Ultrasound-Guided Interscalene Block Anesthesia for Shoulder Arthroscopy JBJS

Ultrasound-Guided Interscalene Block Anesthesia for Shoulder Arthroscopy JBJS

This paper reviews 1319 patients having outpatient arthroscopic surgery and ultrasound-guided interscalene blocks. In the introduction, the authors emphasize the importance of cost control and suggest that interscalene blocks facilitate outpatient procedures by providing muscle relaxation and lessening the need for high-dose opiates and paralytics. Furthermore they point to the postoperative analgesia, which may reduce the need for pain medication after surgery. They also point to the risks of neuropathy and other potential complications of interscalene blocks. They propose that ultrasound guidance may reduce the risk of brachial plexus block and improve its success rate.

In their study patients received both ultrasound-guided interscalene blocks and laryngeal mask airway general anesthesia –distinguishing it from studies in which brachial plexus blocks are used alone without supplementation.

It is important to note that the authors carefully excluded patients with diabetes, patients having manipulations, and patients having capsular releases from this cohort because they were felt to be at high risk for neurological complications. One might extrapolate that these authors would be similarly reluctant to use these blocks in patients having shoulder arthroplasty for the same reasons. Importantly, the authors also carefully excluded patients with any neurologic issues (cervical radiculopathy, multiple sclerosis etc.), infection, coagulopathy, and chronic obstructive pulmonary disease (because of the temporary phrenic nerve paralysis that often results from a plexus block). Only patients of American Society of Anesthesiologists grade 1 or 2 (ASA 1 or 2) were included. The blocks were performed with attending anesthesiologists with more than 50 ultrasound-guided interscalene blocks under their belt. Bottom line is that this study was conducted to optimize both the patients included and the experience of the anesthesiologists.

Patients were discharged 1.5 hours after the end of the arthroscopy and experienced 14 hours of pain relief. The authors carefully documented the complications, very few of which could be attributed to the plexus block. 38 adverse events were noted; three patients had permanent sequelae (an MI, transverse myelitis, and persistent plexopathy). All other cases plexopathy and neuropathy resolved within four months. All but 2.2% of the patients were satisfied to the point that they would choose this anesthetic approach again.

While the authors conclude “Our study strongly supports the use of interscalene block for operative anesthesia and postoperative analgesia in patients undergoing shoulder arthroscopy.”, enthusiasts would be well advised (1) to recognize that “The levels of training and experience of the anesthesiologist are directly proportional to success and safety of regional anesthesia” and (2) to carefully exclude, as these authors admonish, patients at increased risk for complications.

Bottom line: in the hands of highly experienced anesthesiologists, the combination of ultrasound guided plexus block and general anesthesia is a highly attractive option for healthy patients having outpatient arthroscopy. The caveat is that the high degree of success reported here cannot be used to support the application of this anesthetic approach to less healthy patients having more complex surgical procedures and cannot be generalized to less experienced anesthesiologists as we have previously demonstrated.

As explained in previous posts, we avoid the use of brachial plexus blocks in patients having shoulder arthroplasty; they surely do not meet the criteria listed for inclusion in the study discussed above.

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Brachial Plexus Blocks for Upper Extremity Surgery - JAAOS

The January issue of JAAOS publishes an article on brachial plexus blocks by Andrew Green and co-authors. This is a comprehensive review of the relevant anatomy, possible applications, technical considerations.  The authors quote the article by UW shoulder fellow Lenters et al. pointing to a substantial complication rate which, although lower in the hands of anesthesiologists experienced in the technique, was still significant for those who had performed many of them.

As we have discussed in a previous post, we avoid plexus blocks in most cases because of the potential for serious and possibly long term complications that are not seen with general anesthesia. As the authors state, "permanent <nerve> injury can result in substantial disability."  Even though the rate of these injuries is low, we are aware of a number of cases where career-ending neuropathies have occurred in surgeons and engineers and where previously independent individuals became dependent because of irreversible loss of function.

The authors also mention phrenic nerve palsy 'in almost all patients with interscalene block'. Our observations are similar and note that for many individuals with sleep apnea, COPD, or other respiratory conditions, even the transient loss of half of their pulmonary function can be critical.

The authors also describe other systemic complications, pneumothorax, vascular puncture, and the risks of indwelling catheters.

The proponents of blocks point to the value of postoperative analgesia. Our experience is that with shoulder arthritis surgery the use of blocks only delays the onset of pain until the block wears off in the evening or the wee hours of the morning when the nurse/patient ratio is lower.

So, again, after a rather prolonged use of blocks, we no longer find that the advantages outweigh the disadvantages and have discontinued their routine use.

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Anesthesia for shoulder surgery, interscalene brachial plexus block vs. general anesthesia

In most cases, we prefer general anesthesia over brachial plexus block anesthesia for our shoulder arthroplasty and rotator cuff procedures.

The reasons for our recommendation are several:
General anesthesia allows us to monitor nerve function during and after the case - this is important with major shoulder reconstruction.
General anesthesia does not produce a transient paralysis of the diaphragm on the side of surgery.
General anesthesia wears off while the patient is in the recovery room when the high level of nursing is immediately available in contrast to blocks which wear off in the early hours of the morning when nurses are less available.
While the complication rate of either method is low, the complications of brachial plexus block anesthesia include the possibility of long lasting or permanent nerve injury.
We do consider brachial plexus anesthesia when there are special circumstances, such as opiod intolerance or strong patient preference.

Those considering brachial plexus block anesthesia may wish to check out the following link (Complications).
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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.