Effect of Ultrasonographically Guided Axillary Nerve Block Combined With Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial Jae Jun Lee, M.D., Do-Young Kim, M.D., Ph.D., Jung-Taek Hwang, M.D., Ph.D., Sang-Soo Lee, M.D., Ph.D., Sung Mi Hwang, M.D., Ph.D., Gi Ho Kim, M.D., and Yoon-Geol Jo, M.D.
Purpose: The aim of this study was to compare the results of ultrasonographically guided axillary nerve block (ANB) combined with suprascapular nerve block (SSNB) with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. Methods: Forty-two patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this study. Among them, 21 patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL 0.75% ropivacaine and ANB with 10 mL saline. Visual analog scale (VAS) pain score, patient satisfaction (SAT), and lateral pain index (LPI) was checked at 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively. Results: Group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours compared with group 2 (5.1 < 7.6, 4.4 < 6.3, 3.7 < 5.3, 3.2 < 4.5, 2.7 < 4.0, and 2.7 < 3.4, respectively). A significantly high mean SAT and low mean LPI was observed in group 1 at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (4.9 > 2.4, 5.9 > 3.7, 6.3 > 5.0, 6.8 > 5.7, 7.3 > 6.2, 7.5 > 6.6, and 7.7 > 7.0, respectively), (1.1 < 3.0, 0.8 < 2.5, 0.7 < 2.0, 0.7 < 1.6, 0.6 < 1.3, 0.6 < 1.0, and 0.4 < 0.7, respectively). The frequency of rebound pain decreased in group 1 compared with group 2 (P ¼ .032). In addition, rebound phenomenon showed a correlation with ANB on univariate logistic regression (P ¼ .034; odds ratio, 0.246). Conclusions: Ultrasonographically guided ANB combined with SSNB in arthroscopic rotator cuff repair showed an improved mean VAS in the first 24 hours after surgery compared with SSNB alone. The mean SAT and LPI of the combined blocks were better than those of the single block within the first 36 hours. Ultrasonographically guided ANB combined with SSNB also decreased the rebound phenomenon. Level of Evidence: Level I, randomized controlled trial.
T
he incidence of severe postoperative pain after shoulder surgery is 30% to 70%.1,2 The postoperative pain should be relieved for early rehabilitation and recovery.1,2 Patient-controlled analgesia (PCA) with opiate therapy may control some of the postoperative
From Department of Anesthesiology and Pain Medicine (J.J.L., S.M.H., G.H.K.) and Orthopedic Surgery (D-Y.K., J-T.H., S-S.L., Y-G.J.), Chuncheon Sacred Heart Hospital, and the Institute for Skeletal Aging and Orthopedic Surgery (D-Y.K., J-T.H., S-S.L.), College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. ClinicalTrials.gov Identifier: NCT02060812. J.J.L. and D-Y.K. contributed equally to this work. Received November 1, 2013; accepted March 20, 2014. Address correspondence to Jung-Taek Hwang, M.D., Ph.D., Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, 153, Gyo-dong, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13772/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.03.014
pain, but it has several side effects such as nausea, vomiting, and dizziness, which can prevent early discharge.3 Conversely, there are several regional blocks to control postoperative pain. Interscalene brachial plexus block (ISB) is known as one of the most effective regional blocks for shoulder surgery, but it sometimes causes complications such as phrenic nerve palsy.4,5 Suprascapular nerve block (SSNB) is one of the most widely used methods for relieving the pain of shoulder surgery.1,6,7 Axillary nerve block (ANB) is one of the newly adopted methods for shoulder pain control.1,6-8 There are several comparative studies that have showed the effects of SSNB.9-11 There are 2 studies that showed the effects of ANB combined with SSNB.1,6,7 However, to our knowledge, there is no comparative study between ANB combined with SSNB and SSNB alone. The suprascapular nerve is responsible for 70% of the sensory nerve supply to the shoulder joint, including the superior and posterior regions of the shoulder, capsule, acromioclavicular joint, subacromial
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bursa, coracoacromial ligament, and the overlying skin.6,12 The axillary nerve supplies the deltoid muscle and the teres minor muscle; therefore, it is mainly associated with the sensation of the lateral side of the shoulder.6 The aim of this study was to compare the results of ultrasonographically guided ANB combined with SSNB with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. Our hypothesis was that SSNB combined with ANB would provide more effective anesthesia for arthroscopic rotator cuff repair compared with SSNB alone up to 48 hours.
