The shoulder block: A new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain
Department Anaesthesiology and Perioperative Medicine, North Shore Hospital, Takapuna, Auckland, New Zealand. Anaesthesia and intensive care
(Impact Factor: 1.3).
This report describes the development of the shoulder block, an alternative to interscalene brachial plexus blockade for the control of postoperative pain following shoulder surgery. Included is a review of the relevant anatomy of the shoulder joint and its associated structures. Two nerves provide the bulk of the innervation to this area: the suprascapular nerve and the axillary (circumflex) nerve. The shoulder block technique involves selective blockade of both of these nerves instead of general blockade of the entire brachial plexus via the interscalene route. The technique of Meier is used to block the suprascapular nerve in the supraspinous fossa. No descriptions of axillary nerve block were available in the literature, so a technique for blocking this nerve as it travels across the posterior surface of the humerus was developed and is described, along with a discussion of the author's initial clinical experience.
Available from: Ramprasad Sripada
- "As previously mentioned, the majority of the nerve supply to the shoulder is provided by the suprascapular and axillary nerves (Figures 1 and 2). When these nerves are blocked separately, there may be fewer complications and side effects than the traditional interscalene block [3, 4]. The phrenic nerve is not blocked; therefore, these blocks may be used for patients that are not candidates for an interscalene block, for example, severe chronic obstructive pulmonary disease or contra-lateral hemidiaphragmatic paresis. "
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ABSTRACT: The article reviews the current literature regarding shoulder anesthesia and analgesia. Techniques and outcomes are presented that summarize our present understanding of regional anesthesia for the shoulder. Shoulder procedures producing mild to moderate pain may be managed with a single-injection interscalene block. However, studies support that moderate to severe pain, lasting for several days is best managed with a continuous interscalene block. This may cause increased extremity numbness, but will provide greater analgesia, reduce supplemental opioid consumption, improve sleep quality and patient satisfaction. In comparison to the nerve stimulation technique, ultrasound can reduce the volume of local anesthetic needed to produce an effective interscalene block. However, it has not been shown that ultrasound offers a definitive benefit in preventing major complications. The evidence indicates that the suprascapular and/or axillary nerve blocks are not as effective as an interscalene block. However in patients who are not candidates for the interscalene block, these blocks may provide a useful alternative for short-term pain relief. There is substantial evidence showing that subacromial and intra-articular injections provide little clinical benefit for postoperative analgesia. Given that these injections may be associated with irreversible chondrotoxicity, the injections are not presently recommended.
Available from: PubMed Central
- "The nerve is quickly blocked in the suprascapular fossa either with a landmark-only based technique (needle insertion site at 1 cm above the mid point of the scapular spine, at an angle perpendicular to the skin) or with the assistance of a nerve stimulator (contaction of supraspinatus and infraspinatus muscles) or ultrasound device. Concomitant blockade of the axillary nerve has been recently suggested by Price et al. to provide more complete shoulder joint analgesia (33, 34). This technique provides clinically significant improvement in pain control when compared to placebo, but inferior analgesia compared with interscalene block. "
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ABSTRACT: In 1970, Winnie proposed the brachial plexus block as an alternative and effective anaesthesia technique for shoulder surgery. From that date, several techniques have been developed to approach the brachial plexus: the use of a nerve stimulator and, more recently, the ultrasound guided nerve blockade have made the procedure easier and more effective; the availability of the new drugs demonstrates some major advantages due to the application of peripheral blocks. Nowadays the attention has been focused on postoperative pain control: although many techniques have been proposed, the application of a continuous infusion of local anaesthetics through an interscalene catheter seems the best available technique to achieve pain relief after shoulder surgery. Advantages ad disadvantages of regional anaesthesia and adverse events associated with interscalene brachial plexus blockade are reviewed.
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