Hospital, New Delhi, India
| | - Nidhi Agrawal
- Anaesthesiology and Intensive Care, VMMC and Safdarjung Hospital, New Delhi, India
| | - Anju Gupta
- Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Huang F, Yang Z, Su Z, Gao X. The analgesic evaluation of gabapentin for arthroscopy: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25740. [PMID: 34011032 PMCID: PMC8137103 DOI: 10.1097/md.0000000000025740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/07/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The efficacy of gabapentin for pain management of arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of gabapentin versus placebo on the postoperative pain intensity of arthroscopy. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials assessing the effect of gabapentin versus placebo on pain control of arthroscopy. This meta-analysis is performed using the random-effect model. RESULTS Five randomized controlled trials are included in the meta-analysis. Overall, compared with control group for arthroscopy, gabapentin remarkably decreases pain scores at 24 hour (standard mean difference [SMD]=-0.68; 95% confidence interval [CI]=-1.15 to -0.02; P = .21), analgesic consumption (SMD = -18.24; 95% CI=-24.61 to -11.88; P < .00001), nausea and vomiting (OR = 0.42; 95% CI = 0.21 to 0.84; P = .01), but has no obvious influence on pain scores at 6 h (SMD = -1.30; 95% CI = -2.92 to 0.31; P = .11) or dizziness (OR = 1.12; 95% CI = 0.56 to 2.24; P = .75). CONCLUSIONS Gabapentin is effective for pain control after arthroscopy.
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Affiliation(s)
- Feiri Huang
- Department of Orthopedics, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital
| | - Zhifang Yang
- Department of Orthopedics, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital
| | - Zhongliang Su
- Department of Orthopedics, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital
| | - Xiaosheng Gao
- Department of Orthopedics, Affiliated Yueqing Hospital,Wenzhou Medical University, Wenzhou, Zhejiang Province, P.R. China
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13
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Zangrilli J, Szukics P, Austin L, Horneff JG. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev 2021; 9:e20.00191. [PMID: 33999881 DOI: 10.2106/jbjs.rvw.20.00191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
» Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. » While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. » The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. » Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. » Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. » Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.
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Affiliation(s)
- Julian Zangrilli
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Patrick Szukics
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Luke Austin
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Musso D, Klaastad Ø, Ytrebø LM. A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand 2021; 65:674-680. [PMID: 33506505 DOI: 10.1111/aas.13787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/07/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis. METHODS Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15 mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound. RESULTS Median NRS (0-10) at 1, 3, 6, 8 and 24 hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5 mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%). CONCLUSIONS The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty.
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Affiliation(s)
- Dario Musso
- Department of Anaesthesiology University Hospital of North Norway and Acute and Critical Care Research groupUiT ‐ The Arctic University of Norway Tromsø Norway
| | - Øivind Klaastad
- Department of Anaesthesiology University Hospital of North Norway and Institute of Clinical MedicineUiT ‐ The Arctic University of Norway Tromsø Norway
| | - Lars M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway and Acute and Critical Care Research groupUiT ‐ The Arctic University of Norway Tromsø Norway
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15
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. [The impact of unilateral diaphragmatic paralysis on sleep-disordered breathing: a scoping review]. Can J Anaesth 2021; 68:1064-1076. [PMID: 33725316 DOI: 10.1007/s12630-021-01970-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Unilateral diaphragm paralysis (UDP) may potentially worsen sleep-disordered breathing (SDB). Unilateral diaphragm paralysis has been associated with proximal brachial plexus blockade, such as interscalene and supraclavicular block. The impact of UDP in patients with SDB is not known in this context. The objectives of this scoping review were to explore the associations between UDP and worsening SDB severity, oxygenation, and pulmonary function. METHODS A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to include studies involving adult patients (≥ 18 yr) with SDB, where the effects of UDP on SDB severity, oxygenation, and pulmonary function were examined. RESULTS Six studies (n = 100 patients) with UDP and SDB were included. The sample population was derived exclusively from respirology-sleep clinics, and none were surgical patients. Compared with control (no UDP), UDP was associated with an increased respiratory disturbance index, most pronounced during rapid eye movement (REM) sleep and supine sleep. Supine and REM sleep were associated with obstructive and mixed (both obstructive and central) events, respectively. Compared with control, UDP was associated with a lower mean and minimum oxygen saturation and arterial oxygen tension during all sleep stages and in all body positions. The majority of UDP patients were found to have clinically significant reductions in mean forced expiratory volume in one second and forced vital capacity values, consistent with restrictive ventilatory pattern. CONCLUSION We observed an association between UDP and increasing SDB severity, particularly during REM sleep and while sleeping in the supine position. Although we identified weaknesses in study design and lack of perioperative data, anesthesiologists should be aware of this association when considering proximal brachial plexus blockade in patients with SDB.
