Local infiltration instead of nerve block for controlling pain after shoulder arthroplasty

Local infiltration analgesia versus interscalene nerve block for postoperative pain control after shoulder arthroplasty: a prospective, randomized, comparative noninferiority study involving 99 patients

These authors conducted a randomized controlled study to investigate the efficacy of local infiltration analgesia (LIA) and interscalene nerve block (ISB) for early postoperative pain control after total shoulder arthroplasty (TSA).

Patients in the ISB group received a continuous infusion of 0.2% ropivacaine by perineural catheter for 48 hours. 

The surgeon injected 110 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and 0.5 mg of epinephrine before TSA in the LIA group and inserted a catheter into the glenohumeral joint. The next morning, 10 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and epinephrine were injected through the catheter, which was then removed.

The study included 99 patients (50 LIA and 49 ISB patients) with a mean age of 72  years.

No significant difference in the mean pain score was found between the 2 groups for the 48-hour postoperative period.

The  LIA group had significantly less severe pain (P = .003) and less opioid consumption (P = .01) in the recovery room.

Comment: This study suggests that injection of a cocktail of ropivacaine,  ketoprofen, and epinephrine injected before placing the TSA components (50-mL flush in the tissues surrounding the glenoid, 50-mL flush around the humerus into the rotator capsule and cuff, and then 10 mL in the incision) may be as effective as an ISB in controlling pain in the recovery room. 

In our practice, we find that nerve blocks and in-wound catheters are not necessary when a multimodal program of Celebrex, Gabepentin, and Tylenol is used along with patient-controlled analgesia (in the recovery room only). Patients on this program are able to do their own assisted range of motion exercises the night of surgery and usually able to leave the medical center on oral medications the next day.

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Nerve injury after shoulder joint replacement

Neurologic complications of shoulder joint replacement

This author conducted a retrospective review of 211 shoulder arthroplasties in 202 patients. All patients received interscalene regional anesthesia. In 56 patients, this involved the use of a continuous ambulatory interscalene catheter; in the remainder, a singleshot nerve block was administered.

44 patients were identified as having sustained a nerve complication. Reverse shoulder arthroplasty was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved. 

Most nerve complications were transient and resolved within 6 months. 

Comment: It is not clear how each patient was examined for a nerve injury or when the examination was carried out: "In all patients, a comprehensive analysis of all postoperative neurologic complications had been undertaken, including onset, duration, investigation, treatment, and resolution of neurologic symptoms. The diagnosis was established at the time by subjective complaints of the patient and careful clinical assessment of the upper extremity. " "In many of these cases, the patient was not aware of biceps weakness in the postoperative period and tended to complain only of altered sensation in the distribution of the lateral antebrachial cutaneous nerve. " Thus, it is possible that the rate of neurologic complications may be substantially higher than reported here.

This report highlights the difficulty in establishing the etiology of a nerve deficit after surgery: related to the interscalene block, to carpal tunnel syndrome, to compression of the ulnar were at the elbow, to cervical radiculopathy, or to retraction or positioning at the time of shoulder arthroplasty.  This differential diagnosis may be quite difficult to sort out.

To minimize the risk of neurologic problems, we are careful in positioning of the neck, avoiding traction on the arm, limiting the number of minutes the coracoid muscles are retracted during glenoid exposure, and limiting the number of minutes during which the arm is held in extension and external rotation for humeral preparation. We also avoid any form of brachial plexus block. 

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Healing through joint replacement

Supporting progress in shoulder surgery

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Brachial plexus block anesthesia - complications

There are many surgeons who favor a single shot or continuous brachial plexus block. We are not among them. Here are some of the reasons.

Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay

These authors conducted a retrospective review of 697 patients undergoing upper extremity arthroplasty comparing the rate of complications and incidence of potential barriers to discharge and length of stay of patients receiving continuous vs. single-shot perineural brachial plexus block.

The complication rate was 12% (n=63) for the indwelling group and 17% (n=30) for the single-shot group.

The majority of complications were pulmonary, 72% attributable to oxygen desaturation. The indwelling catheter group had 1.61 times higher odds (95% confidence interval, 1.07-2.42; P = .023) of exhibiting any potential barrier to discharge and exhibited a longer length of stay (P = .002).

Our thoughts on interscalene block anesthetics can be viewed here:

Why not just do an interscalene nerve block anesthetic?

and here

The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence.

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Why not just do an interscalene nerve block anesthetic?

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

These authors studied 57 patients undergoing primary shoulder arthroplasty randomized to receive either intraoperative local infiltration of local liposomal bupivacaine (LB) 20 mL bupivacaine/20 mL saline) or preoperative interscalene nerve block (INB).

 Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). 

A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups.

