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ORIGINAL ARTICLE
Year : 2016 | Volume : 50 | Issue : 6 | Page : 584--589
Post operat ve pa n management n shoulder surgery: Suprascapular and ax llary nerve block by arthroscope ass sted catheter
placement
H Çağdaş Basat1, D Hakan Uçar2, Mehmet Armang l3, Berk Güçlü4, Mehmet Dem rtaş5,
1 Department of Orthopaed c Surgery, Koru Hosp tal, Ankara, Turkey
2 Department of Orthopaed c Surgery, Faculty of Med c ne, Yüksek İht sas Un vers ty, Ankara, Turkey 3 Department of Orthopaed c Surgery, Faculty of Med c ne, Ankara Un vers ty, Ankara, Turkey 4 Department of Orthopaed c Surgery, Faculty of Med c ne, Ufuk Un vers ty, Ankara, Turkey 5 Department of Orthopaed c Surgery, Memor al Hosp tal, Ankara, Turkey
Correspondence Address:
Dr. H Çağdaş Basat
Department of Orthopaed c Surgery, Koru Hosp tal, Kızılırmak Mahalles 1450, Sokak No: 13 Cukurambar, Ankara Turkey
Abstract
Background: Postoperat ve pa n management s the part of shoulder surgery to mprove pat ent sat sfact on, start rehab l tat on process rap dly and decrease for hosp tal stay. Var ous treatment modal t es have been used for pa n management, but they have some l m tat ons, s de effects and r sks. Throughout ntraoperat ve and postoperat ve per od, nerve blocks have been used more popularly than others because of eff cacy. For the reg onal nerve block, local anesthet c should be nf ltrated close to the nerve for max mum effect. Consequently, a m of th s study was to evaluate analges c eff cacy when catheters are placed w th ass stance of arthroscope to block suprascapular and ax llary nerves n pat ents undergo ng arthroscop c repa r of rotator cuff under general anesthes a. Mater als and Methods: 24 pat ents (5 males, 19 females; mean age: 54.3 years) who underwent arthroscop c repa r of rotator cuff between June 2014 and September 2014 and were catheter zed to block suprascapular and ax llary nerves dur ng shoulder arthroscopy were ncluded n the study. Cl n cal outcomes were assessed us ng v sual analog scale (VAS) scores preoperat vely and at 0 h, 6 h, 12 h, 18 h, 24 h, and postoperat ve day 2. Results: Preoperat ve and postoperat ve 0 h, 6 h, 12 h, 18 h, 24 h, and day 2 mean VAS scores were 6.38 ± 0.77, 0.44 ± 0.42, 0.58 ± 0.42, 0.63 ± 0.40, 0.60 ± 0.44, 0.52 ± 0.42, and 1.55 ± 0.46, respect vely. No stat st cal d fference was found among 0 h, 6 h, 12 h, 18 h, and 24 h t me po nts; however, compar son of postoperat ve day 2 and postoperat ve 0 h, 6 h, 12 h, 18h and 24 h VAS scores showed stat st cally s gn f cant d fference (P < 0.05). All pat ents were d scharged at the end of 24 h w th no compl cat on. The mean t me ( n m nutes) requ red for block ng suprascapular nerve and ax llar nerve were 14.38 ± 3.21 and 3.75 ± 0.85, respect vely. Conclus on: These results demonstrated that block ng two nerves w th arthroscop c approach was an excellent pa n management method n postoperat ve per od. Accord ngly, pat ents could recover rap dly and pat ents' sat sfact on could be mproved.