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Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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16
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Laumonerie P, Dalmas Y, Tibbo ME, Robert S, Faruch M, Chaynes P, Bonnevialle N, Mansat P. Sensory innervation of the human shoulder joint: the three bridges to break. J Shoulder Elbow Surg 2020; 29:e499-e507. [PMID: 32712453 DOI: 10.1016/j.jse.2020.07.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/29/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Painful shoulders create a substantial socioeconomic burden and significant diagnostic challenge for shoulder surgeons. Consensus with respect to the anatomic location of sensory nerve branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches (ABs) (1) innervating the shoulder joint and (2) the distribution of sensory receptors about its capsule and bursae. MATERIALS AND METHODS Four electronic databases were queried, between January 1945 and June 2019. Thirty original articles providing a detailed description of the distribution of sensory receptors about the shoulder joint capsule (13) and its ABs (22) were reviewed. RESULTS The suprascapular, lateral pectoral, axillary, and lower subscapular nerves were found to provide ABs to the shoulder joint. The highest density of nociceptors was found in the subacromial bursa. The highest density of mechanoreceptors was identified within the insertion of the glenohumeral ligaments. The most frequently identified innervation pattern comprised 3 nerve bridges (consisting of ABs from suprascapular, axillary, and lateral pectoral nerves) connecting the trigger and the identified pain generator areas rich in nociceptors. CONCLUSION Current literature supports the presence of a common sensory innervation pattern for the human shoulder joint. Anatomic studies have demonstrated that the most common parent nerves supplying ABs to the shoulder joint are the suprascapular, lateral pectoral, and axillary nerves. Further studies are needed to assess both the safety and efficacy of selective denervation of the painful shoulders, while limiting the loss of proprioceptive function.
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Affiliation(s)
- Pierre Laumonerie
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France; Anatomy Laboratory, Faculty of Medicine, Toulouse, France.
| | - Yoann Dalmas
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Suzanne Robert
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Marie Faruch
- Department of Radiology, Hôpital Pierre-Paul-Riquet, Toulouse, France
| | | | - Nicolas Bonnevialle
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Pierre Mansat
- Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Toulouse, France
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17
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Caldwell GL, Selepec MA. Surgeon-Administered Nerve Block During Rotator Cuff Repair Can Promote Recovery with Little or No Post-operative Opioid Use. HSS J 2020; 16:349-357. [PMID: 33376459 PMCID: PMC7749895 DOI: 10.1007/s11420-019-09745-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of opioid analgesia is common in both the acute and extended post-operative periods after rotator cuff repair. The current opioid crisis has prompted surgeons to seek alternatives that minimize or even eliminate the need for oral opioids after surgery. QUESTIONS/PURPOSES We sought to investigate the effects on post-operative opioid use of a surgeon-administered block of the suprascapular and axillary nerves in arthroscopic rotator cuff repair (ARCR), in particular to quantify outpatient opioid consumption and duration. METHODS In this prospective observational study, all patients undergoing primary ARCR performed under general anesthesia by a single surgeon were studied over a 15-month period. Of 91 ARCRs performed, 87 patients were enrolled and followed prospectively. At the conclusion of the procedure, the surgeon performed "local-regional" nerve blockade with injections to the sensory branches of the suprascapular nerve and the axillary nerve, as well as local infiltration about the shoulder. Use of medications in the post-anesthesia care unit was left up to the anesthesiologist. Patients were prescribed oral opioids (hydrocodone/acetaminophen 5/325 mg) for analgesia after discharge. The quantity and duration of opioid use and pain scores were recorded for 4 months. Statistical analysis was performed to evaluate factors that could account for greater opioid use. RESULTS Total opioid consumption ranged from 0 to 30 opioid tablets (average, 4.2 tablets) over the 4-month period. Post-operatively, 91% of patients took between ten or fewer tablets, and 39% took no opioids. The average duration of opioid use was 2.4 days. No patients were taking opioids at the 4- to 6-week or 4-month follow-up visits, none required refills, and none received prescriptions from outside prescribers. No statistically significant differences were seen in opioids taken or duration of use in regard to tear size, sex, body mass index, surgery location, or procedure time. There was a significant inverse correlation between opioid use and age. In addition, the cost of the surgeon-performed procedure was substantially lower than that associated with pre-operative nerve blockade performed by an anesthesiologist. All patients were satisfied with the post-operative pain management protocol. Average reported post-operative pain scores were low and decreased at each visit. CONCLUSION With this local-regional nerve-blocking protocol, opioid use after ARCR was unexpectedly low, and a large proportion of patients recovered without any post-surgical opioids. The correlation seen between opioid use and age may not be clinically significant, given the low use of post-operative opioids overall. These results may be useful in guiding post-operative opioid prescribing after ARCR, as well as in lowering costs associated with ARCR.
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Affiliation(s)
- George L. Caldwell
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
| | - Michael A. Selepec
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
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18
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Patel MS, Abboud JA, Sethi PM. Perioperative pain management for shoulder surgery: evolving techniques. J Shoulder Elbow Surg 2020; 29:e416-e433. [PMID: 32844751 DOI: 10.1016/j.jse.2020.04.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
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19
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Yung EM, Got TC, Patel N, Brull R, Abdallah FW. Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis. Anaesthesia 2020; 76:549-558. [PMID: 32596840 DOI: 10.1111/anae.15172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2020] [Indexed: 12/18/2022]
Abstract
Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioid-related side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of -30.9 ([-38.9 to -22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (-2.2 cm [(-4.4 to -0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.