Methods All procedures described in the present study were approved by the institutional review board of our hospital, and all patients gave written informed consent to participate in the study. Between November 2012 and July 2013, 42 patients with rotator cuff tears who had undergone arthroscopic rotator cuff repairs were enrolled in this study. Rotator cuff tears were diagnosed by preoperative magnetic resonance imaging, and the size of the rotator cuff was confirmed at the time of arthroscopic operation. Indication for surgery was a symptomatic full-thickness rotator cuff tear or a partialthickness rotator cuff tear of more than 50% thickness in case of failed conservative therapy. Twenty-one patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL of ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL of ropivacaine and ANB with 10 mL of normal saline. The inclusion criteria for enrollees were (1) a definite rotator cuff tear that needed repair seen on preoperative magnetic resonance imaging, (2) acceptance of arthroscopic surgery including rotator cuff repair, (3) age more than 20 years, and (4) acceptance of preemptive regional block and PCA. Some patients were excluded for the following reasons: (1) they did not undergo arthroscopic rotator cuff repair, (2) they stopped PCA before 48 hours postoperatively because of associated side effects, (3) there was a history of a previous shoulder operation or fracture, or (4) there was a concomitant neurologic disorder around the shoulder. Fifty patients who were scheduled for arthroscopic rotator cuff repair were enrolled in the present study, and all of them satisfied the inclusion criteria. Before the surgery, one patient was excluded because of previous greater tuberosity fracture of the affected shoulder. Another patient declined to participate and was excluded. Power analysis indicated that a total sample size of 34 patients (17 patients in each cohort) would provide a statistical power of 99% with a 2-sided a level of 0.05 to detect significant differences in the visual analog scale (VAS) score at 6 hours
postoperatively, assuming an effect size of 1.56 (mean difference, 2.5, standard deviation, 1.6). This was based on the mean and standard deviation of the VAS at 6 hours postoperatively observed in a pilot study of 20 patients. Double-blinded randomization was performed as follows. The remaining 48 patients were randomly assigned to 1 of 2 groups depending on the additional ANB. Randomization was performed with a computerized random-sequence generator by an independent nurse who prepared a syringe for combined ANB according to the assignment. The patients and all the medical staff who participated in the operation were blinded of the assignment. After the surgery, 2 patients with no rotator cuff tears and 3 patients with only rotator cuff fraying who underwent arthroscopic debridement alone were excluded from this study. One patient was also excluded because PCA had been removed because of hypotension at 1 hour postoperatively. In the end, 42 patients were included in this study. Among them, 21 patients belonged to group 1, and the other 21 patients belonged to group 2 (Fig 1). VAS pain score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, height, and weight were checked preoperatively. All the regional blocks were performed pre-emptively under ultrasonographic guidance. PCA was set at a fixed dose (fentanyl, 0.05 mg/kg loading dose and 0.03 mg/min/kg continuous dose) to remove the effect of a variable amount of PCA. VAS pain score, patient satisfaction (SAT), the percentage of lateral pain in the affected shoulder, and lateral pain index (LPI: VAS the percentage of lateral pain of shoulder O 100) was checked 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively. VAS pain score was selected from 0 to 10, with 0 being no pain and 10 being the most severe pain that the patient had ever experienced.1 SAT was also selected from a scale of 0 to 10, with 0 being unsatisfactory and 10 being very satisfactory.6 The percentage of lateral pain was determined as a value between 0 and 100. One orthopaedic resident blinded to the group assignment and patient information asked the patient, “What is the percentage of lateral pain in the operated shoulder?” while indicating the lateral area of the shoulder as the distribution of the deltoid muscle. LPI was determined as VAS pain score the percentage of lateral pain of the shoulder O 100. Rebound of postoperative pain was confirmed if there had been an increase in the VAS pain score between 1 and 48 hours postoperatively.1,9 All the regional blocks were performed preemptively. When the patient was positioned in the beach chair position (Fig 2), SSNB and ANB were performed by one anesthesiologist under ultrasonographic guidance (S-Nerve; SonoSite, Bothell, WA). A 23-gauge spinal needle was used. Just after skin preparation using povidone-iodine solution, a thin layer of
AXILLARY AND SUPRASCAPULAR NERVE BLOCK
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Fig 1. Flowchart of patient enrollment. ANB, axillary nerve block; PCA, patientcontrolled analgesia; SSNB, suprascapular nerve block.