How to c te th s art cle:
Basat H &, Uçar D H, Armang l M, Güçlü B, Dem rtaş M. Post operat ve pa n management n shoulder surgery: Suprascapular and ax llary nerve block by arthroscope ass sted catheter placement.Ind an J Orthop 2016;50:584-589
How to c te th s URL:
Basat H &, Uçar D H, Armang l M, Güçlü B, Dem rtaş M. Post operat ve pa n management n shoulder surgery: Suprascapular and ax llary nerve block by arthroscope ass sted catheter placement. Ind an J Orthop [ser al onl ne] 2016 [c ted 2018 Jul 26 ];50:584-589
Ava lable from: http://www. joonl ne.com/text.asp?2016/50/6/584/193474
Full Text
Introduct on
Postoperat ve pa n control s a challeng ng s tuat on for a surgeon n pat ents undergo ng shoulder arthroscopy. Postoperat ve pa n can pers st for 48 h n postoperat ve course, even f the pat ent s started on mult modal analges c agents.[1] For pa n management, numerous treatment modal t es have been descr bed to date; however, they have some l m tat ons, s de effects, and r sks. Nonstero dal ant - nflammatory drugs (NSAIDs) can cause reduced platelet funct on, prolonged bleed ng t me and gastr c ulcerat on.[2] Op o ds can lead to nausea, vom t ng, sedat on, const pat on and ntest nal leus. Intraart cular (IA) local anesthet c nject ons alone m ght not be enough to reduce pa n, and eff c ency of IA local anesthet c or morph ne rema ns controvers al.[2],[3] Although nterscalene block (ISB) has been used for ntraoperat ve anesthes a and postoperat ve pa n management, t has ser ous s de effects such as nadvertent ep dural and sp nal anesthes a, sp nal cord njury, bra n damage, brach al plexus njury and paralys s of the vagus and laryngeal recurrent nerves as well as cerv cal sympathet c nerve and pneumothorax. Effect veness of ISB s correlated w th the anesthet st's sk ll level.[4] Recently, suprascapular nerve block (SSNB) and ax llary nerve block (ANB) are used for ntraoperat ve anesthes a and postoperat ve pa n management n shoulder arthroscopy, espec ally for rotator cuff repa r; however, the procedure s techn cally challeng ng and the success rate var es w dely.[5]
Successful ambulatory surgery depends on analges a and t s effect ve and has m n mal adverse effects.[3] For block ng nerve effect vely, local anesthet c should be nf ltrated close to the nerve. Although var ous techn ques have been descr bed SSNB and ANB, none of them could ach eve effect ve pa n management.[3],[4],[6],[7] Our techn que has allowed block ng nerves and plac ng catheters as close to the nerve as poss ble. The a m of th s study was to evaluate postoperat ve analges c eff cacy of suprascapular and ANBs n shoulder arthroscopy for pat ents undergo ng arthroscop c repa r of rotator cuff under general anesthes a. We hypothes zed that suprascapular and ANB would allev ate postoperat ve pa n and reduce requ rement of analges c drugs, thus decreas ng s de effects of med caments and problems ar s ng out of the techn que. Hence, all these benef ts would mprove pat ent sat sfact on and perm t early postoperat ve shoulder rehab l tat on.