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Affiliation(s)
- E M Yung
- Department of Anesthesiology and Pain Medicine, University of Toronto, Canada
| | - T C Got
- Department of Anesthesiology and Pain Medicine, University of Toronto, Canada
| | - N Patel
- Faculty of Medicine, University of British Columbia, Canada
| | - R Brull
- Department of Anesthesiology and Pain Medicine, University of Toronto, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine, University of Toronto, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Canada
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20
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Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery. Anesthesiology 2020; 132:839-853. [DOI: 10.1097/aln.0000000000003132] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background
Interscalene brachial plexus block, the pain relief standard for shoulder surgery, is an invasive technique associated with important complications. The subomohyoid anterior suprascapular block is a potential alternative, but evidence of its comparative analgesic effect is sparse. The authors tested the hypothesis that anterior suprascapular block is noninferior to interscalene block for improving pain control after shoulder surgery. As a secondary objective, the authors evaluated the success of superior trunk (C5–C6 dermatomes) block with suprascapular block.
Methods
In this multicenter double-blind noninferiority randomized trial, 140 patients undergoing shoulder surgery were randomized to either interscalene or anterior suprascapular block with 15 ml of ropivacaine 0.5% and epinephrine. The primary outcome was area under the curve of postoperative visual analog scale pain scores during the first 24 h postoperatively. The 90% CI for the difference (interscalene-suprascapular) was compared against a –4.4-U noninferiority margin. Secondary outcomes included presence of superior trunk blockade, pain scores at individual time points, opioid consumption, time to first analgesic request, opioid-related side-effects, and quality of recovery.
Results
A total of 136 patients were included in the analysis. The mean difference (90% CI) in area under the curve of pain scores for the (interscalene-suprascapular) comparison was –0.3 U (–0.8 to 0.12), exceeding the noninferiority margin of –4.4 U and demonstrating noninferiority of suprascapular block. The risk ratio (95% CI) of combined superior trunk (C5–C6 dermatomes) blockade was 0.98 (0.92 to 1.01), excluding any meaningful difference in superior trunk block success rates between the two groups. When differences in other analgesic outcomes existed, they were not clinically important.
Conclusions
The suprascapular block was noninferior to interscalene block with respect to improvement of postoperative pain control, and also for blockade of the superior trunk. These findings suggest that the suprascapular block consistently blocks the superior trunk and qualify it as an effective interscalene block alternative.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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21
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Rothe C, Lund J, Jenstrup MT, Steen-Hansen C, Lundstrøm LH, Andreasen AM, Lange KHW. A randomized controlled trial evaluating the impact of selective axillary nerve block after arthroscopic subacromial decompression. BMC Anesthesiol 2020; 20:33. [PMID: 32005160 PMCID: PMC6995169 DOI: 10.1186/s12871-020-0952-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The sensory innervation of the shoulder is complex and there are variations in the branching patterns of the sensory fibres. Articular branches from the axillary nerve to the subacromial bursa are described in more than 50% of investigated shoulders but the isolated contribution of sensory input from the axillary nerve has never been investigated clinically. We hypothesized that a selective block of the axillary nerve would reduce morphine consumption and pain after arthroscopic subacromial decompression. METHODS We included 60 patients in a randomized, blinded, placebo-controlled study. Patients were randomized to a preoperative selective ultrasound-guided axillary nerve block with 20 mL ropivacaine (7.5 mg/mL) or 20 mL saline. Primary outcome was intravenous morphine consumption 0-4 h postoperatively. Secondary outcome was postoperative pain evaluated by a visual analogue scale (VAS) score (0-100). RESULTS We analysed data from 50 patients and found no significant difference in 0-4 h postoperative morphine consumption between the two groups (ropivacaine 14 mg, placebo 18 mg (P = 0.12)). There was a reduction in postoperative pain: VAS 0-4 h (area under the curve) (ropivacaine 135, placebo 182 (P = 0.03)), VAS after 8 h (ropivacaine 9, placebo 20 (P = 0.01)) and VAS after 24 h (ropivacaine 7, placebo 18 (P = 0.04)). Eight out of 19 patients with a successful selective axillary nerve block needed an interscalene brachial plexus escape block. CONCLUSIONS Selective block of the axillary nerve has some pain relieving effect, but in this setting the effect was unpredictable, variable and far from sufficient in a large proportion of the patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT01463865). Registered: November 1, 2011.