They concluded that an increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day.

In their discussion, the authors review the safety and complication rates of INB. Weber and Jain evaluated the efficacy of INB in a review of 218 patients. They found that 13% of INBs in their study failed, and 5% of their patients had an abnormal neurologic response the day after surgery. Misamore et al demonstrated that 16% of patients undergoing INB experience immediate postoperative block side effects, with 4.4% of patients experiencing persistent neurologic complications. This study displayed similar results, with 3% of patients experiencing a persistent neurologic complication. A study by Fredrickson and Price suggested that an increase in postoperative motor blockade can be experienced with INB and is associated with a reduction in patient  satisfaction.These findings along with the desire for earlymobilization of the operative extremity suggest the utility of an alternative method for pain control in shoulder arthroplasty.

Evaluating the pharmacokinetics of INB, Busch et al found that the time of pain onset after single-injection ropivacaine INB was 10 hours. Weber and Jain similarly evaluated the efficacy of lidocaine and bupivacaine INB and found  that the mean duration of action of the block was 9 hours. This study demonstrated that INB had similar results, with  pain levels quickly rising after 8 hours postoperatively. Goon et al used a single injection of ropivacaine (25 mL 0.375%)  INB in shoulder arthroplasty patients and found the block’s  effects to last on average 18 hours. This study found similar findings with a peak in pain level seen 21 to 24 hours postoperatively  in the INB group. Whereas INB was more effective  at controlling pain in the first 8 hours postoperatively, there  was a trend toward acute rebound pain at the end of POD 0 as the block’s effects declined. 

Comment: Our reasons for avoiding interscaline blocks for shoulder arthroplasty include (1) desire for documentation of neurological status immediately after surgery, (2) wanting to avoid having a flail unprotected arm as we start immediate postoperative motion exercises, (3) eliminating the risk of block-related neurologic or pulmonary complications, (4) avoiding phrenic nerve paresis with the attendant respiratory compromise, (5) eliminating the inconvenience of a failed block, (6) reducing the cost associated with two different anesthetics (block + general), (7) avoiding the problem of acute rebound pain in the middle of the first postoperative night, and (8) the reluctance of some patients to have a needle placed in their neck.

See also

Brachial plexus block - 13% complication rate

The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

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Information about shoulder exercises can be found at this link.

Use the "Search" 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 as well as the 'ream and run essentials'

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Complications of Nerve Blocks for Shoulder Surgery

A recent article on brachial plexus blocks for upper extremity surgery provides substantial detail regarding these procedures including a somewhat brief section on complications.

While these procedures have their proponents, we have found that the problems and complications associated with brachial plexus blocks overshadow the possible advantages. This is especially the case for nerve dysfunction that may seriously compromise the comfort and function of the arm and may be chronic or event permanent.

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Shoulder arthritis articles from the July issue of the Journal of Bone and Joint Surgery

The July JBJS publishes an article by Gilles Walch and colleagues on Prevalence of Neurologic Lesions After Total Shoulder Arthroplasty. These authors recognize that the nerves of the brachial plexus are at risk in major shoulder surgery. They used electromyography to study patients with reverse total shoulders and with anatomic arthroplasty. Importantly, 9 of 19 shoulders in the reverse group and 13 of 23 shoulders in the anatomic group had neurologic lesions detected BEFORE their joint replacement. At a month after surgery, nine of 19 patients with reverse total shoulders and one of 23 anatomic total shoulders had evidence of new nerve injury, with a rate 10 times higher in the reverse total shoulders. Three additional reverse total shoulder patients had worsening of preoperative nerve deficits. The most commonly involved nerve was the axillary nerve. Eight of these resolved in less than 6 months. They suggested that arm lengthening in reverse total shoulder may be responsible for some of these nerve lesions, although this difference did not appear to be statistically significant with the small number of cases included.

We now understand that there are many possible factors that could contribute to compromised neurological function after shoulder joint replacement, including pre-existing cervical spine or shoulder nerve injuries, nerve injury from brachial plexus block, direct surgical injury, and injury from arm lengthening in reverse total shoulder.  These considerations indicate the need for a complete evaluation of the patient before surgery, a detailed discussion of the risks of nerve injury with the patient, and careful attention to surgical technique.

The observation that one nerve lesion in the 41 shoulders had a new nerve lesion that had not resolved by 6 months is a concern for two reasons. One, if this rate is applied to all of the shoulder arthroplasties performed, it would indicate a rather large number of patients with iatrogenic chronic nerve injury. Secondly, the arthroplasties studied in this paper were performed by one of the most experienced shoulder surgeons in the world. It would seem likely that this nerve injury rate would be much lower than that of less experienced surgeons who perform most of the joint replacements.

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