Mater als and Methods
Twenty four consecut ve pat ents who were d agnosed w th med um or large cuff tear w th retract on < 2 cm were treated by shoulder arthroscopy w th arthroscopy gu ded suprascapular and ax llary nerve blocks between June 2014 and September 2014. The nclus on cr ter a were as follows: (1) Substant al pa n (no poster or pa n) and funct onal l m tat on, (2) retract on <cm, (3) h story of more than 6 months and (4) fa lure of nonsurg cal treatment modal t es. Informed consent was obta ned from all the pat ents [Table 1].{Table 1}
Pat ents were evaluated w th v sual analog scale (VAS) preoperat vely and at postoperat ve 0 h, 6 h, 12 h, 18 h, 24 h, and day 2. (0 = no pa n, 10 = severe pa n). Operat ve procedure
Surger es were carr ed out under general anesthes a n the beach cha r pos t on by the same sen or surgeon. The arthroscopy was ach eved us ng standard poster or “soft spot,” lateral and anterolateral portals for evaluat ng glenohumeral jo nt and subacrom al space. After jo nts were explored, an 18-gauge ep dural needle (Sm ths Med cal ASD, Inc. Keene, USA) was advanced from the rotator nterval to jo nt, w th outs de- n techn que, and d rected toward anter or part of nfer or m ddle glenohumeral l gament and advanced 5 mm nto the jo nt capsule
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for ANB and catheter was advanced through the needle. After locat on, the catheter was ver f ed w th arthroscop c approach (between 4:30 and 7 o'clock rad us for r ght shoulder and between 5 and 7:30 o'clock for left shoulder), we gave half port on of solut ons prepared, wh ch were composed of 10cc of 0.5% bup vaca ne hydrochlor de (marca ne 0.5%, AstraZeneca Inc., London (UK), Turkey), for ANB. [F gure 1]a, [F gure 1]b, [F gure 1]c, [F gure 1]d shows mages obta ned dur ng arthroscopy for ANB. After glenohumeral jo nt was explored and ax llary nerve (AN) was blocked through the poster or portal, the arthroscope was ntroduced nto the subacrom al space through the poster or portal. We used arthroscop c techn ques to block suprascapular nerve (SSN), wh ch was descr bed n 2007 by Lafosse et al.,[8] for releas ng entrapment of SSN at the suprascapular notch w th arthroscop c method. Accord ng to th s techn que after anteromed al bursa was removed to prov de access to the suprascapular notch us ng shaver and rad ofrequency (RF), the scope was ntroduced nto the subacrom al space through the lateral portal and shaver and RF dev ce was ntroduced through the anterolateral portal to complete removal of bursal t ssue. Th s step was done f rst due to swell ng; subacrom al decompress on, b ceps tenotomy or tenodes s, and rotator cuff repa r were done after SSNB. F rst, coracoacrom al l gament was dent f ed, and ts trace was followed down the base of the coraco d. Next, coracoclav cular l gaments (cono d and trapezo d) were dent f ed w th poster or and med al d ssect on. Med al border of those l gaments at the base of the coraco d def ned lateral nsert on of the super or transverse scapular l gament (TSL). The TSL was dent f ed as the med al cont nu ty of the cono d l gament above the scapular notch. The suprascapular artery was eas ly v sual zed super or to the l gament, and the SSN was dent f ed as t travels underneath the l gament. Once TSL was adequately v sual zed, an 18-gauge ep dural needle was advanced below the TSL and through med al border of transverse scapular notch to place the catheter for block ng SSN. When the ep dural needle was or ented correctly, the catheter was advanced nto the needle and the needle was drawn back slowly and catheter pos t on was v sual zed mmed ately below the TSL and med al border of the coraco d. After the catheter was arthroscop cally conf rmed to be n the accurate locat on, we gave half port on of prepared solut ons, wh ch were composed of 10cc of 0.5% bup vaca ne hydrochlor de, for SSNB. [F gure 1]e, [F gure 1]f, [F gure 1]g, [F gure 1]h shows the mages obta ned dur ng arthroscopy for SSNB. After block ng of the two nerves, the rotator cuff tear was mob l zed and repa red us ng suture anchors. All pat ents' tears were repa red double-row anchor techn ques and four b ceps tenotomy and two b ceps tenodes s were performed. All pat ents have performed subacrom al decompress on because of fray ng of coracoacrom al l gament and mp ngement. To complete the procedure, the portals were closed w th an absorbable subcutaneous suture. Eventually, rema n ng port ons of prepared solut ons were g ven through the catheters, wh ch were placed for block ng of SSN and AN. Lastly, a velpeau bandage was used.{F gure 1}
Postoperat ve management
We g ve 5cc of 0.5% bup vaca ne hydrochlor de through both catheters 6 hourly up to end 24 h n postoperat ve per od. At the end of 24 h, we gave the last dose of 0.5% bup vaca ne hydrochlor de w th 40 mg of methylpredn solone acetate (Depo-Medrol, Pf zer Inc., New York (USA), Turkey) and catheters were removed at the end of 24 h. We evaluated pat ents' sat sfact on us ng VAS before add t onal bup vaca ne hydrochlor de doses were g ven. Dur ng th s study, pat ent d d not requ re extra analges c dose for pa n rel ef. Before pat ents were d scharged, we prescr bed NSAID for pa n management, but no pat ent requ red drug for pa n reduct on. All pat ents were mob l zed at postoperat ve f rst 3 h.