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Affiliation(s)
- Christian Rothe
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Jørgen Lund
- Department of Anaesthesiology, Aleris-Hamlet Hospital, Copenhagen, Denmark
| | | | - Christian Steen-Hansen
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark.
| | - Asger Mølgaard Andreasen
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Kai Henrik Wiborg Lange
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
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Ferré F, Pommier M, Laumonerie P, Ferrier A, Menut R, Bosch L, Balech V, Bonnevialle N, Minville V. Hemidiaphragmatic paralysis following ultrasound‐guided anterior vs. posterior suprascapular nerve block: a double‐blind, randomised control trial. Anaesthesia 2020; 75:499-508. [DOI: 10.1111/anae.14978] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2019] [Indexed: 12/26/2022]
Affiliation(s)
- F. Ferré
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - M. Pommier
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - P. Laumonerie
- Département d'Orthopédie Traumatologie Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - A. Ferrier
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - R. Menut
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - L. Bosch
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - V. Balech
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - N. Bonnevialle
- Département d'Orthopédie Traumatologie Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
| | - V. Minville
- Département d'Anesthésie Réanimation Centre Hospitalier Universitaire de Toulouse Purpan Hôpital Riquet Université Toulouse 3‐Paul Sabatier Toulouse France
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Mariano ER, El‐Boghdadly K. Fasten your seatbelts: innovation in regional anaesthesia is a bumpy ride. Anaesthesia 2020; 75:447-450. [DOI: 10.1111/anae.14992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 12/29/2022]
Affiliation(s)
- E. R. Mariano
- Department of Anesthesiology, Peri‐operative and Pain Medicine Stanford University School of Medicine Stanford CA USA
- Anesthesiology and Peri‐operative Care Service Veterans Affairs Palo Alto Health Care System Palo Alto CA USA
| | - K. El‐Boghdadly
- Department of Anaesthesia Guy's and St Thomas’ NHS Foundation Trust London UK
- King's College London UK
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Choi H, Roh K, Joo M, Hong SH. Continuous suprascapular nerve block compared with single-shot interscalene brachial plexus block for pain control after arthroscopic rotator cuff repair. Clinics (Sao Paulo) 2020; 75:e2026. [PMID: 33206761 PMCID: PMC7603171 DOI: 10.6061/clinics/2020/e2026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/21/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES We compared the analgesic efficacy of a continuous suprascapular nerve block (C-SSNB) and a single-shot interscalene brachial plexus block (S-ISNB) for postoperative pain management in patients undergoing arthroscopic rotator cuff repair. METHODS A total of 118 patients undergoing arthroscopic rotator cuff repair were randomly allocated to the S-ISNB or C-SSNB groups. Postoperative pain was assessed using the visual analog scale (VAS) at 1, 2, 6, 12, and 24 h postoperatively. Supplemental analgesic use was recorded as total equianalgesic fentanyl consumption. RESULTS The C-SSNB group showed significantly higher VAS scores at 0-1 h and 1-2 h after the surgery than the S-ISNB group (4.9±2.2 versus 2.3±2.2; p<0.0001 and 4.8±2.1 versus 2.4±2.3; p<0.0001, respectively). The C-SSNB group showed significantly lower VAS scores at 6-12 h after the surgery than the S-ISNB group (4.1±1.8 versus. 5.0±2.5; p=0.031). The C-SSNB group required significantly higher doses of total equianalgesic fentanyl in the post-anesthesia care unit than the S-ISNB group (53.66±44.95 versus 5.93±18.25; p<0.0001). Total equianalgesic fentanyl in the ward and total equianalgesic fentanyl throughout the hospital period were similar between the groups (145.99±152.60 versus 206.13±178.79; p=0.052 and 199.72±165.50 versus 212.15±180.09; p=0.697, respectively). CONCLUSION C-SSNB was more effective than S-ISNB at 6-12 h after the surgery for postoperative analgesia after arthroscopic rotator cuff repair.
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Affiliation(s)
- Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Kyungmoon Roh
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Mina Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea
- *Corresponding author. E-mail:
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Cho N, Kang RS, McCartney CJL, Pawa A, Costache I, Rose P, Abdallah FW. Analgesic benefits and clinical role of the posterior suprascapular nerve block in shoulder surgery: a systematic review, meta-analysis and trial sequential analysis. Anaesthesia 2019; 75:386-394. [PMID: 31583679 DOI: 10.1111/anae.14858] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2019] [Indexed: 11/28/2022]
Abstract
The posterior suprascapular nerve block has been proposed as an analgesic alternative for shoulder surgery based on the publication of several comparisons with interscalene block that failed to detect differences in analgesic outcomes. However, quantification of the absolute treatment effect of suprascapular nerve block on its own, in comparison with no block (control), to corroborate the aforementioned conclusions has been lacking. This study examines the absolute analgesic efficacy of suprascapular nerve block compared with control for shoulder surgery. We systematically sought electronic databases for studies comparing suprascapular nerve block with control. The primary outcomes included postoperative 24-h cumulative oral morphine consumption and the difference in area under the curve for 24-h pooled pain scores. Secondary outcomes included the incidence of opioid-related side-effects (postoperative nausea and vomiting) and patient satisfaction. Data were pooled using random-effects modelling. Ten studies (700 patients) were analysed; all studies examined landmark-guided posterior suprascapular nerve block performed in the suprascapular fossa. Suprascapular nerve block was statistically but not clinically superior to control for postoperative 24-h cumulative oral morphine consumption, with a weighted mean difference (99%CI) of 11.41 mg (-21.28 to -1.54; p = 0.003). Suprascapular nerve block was also statistically but not clinically superior to control for area under the curve of pain scores, with a mean difference of 1.01 cm.h. Nonetheless, suprascapular nerve block reduced the odds of postoperative nausea and vomiting and improved patient satisfaction. This review suggests that the landmark-guided posterior suprascapular nerve block does not provide clinically important analgesic benefits for shoulder surgery. Investigation of other interscalene block alternatives is warranted.
