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

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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).

Is a plexus block of value for shoulder arthroplasty?

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial 

These authors sought to evaluate whether liposomal bupivacaine would provide superior pain relief for shoulder replacement patients over bupivacaine alone. Patients received two anesthetics, a general anesthetic and a block with one of the two bupivacaine formulations.

They found no clinically relevant advantage to the use of liposomal bupivacaine over plain bupivacaine. Complications from the blocks were not reported.

Comment: There is no question that narcotic pain medications place patients at risk for nausea/vomiting, respiratory depression, constipation, falling, urinary retention, and confusion. 

While some authors use plexus blocks to minimize narcotics, as shown below, plexus blocks have potentially serious risks as well.

Our practice is to avoid the risks, time and cost of plexus blocks for shoulder arthroplasty. Instead, we employ preoperative education and a multimodal approach including Tylenol, Celebrex and Gabapentin. Assisted motion is started for all anatomic arthroplasties immediately after surgery 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 ream and run 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:

 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.

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.

How you can support research in shoulder surgery Click on this link.

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 block complications

Risk Factors for Complications and Return to the Emergency Department after Interscalene Block Using Liposomal Bupivacaine for Shoulder Surgery

These authors note that Exparel® has recently gained favor for use in interscalene regional block for shoulder surgery, but that it apparently has adverse effects in addition to those associated with interscalene blocks using other agents.

They conducted aretrospective chart review of all patients undergoing shoulder surgery with an Exparel® interscalene block in an 8-month period.

352 patients were included of which 58 (16.5%) had postoperative complications related to their interscalene block, including 37 (10.5%) minor complications and 21 (6.0%) major complications leading to an emergency department visit. 

Univariate analysis yielded ASA score (p=0.03) as a significant predictor of minor complications. A multivariate logistic regression analysis yielded ASA score (p=0.096, Odds ratio=1.64) as trending towards being a significant risk factor for minor complications. 

Univariate analysis yielded age (p=0.006), ASA score (p=0.009), and CCI score (p=0.002) as significant predictors of major complications. Multivariate logistic regression analysis yielded ASA score (p=0.049, Odds ratio=2.25) as the only significant risk factor for major complications.

The authors recommended that surgeons and anesthesiologists should strongly consider a patient’s ASA score, in addition to their pulmonary and cardiac history, when deciding whether the patient is an appropriate candidate for interscalene regional block using Exparel® for shoulder surgery.

Comment: Recognized complications of interscalene blocks include transient and permanent brachial plexus injury, recurrent laryngeal nerve blockade, Horner's syndrome, hematoma, brain damage, bradycardia, pneumothorax, hypotension, carotid artery puncture, and rebound pain. 

In the four decades of our arthroplasty practice we have found that brachial plexus blocks do not add to patient satisfaction or patient safety. Using a preoperative cocktail of Celebrex, Gabapentin, and Tylenol, and a rapid postoperative transition to oral analgesics, patients are able to start active assisted range of motion exercises immediately after surgery, avoiding the cost and risks of interscalene blocks.

Here are some other related articles

Randomized Controlled Trial of Interscalene Block Compared with Injectable Liposomal Bupivacaine in Shoulder Arthroplasty 

These authors list the shortcomings of interscalene brachial plexus block as technical failure and rebound pain. They could also have added to these shortcomings (1) increase cost, (2) increase time, (3) increased rate of complications, (4) risk of phrenic nerve palsy (5) patient frustration with having a 'dead arm' until the block wears off, and (6) inability to do a post op neurological exam.

They randomized patients undergoing primary shoulder arthroplasty to either interscalene brachial plexus block or intraoperative soft-tissue infiltration of bupivacaine liposome injectable suspension.

They found that the mean total postoperative narcotic consumption over 24 hours after the surgical procedure was 14.8 ± 11.3 morphine equivalent units in the block group compared with 14.4 ± 16.8 morphine equivalent units in the suspension group (p = 0.849). The mean VAS pain score was significantly lower in the blockade group than in the suspension group at 0 hours postoperatively (0.8 ± 2.2 compared with 3.3 ± 2.7 points; p < 0.001) and at 8 hours postoperatively (1.4 ± 2.4 compared with 3.2 ± 2.2 points; p < 0.001), but it was not significantly different at 16 hours postoperatively (4.3 ± 2.8 compared with 3.8 ± 2.4 points; p = 0.348). The VAS pain scores were significantly higher (p = 0.021) in the block group (4.9 ± 2.7 points) compared with the suspension group (3.9 ± 2.3 points) at 24 hours postoperatively. 

What is particularly concerning about the VAS pain scores for interscalene block is that at 24 hours the pain was worse than it was preoperatively as shown in this graph

The costs of these two modalities were not available.

They concluded that  interscalene brachial plexus block provided improved pain scores for the first 8 hours after the surgical procedure, pain scores were worse at 24 hours. The optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation. 