Stat st cal analys s was performed us ng Mann–Wh tney U-test. The conf dence level was 95%, and s gn f cance was set to P < 0.05. Analyses were conducted us ng SPSS vers on 15 for W ndows (SPSS Inc., Ch cago, IL, USA) software.
Results
No spec f c compl cat on secondary to nerve block procedure was postoperat vely found n pat ents. In the postoperat ve per od, no pat ent compla ned of or showed motor def c ts, vom t ng, or nausea.
Preoperat ve and postoperat ve 0 h, 6 h, 12 h, 18 h, 24 h, and day 2 mean VAS scores were 6.38 ± 0.77, 0.44 ± 0.42, 0.58 ± 0.42, 0.63 ± 0.40, 0.60 ± 0.44, 0.52 ± 0.42, and 1.55 ± 0.46, respect vely [Table 2]. No stat st cal d fference was found among postoperat ve 0 h, 6 h, 12 h, 18 h, and 24 h scores. However, compar son of postoperat ve day 2 and postoperat ve 0 h, 6 h, 12 h, 18 h, and 24 h VAS scores showed a stat st cally s gn f cant d fference (P < 0.05) [Table 3]. These results demonstrate that ntraoperat ve blockage of two nerves prov ded excellent pa n rel ef n postoperat ve per od. All pat ents were d scharged w thout any compl cat on at the end of 24 h. And they were seen on postoperat ve day 2 to change dress ng and to evaluate pa n w th VAS scores. The mean t me (m nutes) of suprascapular and ANBs was 14.38 ± 3.21 and 3.75 ± 0.85, respect vely.{Table 2}{Table 3}
D scuss on
Postoperat ve pa n management s the most mportant part of the shoulder surgery to fac l tate convalescence, shorten hosp tal stay and start rehab l tat on exerc se earl er.[5],[9] After rotator cuff surgery, Boss et al. [2] emphas zed that severe postoperat ve pa n was seen w th n f rst 48 h. NSAIDs, op ate analges c drugs, pat ent-controlled analges a (PCA), IA nject ons of morph ne or local anesthet cs, and nerve blocks such as ISB, SSNB, or ANB are commonly used for reduc ng postoperat ve pa n. These treatment modal t es can be used alone or n comb nat on.
Recently, reg onal nerve blocks have been a more popular techn que than NSAIDs, op ate analges c drugs, PCA and IA nject ons. Blocks reduce both ntraoperat ve and postoperat ve pa n eff c ently n arthroscop c shoulder surgery. Compl cat ons such as vom t ng, nausea, sedat on, or unsat sfactory analges c effects cannot be observed.[10],[11] The ISB has turned nto a preferred techn que for ntraoperat ve anesthes a and postoperat ve analges a worldw de. Espec ally, cont nuous ISB block v a a catheter after shoulder arthroscopy has reduced pa n effect vely n compar son w th other techn ques. However, th s techn que has been assoc ated w th potent al s de effects and compl cat ons, such as rebound pa n, phren c nerve palsy resp ratory d stress, or d aphragmat c pares s.[12],[13],[14] The comb nat on of SSNB and ANB has been also used effect vely for anesthes a n shoulder arthroscopy,[6] and these blocks have prov ded safe analges a n ntraoperat ve and early postoperat ve per ods. However, landmarks of SSN and AN could not have been descr bed accurately so far. The ph losophy of reg onal nerve blocks s that the local anesthet c should be nf ltrated close to the nerve to the max mum extent.[5] Therefore, the landmarks of the nerves should be
dent f ed prec sely.