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Affiliation(s)
- N Cho
- Department of Anesthesiology and Pain Medicine, University of Ottowa, ON, Canada
| | - R S Kang
- Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottowa, ON, Canada
| | - A Pawa
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I Costache
- Department of Anesthesiology and Pain Medicine, University of Ottowa, ON, Canada
| | - P Rose
- Department of Anesthesiology and Pain Medicine, University of Ottowa, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine, University of Ottowa, ON, Canada
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Tran DQ, Layera S, Bravo D, Cristi-Sanchéz I, Bermudéz L, Aliste J. Diaphragm-sparing nerve blocks for shoulder surgery, revisited. Reg Anesth Pain Med 2019; 45:rapm-2019-100908. [PMID: 31541010 DOI: 10.1136/rapm-2019-100908] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/28/2019] [Accepted: 09/04/2019] [Indexed: 12/21/2022]
Abstract
Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence <10%.
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Affiliation(s)
- De Q Tran
- Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Sebastián Layera
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Daniela Bravo
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Iver Cristi-Sanchéz
- Escuela de Kinesiología, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
| | - Loreley Bermudéz
- Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
| | - Julián Aliste
- Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
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Bickelhaupt B, Eckmann MS, Brennick C, Rahimi OB. Quantitative analysis of the distal, lateral, and posterior articular branches of the axillary nerve to the shoulder: implications for intervention. Reg Anesth Pain Med 2019; 44:rapm-2019-100560. [PMID: 31289237 DOI: 10.1136/rapm-2019-100560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/17/2019] [Accepted: 06/09/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The terminal sensory branches innervating the shoulder joint are potential therapeutic targets for the treatment of shoulder pain. This cadaveric study investigated in detail the anatomic pathway of the posterior terminal sensory branch of the axillary nerve (AN) and its relationship to nearby anatomic structures for applications, such as nerve block or ablation of the shoulder joint. METHODS For this study, nine shoulders were dissected. Following dissection, methylene blue was used to stain the pathway of the terminal sensory branches of the AN to provide a visual relationship to the nearby bony structures. A transparent grid was overlaid on the humeral head to provide further detailed information regarding the innervation to the shoulder joint. RESULTS Eight of the nine shoulders displayed terminal sensory branches of the AN. The terminal sensory branches of the AN innervated the posterolateral head of the humerus and shoulder capsule and were deep and distal to the motor branches innervating the deltoid muscle and teres minor muscle. All terminal branches dissected innervated the shoulder capsule at the posteroinferior-lateral aspect of the greater tuberosity of the humerus. All specimens displayed innervation to the shoulder joint in the lateral most 25% and inferior most 37.5% before methylene blue staining. CONCLUSION The terminal sensory branches of the AN consistently innervate the inferior and lateral aspects of the posterior humeral head and shoulder capsule. These nerves are easily accessible and would provide a practical target for nerve block or ablation to relieve shoulder pain without compromising motor integrity.
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Affiliation(s)
- Brittany Bickelhaupt
- Rehabilitation, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Maxim S Eckmann
- Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Caroline Brennick
- Rehabilitation, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Omid B Rahimi
- Cellular and Structural Biology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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González-Arnay E, Jiménez-Sánchez L, García-Simón D, Valdés-Vilches L, Salazar-Zamorano CH, Boada-Pié S, Aguirre JA, Eichenberger U, Fajardo-Pérez M. Ultrasonography-guided anterior approach for axillary nerve blockade: An anatomical study. Clin Anat 2019; 33:488-499. [PMID: 31050830 DOI: 10.1002/ca.23394] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/09/2019] [Accepted: 04/26/2019] [Indexed: 01/24/2023]
Abstract
Combined ultrasound (US)-guided blockade of the suprascapular and axillary nerves (ANs) has been proposed as an alternative to interscalene blockade for pain control in shoulder joint pathology or postsurgical care. This technique could help avoid respiratory complications and/or almost total upper limb palsy. Nowadays, the AN blockade is mostly performed using an in-plane caudal-to-cephalic approach from the posterior surface of the shoulder, reaching the nerve immediately after it exits the neurovascular quadrangular space (part of the spatium axillare). Despite precluding most respiratory complications, this approach has not made postsurgical pain relief any better than an interscalene blockade, probably because articular branches of the AN are not blocked.Cephalic-to-caudal methylene blue injections were placed in the first segment of the AN of six Thiel-embalmed cadavers using an US-guided anterior approach in order to compare the distribution with that produced by a posterior approach to the contralateral AN in the same cadaver. Another 21 formalin-fixed cadavers were bilaterally dissected to identify the articular branches of the AN.We found a good spread of the dye on the AN and a constant relationship of this nerve with the subscapularis muscle. The dye reached the musculocutaneous nerve, which also contributes to shoulder joint innervation. We describe the anatomical landmarks for an ultrasonography-guided anterior AN blockade and hypothesize that this anterior approach will provide better pain control than the posterior approach owing to complete blocking of the joint nerve. Clin. Anat. 33:488-499, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Emilio González-Arnay