Comment: In our primary and revision arthroplasty practice we use neither nerve blocks or the liposomal bupivacaine. Instead we use patient controlled analgesia for the first few hours after surgery and transition to oral analgesics the evening of surgery. With this protocol patients are able to comfortably start continuous passive motion and assisted range of motion exercises immediately after surgery in the recovery room. This is a very cost effective approach, avoiding the increased cost of nerve blocks or the liposomal bupivacaine as well as the time, complications, technical failure, and rebound pain of nerve blocks. Patient satisfaction is high, even among those taking substantial narcotics preoperatively.

Readers may wish to review a similar study:

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: Again 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

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial

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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How you can support research in shoulder surgery Click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Why bother with interscalene blocks for shoulder arthroplasty?

Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty

These authors point out that although regional nerve blockade is commonly used for shoulder arthroplasty, complications and rebound pain (see this link) can create problems for the patient and for the surgeon.

The purpose of their study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade.

From a shoulder registry, 305 patients who underwent TSA and reverse TSA from 2012-2018 were included in this study. All procedures were performed by the same surgeon, in the same manner with standard implants. Only patients who underwent anatomic, reverse, or revision reverse TSA were included. 

From June 21, 2012, to December 13, 2015 144 patients were administered general anesthesia with regional anesthesia. The interscalene nerve block was performed by anesthesiologists who are facile and skilled in this procedure using ultrasound guidance with nerve stimulation.

From December 14, 2015 to June 25, 2018, 161 patients were administered general anesthesia in addition to a local injection consisting of a weight-based mixture of 0.25% ropivacaine, morphine, epinephrine, and ketorolac. The solution was injected both in and around the joint; this included the glenohumeral joint, deltoid, and subacromial space, as well as the subcutaneous tissue surrounding the incision.

Immediate postoperative pain scores were not significantly different between groups.

The median hospital length of stay was 1 day in the local injection group and 2 days in the interscalene nerve block  group.

Opioid consumption during the first 24 hours following surgery was significantly reduced in the local infiltration group compared with the interscalene block group.

No 90-day postoperative nerve complications occurred in the local infiltration group, whereas 2 patients who received interscalene blocks had nerve complications. Both patients experienced wrist drop as well as persistent pain in the thumb and index finger for 6 months after surgery in one patient and numbness in the index and middle fingers lasting for 13 months in the other patient. 

Ninety-day postoperative cardiopulmonary complications occurred in 5 patients in the local infiltration group compared with 8 patients in the interscalene block group. These included deep venous thrombosis, hematoma, stroke, myocardial infarction, and severe hypoxia with saturation of less than 80% requiring intensive care unit admission.

The cost of the weight-based injection mixed in a hospital pharmacy is approximately $25. In contrast to regional anesthesia, local injections can be performed in minimal time, usually less than a minute.

The cost of regional anesthetic supplies, ultrasound use, and professional fees ranges from $1500-1800. On average, an additional 25.0 minutes was required to administer the regional block in the interscalene block group, whereas no additional time was required in the local infiltration group. 

Comment: Many surgeons seem convinced that interscalene blocks are preferred for shoulder arthroplasty. However, like the authors of this paper, we are aware of the downsides and risks (see this link and link) and, as a result, we have not used plexus blocks in our arthroplasty practice for two decades. 

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 associated with two different anesthetics (block + general), (7) avoiding the problem of acute rebound pain in the middle of the first postoperative night, (8) the reluctance of some patients to have a needle placed in their neck

and (9) it isn't necessary when preoperative teaching and oral multimodal drugs (Celebrex, Tylenol, and Gabapentin) are used (see below). 

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.
To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Interscalene block and "rebound pain"

Interscalene Block with and without Intraoperative Local Infiltration with Liposomal Bupivacaine in Shoulder Arthroplasty A Randomized Controlled Trial

These authors point out that interscalene brachial plexus block can be an effective anesthetic technique for shoulder arthroplasty lasting for about 8 hours after surgery; but that “rebound pain” can intensify the patient’s postoperative pain and narcotic usage when the block wears off.

They evaluated the use of Exparel (liposomal bupivacaine) injected into the soft tissues at the surgical site in reducing the  postoperative pain scores and narcotic consumption following shoulder arthroplasty performed with interscalene block.

They found that patients treated with Exparel required significantly more postoperative narcotics and demonstrated no significant reduction in pain scores over the first 72 hours after primary shoulder arthroplasty. An explanation for this increase was not determined in this study.

Data above are for first 24 h after surgery

Comment: The problem of "rebound pain" is one of several downsides of interscalene block, especially since it is likely to occur in the evening or night after surgery. After an interscalene block (with or without Exparel) the pain starts to increase 8 hours after surgery and continued to rise until 24 hours post op. This post-block rebound pain can inconvenience patients, family, nurses, and housestaff.

This randomized controlled trial showed that Exparel was not effective in managing the problem of rebound pain after an interscalene block.