Shoulder s nnervated by SSN, AN, and lateral pectoral nerve. Poster or and super or parts of jo nt capsule are nnervated by SSN. Antero nfer or part of jo nt capsule s nnervated by AN. Anterosuper or part of jo nt s nnervated by lateral pectoral nerve. The SSN and AN carr es almost all sensor al mpulses to and from shoulder. Hence, contr but on of lateral pectoral nerves m ght rema n unnot ced for rotator cuff surgery.[4],[5],[15] Accord ngly, SSN and AN blocks prov de effect ve management of pa n n postoperat ve course of arthroscop c rotator cuff surgery.
Anatom es and traces of nerves and locat on of sensor al branches of the SSN and AN should be well known to carry out block anesthes a n ntra- and postoperat ve pa n management. The SSN or g nates from the super or brach al plexus as a sensory-motor nerve, close to Erb's po nt.[8] It crosses the poster or tr angle of the neck to the scapular notch, goes on deep to the trapez us and omohyo d muscles and then follows the suprascapular artery to the notch. The suprascapular notch s a bony depress on med al to the base of the coraco d process w th ts super or aspect roofed by the TSL. The artery passes over the TSL, whereas the nerve passes underneath th s l gament.[4],[15],[16] Rarely, both of them can pass underneath TSL.[17] At an average of 4.5 cm prox mal to the TSL, a relat vely large super or art cular branch separates from the ma n stem and runs along w th t to enter the suprascapular notch underneath the TSL at ts most lateral aspect. Immed ately after enter ng the suprascapular notch, the SSN turns laterally around the base of the coraco d process, to wh ch t cons stently releases small per osteal tw gs and a small branch to the coracoclav cular l gaments.[15],[18] The ma n art cular branch then advances laterally n the nterval between the dorsum of the coraco d and the suprascapular muscle, wh ch s f lled w th fat and connect ve t ssue and spl ts nto 2 term nal branches. One of them descends to nnervate the coracohumeral l gament and ts adjacent capsular reg on, and the other spl ts nto several small branches nnervat ng the subacrom al bursa and the poster or aspect of the acrom oclav cular jo nt capsule. The ma n stem of the SSN traverses underneath the TSL nto the suprascapular fossa and releases the ma n muscular branch to the suprasp natus muscle shortly after th s passage, wh ch takes off med ally. At the level of the scapula sp ne, a relat vely large constant nfer or art cular branch separates laterally and travels obl quely toward the poster or jo nt capsule. On ts course, th s nfer or art cular branch releases several small branches that dev ate upward and downward to term nate where the tendon of the nfrasp natus muscle merges w th the poster or jo nt capsule and rotator cuff. The SSN then term nates by nnervat ng the nfrasp natus muscle.[8],[15],[16] Accord ng to these anatom c p ctures, under the TSL s opt mal place for block ng SSN because of n t al po nt for separat on of sensor al braches of jo nt. Dur ng arthroscopy, we placed the ep dural needle underneath the TSL and advanced catheter nto the needle near the SSN, so block ng was ach eved.