- Department of Anatomy, Histology and Neuroscience, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Lorena Jiménez-Sánchez
- Department of Anatomy, Histology and Neuroscience, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Diego García-Simón
- Department of Anesthesiology and Reanimation, Móstoles University Hospital, Madrid, Spain
| | - Luis Valdés-Vilches
- Department of Anesthesiology and Reanimation, Puerta del Sol Hospital, Málaga, Spain
| | | | - Sergi Boada-Pié
- Department of Anesthesiology and Reanimation, Joan XXXIII University Hospital, Tarragona, Spain
| | - José Alejandro Aguirre
- Department of Anesthesia, Intensive Care and Pain Therapy, Balgrist University Hospital, Zürich, Switzerland
| | - Urs Eichenberger
- Department of Anesthesia, Intensive Care and Pain Therapy, Balgrist University Hospital, Zürich, Switzerland
| | - Mario Fajardo-Pérez
- Department of Anatomy, Histology and Neuroscience, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Department of Anesthesiology and Reanimation, Móstoles University Hospital, Madrid, Spain
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Anaesthesia for arthroscopic shoulder surgery, do we have alternatives to the interescalene block? ACTA ACUST UNITED AC 2019; 66:406-407. [PMID: 31023566 DOI: 10.1016/j.redar.2019.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 11/23/2022]
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30
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Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ 2019; 19:98-104. [PMID: 33456877 DOI: 10.1016/j.bjae.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- D W Hewson
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK
| | - M Oldman
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - N M Bedforth
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK
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Tran J, Peng PWH, Agur AMR. Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention. Reg Anesth Pain Med 2019; 44:rapm-2018-100152. [PMID: 30635516 DOI: 10.1136/rapm-2018-100152] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2011, chronic shoulder joint pain was reported by 18.7 million Americans. Image-guided radiofrequency ablation has emerged as an alternative intervention to manage chronic shoulder joint pain. To optimize the effectiveness of shoulder denervation, it requires a detailed understanding of the nerve supply to the glenohumeral and acromioclavicular joints relative to landmarks visible with image guidance. The purpose of this cadaveric study was to determine the origin, course, relationships to bony landmarks, and frequency of articular branches innervating the glenohumeral and acromioclavicular joints. METHODS Fifteen cadaveric specimens were meticulously dissected. The origin, course, and termination of articular branches supplying the glenohumeral and acromioclavicular joints were documented. The frequency of each branch was determined and used to generate a frequency map that included their relationships to bony and soft tissue landmarks. RESULTS In all specimens, the posterosuperior quadrant of the glenohumeral joint was supplied by suprascapular nerve; posteroinferior by posterior division of axillary nerve; anterosuperior by superior nerve to subscapularis; and anteroinferior by main trunk of axillary nerve. Less frequent innervation was found from lateral pectoral nerve and posterior cord. The acromioclavicular joint was found to be innervated by the lateral pectoral and acromial branch of suprascapular nerves in all specimens. Bony and soft tissue landmarks were identified to localize each nerve. CONCLUSIONS The frequency map of the articular branches supplying the glenohumeral and acromioclavicular joints, as well as their relationship to bony and soft tissue landmarks, provide an anatomical foundation to develop novel shoulder denervation and perioperative pain management protocols.
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Affiliation(s)
- John Tran
- Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Philip W H Peng
- Department of Anesthesia, Toronto Western Hospital, Wasser Pain Management Center, University of Toronto, Toronto, Ontario, Canada
| | - Anne M R Agur
- Division of Anatomy, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Pani N, Routray SS, Pani S, Mallik S, Pattnaik S, Pradhan A. Post-operative analgesia for shoulder arthroscopic surgeries: A comparison between inter-scalene block and shoulder block. Indian J Anaesth 2019; 63:382-387. [PMID: 31142882 PMCID: PMC6530293 DOI: 10.4103/ija.ija_65_19] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Shoulder arthroscopic surgeries can produce intense post-operative pain. Inter-scalene block (ISB) provides good analgesia after shoulder surgery, but concerns over its associated risks have prompted the search for alternatives. Shoulder block (SHB), which includes suprascapular block along with axillary nerve (AN) block, was recently proposed as an alternative to ISB, but evidence of its efficacy is conflicting. The aim of our study was to compare SHB with ISB in shoulder surgery for post-operative analgesia. Methods A total of 76 patients scheduled for shoulder arthroscopic surgery were equally divided into 2 groups of 38 patients each: ISB group and SHB group. Both the nerve blocks were achieved by using ultrasound and a nerve stimulator. Visual analogue scale (VAS) scores were evaluated at 1, 4, 6, 12 and 24 h post-operatively. The time to first analgesia request, total analgesic requirement for 24 h post-operatively, patient satisfaction and any complications were recorded. Results SHB provided equivalent analgesia to ISB in terms of post-operative VAS scores. Time to first analgesic request was 6.2 ± 1.3 h in ISB group and 5.9 ± 1.2 h in SHB group, which was not statistically significant. Complications like subjective dyspnoea and weakness of arm were significantly higher in ISB group compared to SHB group. Patient satisfaction scores were also significantly higher in SHB group compared to ISB group. Conclusion SHB is as effective as ISB for post-operative pain relief and with fewer complications due to selective blockade of suprascapular and axillary nerves.