As these authors point out in a previous report (see link), "The optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation."

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Interscalene brachial plexus block and respiratory compromise

These authors present an interesting case of persistent diaphragmatic paralysis associated with an intescalene brachial plexus block (ISB).

While interscalene nerve blocks have are often used for shoulder surgery, they are not without risk and carry an overall complication rate between 2% and 4%.

Transient ipsilateral hemidiaphragmatic paralysis can be observed in association with ISB, and may transiently occur in up to 100% of patients because the phrenic nerve is close to the target brachial plexus nerve roots.

They point out that interscalene block (ISB) can result in a 20% to 25% decrease in forced vital capacity attributable to ipsilateral diaphragm paralysis associated with phrenic nerve involvement during an ISB. Healthy patients are able to compensate for this decrease in forced vital capacity by increasing their respiratory rate and using accessory respiratory muscles until the block wears off, which typically occurs within 3 to 5 hours. They advise that caution should be taken in patients with preexisting respiratory conditions because an ISB may predispose these patients to potential respiratory complications. Although rare, the occurrence of chronic respiratory symptoms is a possible severe complication that has been associated with the use of ISB. They suggest that supportive measures, including supplemental oxygen, airway access, and postoperative surveillance, are key in preventing respiratory complications associated with ISB.

Comment: We do not use interscalene blocks in our practice for multiple reasons (cost, time, complications, pain rebound) as expressed here.

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Use the "Search" box to the right to find other topics of interest to you. 

How you can support progress in shoulder surgery

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'

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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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.

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The value of pain management after shoulder joint replacement: Exparel, nerve block, or tried and true?

A prospective randomized controlled trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine versus continuous interscalene catheter

These authors compared two methods of pain management after shoulder arthroplasty, noting that the often advocated interscalene block can be associated with technical problems with administration that could lead to inadequate pain control, failure of nerve blockade, residual neurapraxia, displacement of the catheter postoperatively, systemic toxicity, and respiratory and neurologic complications.

Liposomal bupivacaine (Exparel) is a long-acting, local anesthetic for single-dose infiltration into the surgical site. It is manufactured by Pacira Pharmaceuticals who sponsored this study comparing Exparel combined with a single bolus interscalene block to a continuous interscalene nerve block.

The two groups had equivalent narcotic use, pain scores, and time to first narcotic rescue within the first 24 hours (P > .05). 

The costs associated with the single bolus interscalene nerve block and continuous interscalene nerve block were $1532 and $1850, respectively. In addition to procedure costs, the use of an infusion pump can cost up to $300. The cost of Exparel at that institution was $315.

Comment: In our practice pain management after shoulder arthroplasty is critical, because we implement immediate postoperative range of motion exercises and continuous passive motion starting in the PACU. In our hands the most effective approach involves neither inter scalene blocks or Exparel, but rather patient controlled analgesia for the afternoon of surgery and then transition to oral analgesics that evening. In this manner rebound in pain is avoided, motion is facilitated, complications are avoided, and patients are routinely ready for discharge on the second postoperative morning.

Our method of pain management is routinely successful for patients having the ream and run procedure, CTA arthroplasty, and total shoulder arthroplasty, enabling patients to successfully establish their self-assisted range of motion on the first postoperative day as shown by the two examples below.

At our institution, we are cost aware. Coincidentally, we just received this email: "Just an update on the plan to try to curtail the exploding Exparel costs at the Medical Center. The $315 per dose for Exparel is unreimbursed by most insurers at present."

Readers may also wish to review: Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial

These authors point out that although they can be effective at decreasing opioid requirements, "peripheral nerve blocks expose the patient to an additional procedure with associated complications. Interscalene blocks have been associated with cardiovascular instability (ie, bradycardia and hypotension) in up to 29% of patients operated on in a beach chair position. Neurologic complications, including persistent neurologic pain, dysesthesia down the arm, postoperative paralysis, perineural entrapment of the catheter, vocal cord paralysis, and hemidiaphragmatic paralysis from phrenic nerve palsy, have also been described. Finally, there is a significant cost to regional management of pain" and that "liposomal bupivacaine has previously been shown to provide a cost savings compared with nerve blocks ranging from $1300 to $1600 per case"

They compared the use of liposomal bupivacaine (Exparel) to an indwelling inter scalene nerve block in 83 shoulder arthroplasty patients: 36 patients received liposomal bupivacaine and a “bridge” of 30 mL of 0.5% bupivacaine, and 47 patients received an ndwelling inter scalene nerve block.

Visual analog scale pain scores were statistically higher in the liposomal bupivacaine cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the liposomal bupivacaine cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). 

The lengths of stay were comparable:

While both methods appear to be effective in the PACU and for post operative day 0, both were associated with an increase in the need for opiates on post operative day 1, indicating rebound pain which needed management.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

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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'See from which cities our patients come.