sterile ultrasonographic transmission gel (Sung Heung, Pucheon, Kyungki-do, Republic of Korea) was placed between the ultrasonographic transducer and the skin. SSNB was performed first, and the entry site was the
Fig 2. Pre-emptive suprascapular nerve block (SSNB) and axillary nerve block (ANB) with patient in beach chair position. White arrow is the entry point of SSNB, which is located at the midpoint between the anterolateral angle of the acromion and the medial end of the scapular spine. The white star is the entry point of the ANB, which is located at a point 1.5 cm medial and 2 cm inferior to the posterolateral angle of the acromion.
midpoint between the anterolateral angle of the acromion and the medial end of the scapular spine. With the linear probe parallel to the scapular spine, the suprascapular notch was identified and the block was performed by penetrating the transverse scapular ligament with 10 mL of 0.75% ropivacaine, because the scapular nerve and artery were located at the suprascapular notch (Fig 3A).13,14 ANB was performed just after the SSNB, and the entry site was a point 1.5 cm medial and 2 cm inferior to the posterolateral angle of the acromion. With the linear probe parallel to the longitudinal axis of the humerus, the posterior circumflex artery was identified and the block was performed just above the artery with 10 mL of 0.75% ropivacaine or 10 mL of normal saline (Fig 3B).8 Color Doppler ultrasonography may be helpful for identifying the arterial structures; they were sometimes undetectable but could be identified by detecting a pulsatile motion. In group 1, the mean patient age was 54.0 8.0 years (range, 43 to 69 years), and the mean body mass index (BMI) was 24.6 3.0 kg/m2 (range, 19.0 to 29.0 kg/ m2). In the control group, the mean age was 55.8 8.0 years (range, 39 to 72 years) and the mean BMI was 24.4 3.1 kg/m2 (range, 17.0 to 30.0 kg/m2). The symptom duration was defined as the duration of symptoms before surgery. The overall demographic data such as the mean age, BMI, and symptom duration
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Fig 3. Ultrasonographically guided suprascapular nerve block (SSNB) and axillary nerve block (ANB). (A) Suprascapular nerve block (SSNB). The transverse view of the scapular fossa and the suprascapular notch. The ultrasound transducer was parallel to the scapular spine. White arrow is spinal needle and white star is suprascapular notch. The block was performed by penetrating the transverse scapular ligament. (B) Axillary nerve block (ANB). The ultrasound transducer was parallel to the longitudinal axis of the humerus. White arrow is spinal needle and white star is posterior circumflex artery. The block was performed just above the artery. CP, coracoid process; DM, deltoid muscle; HS, humeral shaft; LT, lateral head of triceps brachii muscle; SM, supraspinatus muscle; TM, teres minor muscle; TM, teres minor muscle; TSL, transverse scapular ligament.