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Affiliation(s)
- Nibedita Pani
- Department of Anaesthesiology and Critical Care, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Sidharth S Routray
- Department of Anaesthesiology and Critical Care, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Soveena Pani
- Department of Anaesthesiology and Critical Care, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Soumyakanta Mallik
- Department of Anaesthesiology and Critical Care, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Santiswaroop Pattnaik
- Department of Anaesthesiology and Critical Care, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - Amit Pradhan
- Department of Anaesthesiology and Critical Care, KIMS, Bhubaneswar, Odisha, India
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Feigl G, Aichner E, Mattersberger C, Zahn P, Avila Gonzalez C, Litz R. Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation. Br J Anaesth 2018; 121:883-889. [DOI: 10.1016/j.bja.2018.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/14/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022] Open
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Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery. Anesthesiology 2018; 129:47-57. [DOI: 10.1097/aln.0000000000002208] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
The interscalene nerve block provides analgesia for shoulder surgery, but is associated with diaphragm paralysis. One solution may be performing brachial plexus blocks more distally. This noninferiority study evaluated analgesia for blocks at the supraclavicular and anterior suprascapular levels, comparing them individually to the interscalene approach.
Methods
One hundred-eighty-nine subjects undergoing arthroscopic shoulder surgery were recruited to this double-blind trial and randomized to interscalene, supraclavicular, or anterior suprascapular block using 15 ml, 0.5% ropivacaine. The primary outcome was numeric rating scale pain scores analyzed using noninferiority testing. The predefined noninferiority margin was one point on the 11-point pain scale. Secondary outcomes included opioid consumption and pulmonary assessments.
Results
All subjects completed the study through the primary outcome analysis. Mean pain after surgery was: interscalene = 1.9 (95% CI, 1.3 to 2.5), supraclavicular = 2.3 (1.7 to 2.9), suprascapular = 2.0 (1.4 to 2.6). The primary outcome, mean pain score difference of supraclavicular–interscalene was 0.4 (–0.4 to 1.2; P = 0.088 for noninferiority) and of suprascapular–interscalene was 0.1 (–0.7 to 0.9; P = 0.012 for noninferiority). Secondary outcomes showed similar opioid consumption with better preservation of vital capacity in the anterior suprascapular group (90% baseline [P < 0.001]) and the supraclavicular group (76% [P = 0.002]) when compared to the interscalene group (67%).
Conclusions
The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.
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Affiliation(s)
- David B. Auyong
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Neil A. Hanson
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Raymond S. Joseph
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Brian E. Schmidt
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - April E. Slee
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Stanley C. Yuan
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
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Abdolrazaghnejad A, Banaie M, Tavakoli N, Safdari M, Rajabpour-Sanati A. Pain Management in the Emergency Department: a Review Article on Options and Methods. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2018; 2:e45. [PMID: 31172108 PMCID: PMC6548151 DOI: 10.22114/ajem.v0i0.93] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services. EVIDENCE ACQUISITION In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED). RESULTS For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful. CONCLUSION This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.
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Affiliation(s)
- Ali Abdolrazaghnejad
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Banaie
- Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Trauma and Injury research center, Iran university of medical sciences, Tehran, Iran
| | - Mohammad Safdari
- Department of Neurosurgery, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
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Reply to Dr Price. Reg Anesth Pain Med 2018; 43:334-335. [PMID: 29561539 DOI: 10.1097/aap.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between patients, surgeon, and anesthetist. A multimodal approach with preemptive medication, regional blockade, local anesthetics, and a combination of acetaminophen, nonsteroidal antiinflammatory drugs, tramadol, and gabapentinoids postoperatively leads to pain control and patient satisfaction. Assessment of patients' expectations constitutes a vital aspect of the preoperative patient evaluation. Educating and psychologically preparing patients reduces postoperative pain. Patients with anxiety and depression, preoperative narcotic use, and medical comorbidities are at an increased risk for suboptimal pain control. Minimizing narcotic use decreases opioid-related adverse effects and facilitates productive rehabilitation efforts.