The AN or g nates from the sp nal cord at the C5 and C6 level w th occas onal contr but on from the C4 pos t on. It s branch of the poster or cord of the brach al plexus, lateral to the rad al nerve, and poster or to brach al artery.[4] Along ts course across the subscapular muscle, the AN releases ts f rst art cular branch, wh ch slowly separates tself from the ma n stem as t runs to the nfer or-anter or jo nt capsule. As the AN enters the fat and connect ve t ssue near the lower edge of the subscapular muscle, t spl ts nto ts 2 ma n branches. The med al branch ma nly suppl es branches for the scapular aspect of the nfer or anter or capsule and parts of the ax llary recess, whereas the lateral branch runs along the nfer or edge of the subscapular muscle to f nally nnervate the humeral parts of the anter or capsule. The muscular branch, wh ch nnervates the teres m nor, ssues a small art cular branch at the level of nsert on of the long head of the tr ceps to the lateral ax llary recess.[15],[19] Accord ng to Uno et al. ,[20] the AN stayed n the m ddle th rd of the “capsular hammock” between the gleno d and humeral neck and t has an nt mate relat on w th the shoulder capsule between the 5 and 7 o'clock (r ght shoulder) pos t ons. Eak n et al.[21] reported that the nerve was closest to the gleno d at the 4:30 O'clock pos t on. Pr ce et al. [22] reported that AN l es closest to the gleno d at the 6 o'clock pos t on, and the AN travels at a f xed d stance from the
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nfer or glenohumeral l gament throughout ts course, and ts average d stance from the nfer or glenohumeral l gament s 2.5 mm. The study of Bryan et al. [23] showed that AN average d stance from the nfer or glenohumeral l gament s 3.2 mm. Accord ng to these anatom c descr pt ons, anter or shoulder capsule between the 4:30 and 7 o'clock (r ght shoulder) pos t ons s opt mal place for block ng AN because of the n t al po nt of separat on of sensor al braches of jo nt. Dur ng arthroscopy, we placed the ep dural needle to the anter or jo nt capsule between 4:30 and 6 o'clock pos t on and advanced the needle 5 mm through the jo nt capsule and then advanced catheter nto the needle to block AN.
In th s study, TSL was not resected because of hav ng no retraced rotator cuff tears more than 2 cm and no poster or shoulder pa n w th spec al test descr bed by Sahu et al. [24] Yamakado [1] reported that rotator cuff repa r w th placed pa n catheter adjacent to the SSN v a arthroscop cally was h ghly effect ve n controll ng postoperat ve pa n. In that study, TSL release was performed on each pat ent dur ng the surgery.
Checcucc et al. [4] report that 20 consecut ve pat ents underwent arthroscop c procedures for shoulder cuff d seases were performed comb ned SSNB and ANB us ng the dent f ed landmarks; however, general anesthes a was not performed on any pat ents. Accord ng to th s study, comb ned blocks were adequate for ntraoperat ve anesthes a and postoperat ve analges a for certa n procedures of shoulder arthroscop c surgery. Our VAS results were s m lar n th s study; however, our VAS score was lower. As emphas zed n l terature,[1],[3],[4],[5], [7],[9],[18 the outcomes performed comb ned block of SSN and AN prov de good pa n rel ef for postoperat ve per ods. Pat ent sat sfact on s ncreased by th s way. We performed block ng of SSN an AN dur ng surgery by mon tor ng, so reg onal nerve blocks ph losophy were performed as close to nerve as poss ble.
In the l terature,[2],[3],[4],[5],[6],[7],[18],[25],[26] there s no consensus about used k nds, m xtures and comb nat on of local anesthet c agents and comb nat ons w th other drugs such as cort sone. F rst, we used 10cc of 0,5% bup vaca ne hydrochlor de for block ng SSN and AN n shoulder arthroscopy, after that we used 5cc of 0,5% bup vaca ne hydrochlor de n each catheter respect vely dur ng 6 h ntervals up to 24 h. At the end of the 24 h, we used last doses w th comb ned 40 mg methylpredn solone acetate and we removed the catheters. These m xtures and comb nat ons of local anesthet c agent w th cort sone prov de effect ve analges a after shoulder surgery. We d d not need to g ve add t onal analges c drugs such as NSAIDs, op o ds or PCA.
Our study has some l m tat ons such as small case number and no control or compar son groups. Bes des, learn ng curve was decreased w th t me (requ red mean t me [m nutes] for block ng of SSN and AN: 14.38, 3.75, respect vely). We th nk that blocks should be done at the beg nn ng of the surgery because of swell ng of t ssue.
Conclus on
We obta ned good comparable results w th the l terature about reduct on of postoperat ve pa n and prov ded rap d recovery and rehab l tat on. F nanc al support and sponsorsh p
N l.
Confl cts of nterest
There are no confl cts of nterest.
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Thursday, July 26, 2018
