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6 Articles in this Series
Introduction
A Challenging Case of Postoperative Hyperalgesia
Are Serum Bupivacaine Levels a Concern During Postoperative Analgesia?
Postoperative Shoulder Pain: Which Analgesic Block Is Best?
TAP Block Could Help Diagnose Nerve Entrapment Syndrome
Ultrasound-Guided Injections for Pregnant Women with Sacroiliac Joint Pain
Using Intrathecal Patient-Controlled Analgesia in the Postop Setting: Case Report

Postoperative Shoulder Pain: Which Analgesic Block Is Best?

Interview with Stan C. Yuan, MD

While interscalene blocks (ISBs) may be considered the gold standard of postoperative shoulder pain relief, new research suggests there may be little difference in pain control from other types of blocks, including supraclavicular (SCB) and suprascapular blocks (SSB).

In a study presented at this year’s meeting, a team of physicians based out of the Virginia Mason Medical Center in Seattle, Washington, performed a side-by-side comparison to judge the clinical utility of the 3 types of analgesic blocks.1

“We conducted this study with the intention to improve pulmonary function without sacrificing pain control,” Stan C. Yuan, MD, told Practical Pain Management. “Interscalene block has been performed for a long time and it is the gold standard. However, the down side of this block is it produces shortness of breath due to paralysis of the phrenic nerve. Moving further away from this location [ie, supraclavicular and suprascapular blocks] may improve lung function,” Dr. Yuan said.

According to the authors, variations in diaphragmatic paresis as measured by forced vital capcity (FVC) differ depending on the type of block. Reductions in FVC were 38%, 30%, and 18% for ISB, SCB, and SSB respectively,  at 24 hours. Because of this, clinical outcomes may vary when applying continuous infusion at 1 of the 3 different locations along the brachial plexus.

To test this, the researchers conducted a randomized clinical trial of 189 subjects, all of which underwent rotator cuff repair (RCR) surgery. The patients, who were split into 3 groups based on the type of analgesic block they received (ISB, SCB, and SSB), were evaluated for their opioid use and numerical rating scores (NRS) pain scores after 24 hours postoperatively. Doctors also made note of patient satisfaction and whether any side effects were experienced over the 24 hours.

All patients received the same dose of ropivacaine (0.5% 15mL bolus) for all blocks as a continuous infusion of 0.2% ropivacaine at 6 mL/hr started in the postoperative acute care unit (PACU). The pain scores similar between the groups with average pain scores being 1.8, 2.5, and 1.8, for ISB, SCB, and SSB groups, respectively (P = 0.10). The same was true for worst pain scores, which were 4.7, 3.9, and 3.7, for ISB, SCB, and SSB, respectively (P = 0.37).

Use of oxycodone over the 24 hours after surgery also was similar between treatment groups, at 22.8 mg, 19.8 mg, and 18.4 mg, for ISB, SCB, and SSB groups, respectively (P = 0.57).

According to doctors, this research suggests placement of perineural catheters does not make a significant difference on patients’ pain or opioid consumption following surgery. However, the researchers did find significantly more side effects were reported with the proximal brachial plexus blocks as opposed to the suprascapular blocks.

Previous studies have found reductions in vital capacity to be more apparent with ISBs. This may need to be taken into consideration for some patients, such as those with pulmonary disease, who may not be able to tolerate a reduction in vital capacity, the authors concluded.

Suprascapular blocks may be better for a patient with underlying lung dysfunction. However, while the adverse effects may be higher for interscalene and supraclavicular blocks, their usage has existed for a while in the practice, so the choice of block should rest on the discretion of the doctor, Dr. Yuan said.

“Blocks should be based on the comfort level of the doctor. Suprascapular nerve block is a newer block, which requires a little more technical skill. And they should choose the block based on the medical condition of the patient,” Dr. Yuan said.

 

Reference

1. Sirs N, Yuan SC, Hanson NA, et al. Randomized study evaluating pain and opioid consumption in continuous interscalene, supraclavicular, and suprascapular nerve catheters after rotator cuff repair. Poster presented at: Regional Anesthesiology and Acute Pain Medicine Meeting. April 6-8, 2017; San Francisco, CA. Poster 3645.

Next summary: TAP Block Could Help Diagnose Nerve Entrapment Syndrome
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