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Affiliation(s)
- Jason L Codding
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
| | - Charles L Getz
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA
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Huang Y, Chiu F, Webb CA, Weyker PD. Review of the evidence: best analgesic regimen for shoulder surgery. Pain Manag 2017; 7:405-418. [PMID: 28936915 DOI: 10.2217/pmt-2017-0013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Multimodal pain management has been advocated in patients experiencing acute pain after surgical procedures due to tissue damage and the subsequent inflammatory response. For patients undergoing shoulder surgeries, studies have definitively shown that interscalene blocks (ISBs) via single-injection or continuous infusion can reduce the total opioid consumption and can lower pain scores after surgery. In some cases, ISBs can be used as the sole anesthetic during shoulder surgeries and spare patients of receiving general anesthesia. However, clinicians should be fully aware of potential pulmonary complications of ISBs and weigh the risk-benefit ratio in patients with limited pulmonary reserve.
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Affiliation(s)
- Yolanda Huang
- Department of Anesthesiology, Division of Orthopedic & Regional Anesthesia, Columbia University Medical Center
| | - Felicia Chiu
- Department of Anesthesiology, Division of Orthopedic & Regional Anesthesia, Columbia University Medical Center
| | - Christopher Aj Webb
- The Permanente Medical Group, Kaiser Permanente Northern California.,Adjunct Assistant Clinical Professor. Department of Anesthesia & Perioperative Care. University of California San Francisco School of Medicine
| | - Paul David Weyker
- Department of Anesthesiology, Divisions of Critical Care, Liver Transplant Anesthesia, Pain Medicine & Regional Anesthesia, Columbia University Medical Center
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Affiliation(s)
- Neel Desai
- Specialist Registrar in Anaesthetics, Department of Anaesthetics, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP
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Abstract
Abstract
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.
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Dhir S, Sondekoppam RV. Reply to Dr Price. Reg Anesth Pain Med 2017; 42:123. [DOI: 10.1097/aap.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nam YS, Panchal K, Kim IB, Ji JH, Park MG, Park SR. Anatomical study of the articular branch of the lateral pectoral nerve to the shoulder joint. Knee Surg Sports Traumatol Arthrosc 2016; 24:3820-3827. [PMID: 26194117 DOI: 10.1007/s00167-015-3703-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to document the distribution of the articular branch of the lateral pectoral nerve (LPN) to the shoulder and to identify a suitable point for its blockade. METHODS This study involved the dissection of 43 shoulders of 22 unembalmed cadavers (6 male and 16 female) to identify the LPN and its articular branch to the shoulder. To identify the suitable anatomical point for blocking the articular branch of the LPN, several anatomical landmarks around the shoulder were measured. RESULTS The articular branch of the LPN to the shoulder was present in 29 of 43 cases (67.4 %). The appropriate point to block the articular branch of the LPN was identified at a mean distance of 1.5 cm below the clavicle, on the line connecting the closest points between the clavicle and the coracoid process, and at a mean depth of 1.0 cm from the skin. CONCLUSION The articular branch of the LPN to the shoulder, as well as the muscular and cutaneous branches of the LPN, covers a portion of the shoulder joint with suprascapular and axillary nerves. Surgeons might consider a peripheral block of the suprascapular, axillary, and LPNs to provide maximum block coverage after shoulder joint surgery.
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Affiliation(s)
- Young-Seok Nam
- Department of Anatomy, Catholic Institute for Applied Anatomy, The Catholic University of Korea, Seoul, South Korea
| | - Karnav Panchal
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, South Korea
| | - In-Beom Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, The Catholic University of Korea, Seoul, South Korea
| | - Jong-Hun Ji
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, South Korea.
| | - Min-Gyu Park
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, South Korea
| | - Sung-Ryeoll Park
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, South Korea
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Park JY, Bang JY, Oh KS. Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery. Knee Surg Sports Traumatol Arthrosc 2016; 24:3877-3883. [PMID: 26733274 DOI: 10.1007/s00167-015-3902-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/26/2015] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | - Jin-Young Bang
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea.
| | - Kyung-Soo Oh
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, South Korea
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Flohr-Madsen S, Ytrebø LM, Valen K, Wilsgaard T, Klaastad Ø. A randomised placebo-controlled trial examining the effect on hand supination after the addition of a suprascapular nerve block to infraclavicular brachial plexus blockade. Anaesthesia 2016; 71:938-47. [DOI: 10.1111/anae.13504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/25/2022]
Affiliation(s)
- S. Flohr-Madsen
- University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - L. M. Ytrebø
- University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - K. Valen
- University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - T. Wilsgaard
- University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
| | - Ø. Klaastad
- University Hospital of North Norway and UiT-The Arctic University of Norway; Tromsø Norway
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Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg 2016; 120:1114-1129. [PMID: 25822923 DOI: 10.1213/ane.0000000000000688] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery. METHODS We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed. RESULTS A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results. CONCLUSIONS ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.
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Affiliation(s)
- Faraj W Abdallah
- From the *Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesia and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; ‡Division of Obstetric Anesthesia, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; §Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada; ║Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada; and ¶Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Canada
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Zanfaly H, Aly A. Shoulder block versus interscalene block for postoperative pain relief after shoulder arthroscopy. AIN SHAMS JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.4103/1687-7934.182272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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New Brachial Plexus Blocks Highlight Issues With Traditional Axillary Approach. Reg Anesth Pain Med 2016; 41:656-7. [DOI: 10.1097/aap.0000000000000428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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