showed no statistically significant differences between group 1 and group 2 (Table 1). All patients in this study underwent arthroscopic rotator cuff repair and subacromial decompression. All procedures were performed by one surgeon who specialized in shoulder and elbow surgery and sports medicine. Four routine arthroscopic portals (anterior, posterior, lateral, and posterolateral) were used in the arthroscopic surgery. After bursectomy, arthroscopic subacromial decompression was performed with acromioplasty and spur removal in all patients. A suture bridge technique was mainly used for rotator cuff repair with a 5.0-mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL) and a 4.75-mm Bio-SwiveLock (Arthrex). A tendon-to-tendon suture technique was sometimes used for small to medium tears located around a
musculotendinous junction.15,16 Depending on the concomitant diseases, a long lead of biceps (LHB) tenotomy or tenodesis, distal clavicle resection, and anterior capsulotomy were performed simultaneously. LHB tenodesis was performed at the suprapectoral region of the bicipital groove using a 7-mm SwiveLock for tenodesis using an all-arthroscopic technique. Adhesive capsulitis was defined as passive forward elevation less than 100o and passive external rotation at the side of less than 30o.17,18 Operation time was defined as the duration between symptom onset and operation. Operative data is shown in Table 2. Postoperatively, a shoulder-immobilizing sling with an abduction pillow was prescribed for each patient with instruction to maintain the shoulder at 30o to 40o internal rotation and 20o abduction. The postoperative
Table 1. Demographic Characteristics Factors No. Age (yr)* Sex (male to female) Dominant/nondominant Symptom duration (mo)* Preoperative height (cm)* Preoperative weight (kg)* Preoperative BMI (kg/m2)* Preoperative VAS score* Preoperative ASES score* Preoperative Constant score*
Group 1 21 54.0 8.0 (43-69) 14:7 13/8 14.9 164.7 67.0 24.6 5.6 48.5 56.2
15.9 (3.0-60.0) 8.7 (148.0-176.0) 12.5 (45.0-85.0) 3.0 (19.0-29.0) 2.1 (2.0-8.0) 15.2 (25.0-82.0) 12.6 (35.6-83.6)
Group 2 21 55.8 8.0 (39-72) 14:7 13/8 11.7 162.9 65.1 24.4 6.4 39.0 52.6
28.0 (3.0-132.0) 9.3 (150.0-177.0) 13.1 (49.0-87.0) 3.1 (17.0-30.0) 1.5 (3.0-8.0) 17.4 (13.0-73.0) 9.3 (38.5-72.9)
Confidence Interval of the Difference P Value 6.8-3.2 0.3-0.3 (male ¼ 1, female ¼ 0) 0.3-0.3 (dominant ¼ 1, nondominant ¼ 0) 11.1-17.6 3.9-7.4 6.1-9.9 1.7-2.1 1.9-0.3 0.6-19.7 3.3-10.5
.470 1.000 1.000 .098 .520 .597 .841 .228 .065 .299
This analysis was performed using the Mann-Whitney U test or the t test for independent samples according to the normality of data to evaluate the differences between the mean values of group 1 and group 2 (P < .05). ASES, American Shoulder and Elbow Surgeons; BMI, body mass index, VAS, visual analog scale (pain). *Factors are presented as the mean standard deviation, with the range in parentheses.
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AXILLARY AND SUPRASCAPULAR NERVE BLOCK Table 2. Operative Characteristics Factors No. Operation time (min)* RCT size (cm)* Suture bridge repair Single-row repair Tendon-to-tendon repair SC lesion Debridement Repair using suture anchor Tendon-to-tendon repair LHB lesion Debridement Tenotomy Tenodesis ADCR Anterior capsulotomy
Group 1 21 81 31 (45-145) 2.4 1.1 (1.0-5.0) 18 0 3
Group 2 21 84 30 (40-140) 2.6 1.3 (1.0-5.5) 17 0 4
5 1
3 0
1
0
2 0 1 1 5
4 0 1 1 3
NOTE. Operation time was the duration between symptom onset and operation. Debridement was performed for fraying or spontaneous rupture of LHB. Fraying was defined as an LHB lesion less than 50%. Tenodesis or tenotomy was performed in patients with LHB dislocation, subluxation, or tear involving more than 50%. ADCR was performed for symptomatic AC arthritis. Anterior capsulotomy was performed for adhesive capsulitis. AC, acromioclavicular joint; ADCR, arthroscopic distal clavicle resection; LHB, long head of biceps; RCT, rotator cuff tear; SC, subscapularis. *Factors are presented as the mean standard deviation with the range in parentheses.
rehabilitation was individualized according to the size of the rotator cuff tear and the tissue quality of the torn rotator cuff.15,16 The patients without a rotator cuff tear were allowed passive forward elevation using a pulley at 48 hours postoperatively, just after PCA had been discontinued. A nonsteroidal anti-inflammatory drug (45 mg of diclofenac) was given intramuscularly to patients in combination with intravenous injection of a proton pump inhibitor (40 mg of pantoprazole) just before going to bed on the operative day. From the first postoperative day to the day of discharge (commonly the third postoperative day), a nonsteroidal antiinflammatory drug (100 mg of aceclofenac) was given orally with a drug protective of the gastric mucosa (60 mg of eupatilin) twice daily. The normally distributed data between the groups was analyzed using a t test for independent samples. Otherwise, a nonparametric Mann-Whitney U test was used. Probable factors that might affect rebound of pain were analyzed using univariate logistic regression. In analyzing the relation between the addition of ANB and the rebound pain, the odds ratio represents the odds of rebound pain in patients treated with ultrasonographically guided ANB þ SSNB/the odds of rebound pain with ultrasonographically guided SSNB alone. Statistical analysis was performed using SPSS, version
13.0 (SPSS, Chicago, IL). The significance level was set at P < .05.
