For shoulder arthroplasty, local infiltration analgesia was of greater value to the patient than interscalene block

 Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty A Prospective Randomized Clinical Trial

These authors point out that while interscalene blocks can provide effective analgesia following shoulder arthroplasty, they risk serious complications in 5% to 16% of cases, including infection, pneumothorax, hematoma, peripheral nerve injuries, Horner syndrome, phrenic nerve palsy, respiratory distress and “rebound” pain as the block wears off. They also alter sensory and motor function of the upper extremity, removing protective sensation and precluding accurate neurologic examination in the immediate postoperative period. Finally, they are more expensive than local infiltration analgesia (LIA). See Interscalene blocks for shoulder surgery - more costly and more risky. and Interscalene block complications

The purpose of their study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty in a prospective randomized clinical trial of patients undergoing primary shoulder arthroplasty.

Both groups had general anesthetics. The block group (n=37) received a preoperative interscalene block using liposomal bupivacaine, and the injection group (n=37) received an intraoperative LIA injection of ropivacaine, epinephrine, ketorolac, and normal saline solution. 

The mean hospital charge for the interscalene block procedure was $1,718, which was over ten times greater than that for LIA injection ($157). The difference in anesthesia professional fees and total procedure time were not presented. The mean hospital length of stay was significantly longer for the patients receiving blocks. 

There was no significant difference in opioid consumption between the groups at any time points postoperatively. 

In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. 

One patient in the block group developed transient phrenic nerve palsy with hypoxemia.  One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. 

In this study local infiltration analgesia was of substantially greater value than interscalene block because both methods provided similar analgesia while interscalene block was over ten times more costly and risked serious complications.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Interscalene blocks for shoulder surgery - more costly and more risky

Single Shot Interscalene Regional Anesthesia Provides Noninferior Analgesia And Decreased Complications Compared With An Indwelling Catheter for Arthroscopic And Reconstructive Shoulder Surgery

These authors compared the efficacy, safety, and complication rates of regional anesthesia in shoulder surgery in 1888 patients lumping together those who underwent shoulder arthroplasty (n=417) and arthroscopic shoulder surgery (n=1471). The blocks were performed under ultrasound guidance by an anesthesiologist with subspecialty training in regional anesthesia.

Ten times as many patients had a continuous interscalene nerve block with a catheter (CIB n=1728) than a single shot interscalene block (SSIB n=160). The allocation was not randomized, but based on patient risk factors and surgeon preference. Patients received phone calls on postoperative days one, two, and seven and fourteen to assess pain levels (NRS) and complications.

They arbitrarily dismissed block related symptoms lasting a week or less as "side effects"; symptoms lasting beyond a week were labeled “complications”.

Using this definition, there were 3 complications (2%) in the SSIB group and 172 complications (10%) in the CIB group. The most frequent complication in the CIB group was shortness of breath (n=135) while in the SSIB group was persistent numbness (n=2).

Ten patients in the CIB group required  Emergency Department (ED) visits secondary to block complications compared to no ED visits in the SSIB group. The relative risk for having a documented complication was 5 times greater in the CIB group. Ten patients in the CIB cohort had block-related ED visits; whereas, no patients in the SSIB had an ED visit.

CIB was associated with $848.18 more hospital and provider payments relative to SSIB. In addition to the direct costs, patients receiving CIB require the  added burden of an additional staff member or established members of the clinical team to call and check on patients with indwelling catheters. Even more costly was is the diagnostic testing for pulmonay complications in the ED, which often includes both cardiac and pulmonary embolism evaluation.

Comment: This study again demonstrates the cost and complications lasting over 1 week associated with interscalene blocks. They did not analyze the complications lasting less than 1 week - many of which may have been substantial. 

A randomized controlled trial, Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial, found a 21% complication rate for continuous block and a 5.4% rate of complications for single shot blocks.

In Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay, the 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 findings of a recent review, Pain Management After Shoulder Arthroplasty: A Systematic Review of Randomized Controlled Trials, are important.Those authors found that the overall cost of single-injection block and continuous block can approach $1,500 and $1,850, respectively, if professional fees are included.

Complications seem with interscalene blocks include phrenic nerve palsy, dyspnea, and persistent distal neuropathy; complications after interscale blocks have been reported in up to 36% of cases. Rebound pain can be substantial when the block wears off 8-24 hours after surgery.  In some cases, rebound pain can lead to greater pain levels and increased narcotic requirement after interscalene block compared to local infiltration. While higher concentrations of an anesthetic such as ropivacaine may produce a more dense block, undesirable effects such as a more pronounced rebound effect, a prolonged motor blockade, and risk of neurotoxicity

Complications of continuous interscalene block are more frequent than for single shot blocks,  including  phrenic nerve block, hemidiaphragmatic palsy, dyspnea, dysphagia, infection, dislodgement, and catheter malposition. 

See also Why not just do an interscalene nerve block anesthetic? and The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence.

In our practice blocks are avoided for almost all arthroplasties. Pain management starts preoperatively with preoperative education, Tylenol, Celebrex and Gabapentin. Patients are started on oral analgesics in the recovery room.

With this "block-less" program our patients have minimal difficulty in starting their immediate postoperative range of motion exercises as is shown here for a 63 year old man on the morning after his total shoulder arthroplasty immediately prior to his discharge.

Our reasons for avoiding routine interscalene 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 (professional and materials) 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.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Shoulder arthroplasty - is a brachial plexus block of value?

Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial

In a randomized study, these authors compared continuous interscalene block (CIB) with single-shot interscalene block for postoperative control in 76 patients having shoulder arthroplasty.

Pain scores (P = 0.010) and opioid use (P = 0.003) on the first postoperative day were lower in the CIB group, but there was no difference in length of stay. Note that over half of the patients had a length of stay over one day.

Adverse events were more common in the CIB group; 10% of catheters pulled out prematurely. One patient required pacemaker implantation after syncopal episodes that may have been related to inadvertent intravascular injection.The authors point out that with plexus block anesthesia, the potential for serious complication remains and that centers with great experience in regional anesthesia have reported serious complications including pneumothorax and intravascular injection as well as transient and permanent postoperative loss of nerve function. 

They conclude that the benefits of CIB may not justify the complication rate and higher costs*.

*Note that the costs listed in this table do not include the professional fees for the anesthesiologist's time for performing either a single shot or a CIB.

Comment: This is a well-done randomized trial.

There is no question that narcotic pain medications place patients at risk for nausea/vomiting, respiratory depression, constipation, falling, urinary retention, and confusion. However, as shown by these authors, plexus blocks have potentially serious risks as well.

To reduce these risks, we employ a multimodal approach without plexus blocks using preoperative education, Tylenol, Celebrex and Gabapentin. Assisted motion is started for all anatomic arthroplasties immediately after surgery in the recovery room. Patients have their PCA discontinued the evening of surgery and are almost always ready for discharge on the first morning after surgery.

With this "block-less" program our patients have minimal difficulty in starting their immediate postoperative range of motion exercises as is shown here for a 63 year old man on the morning after his total shoulder arthroplasty immediately prior to his discharge.

Our reasons for avoiding interscalene 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 (professional and materials) 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.

Here is a bit more discussion regarding the issues with blocks:

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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