Results The mean postoperative VAS showed an overall sequential decrease as time passed in groups 1 and 2, whereas the mean postoperative SAT showed an overall sequential increase. The mean postoperative percentage of lateral pain and LPI showed a sequential decrease in group 2 but did not show a definite sequential decrease in group 1 (Table 3). Twenty-one patients in group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours (P < .001, P < .001, P ¼ .002, P ¼ .007, P ¼ .002, P ¼ .041, respectively) and a significantly high mean SAT at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (P < .001, P < .001, P ¼ .004, P ¼ .013, P ¼ .007, P ¼ .043, and P ¼ .020, respectively) compared with group 2. The mean percentage of lateral pain in group 1 was significantly low at 1, 3, 6, 12, 18 hours compared with that of group 2 (P ¼ .003, P < .001, P ¼ .001, P ¼ .003, P ¼ .008, respectively). The mean LPI of group 1 was significantly low at postoperative 1, 3, 6, 12, 18, 24, and 36 hours compared with that of group 2 (P < .001, P < .001, P < .001, P ¼ .001, P ¼ .004, P ¼ .024, P ¼ .046, respectively) (Table 3). Six patients in group 1 and 13 patients in group 2 showed rebound of pain. The frequency of rebound pain significantly decreased in group 1 compared with group 2 (P ¼ .032), but other factors such as age, sex, and height did not show a statistical difference between groups 1 and 2 (Table 4). In addition, the rebound phenomenon showed a correlation with ANB on univariate logistic regression (P ¼ .034; odds ratio, 0.246), but other factors did not correlate with ANB (Table 5). All the rebound pain occurred between 12 and 48 postoperatively. Nausea was observed in one patient in group 1 and one patient in group 2. However, patients with nausea were not excluded from this study because the nausea was tolerable. There were no other complications, such as paresthesia, until at least 3 months postoperatively on outpatient department follow-up.
Discussion Postoperative pain control in arthroscopic shoulder surgery is a challenging area.19 Such control is important for early rehabilitation and early return to daily activities of life. Pain is one of the major factors that can influence the duration of hospital stay. In one report, when the postoperative pain was controlled, the mean length of hospital stay was reduced by 4.7% after general anesthesia.20 There are several methods to control postoperative pain in shoulder surgery. One is a constant analgesic infusion pump, which has been reported as an effective method in a previous randomized study, but there are
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Table 3. Scores Associated With Pain According to Postoperative Time Postoperative time VAS according to postoperative time 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr SAT according to postoperative time 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr Percentage of lateral pain 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr LPI 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr
Group I
Group II
Confidence interval of the difference
p-value
5.1 4.4 3.7 3.2 2.7 2.7 2.3 2.1
1.6 1.4 1.4 1.8 1.6 1.5 1.4 1.4
(1-8) (1-8) (1-7) (1-8) (1-8) (1-7) (0-5) (0-6)
7.6 6.3 5.3 4.5 4.0 3.4 2.9 2.6
1.5 1.4 1.5 1.4 1.4 1.2 1.0 1.2
(4-10) (3-9) (3-8) (2-7) (1-6) (1-6) (2-6) (1-7)
L3.4-(L1.5) L2.7-(L1.0) L2.5-(L0.7) L2.3-(L0.2) L2.2-(L0.4) L1.6-0.2 1.3-0.2 1.3-0.4
Purpose: The aim of this study was to compare the results of ultrasonographically guided axillary nerve block (ANB) combined with suprascapular nerve block (SSNB) with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. Methods: Forty-two patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this study. Among them, 21 patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL 0.75% ropivacaine and ANB with 10 mL saline. Visual analog scale (VAS) pain score, patient satisfaction (SAT), and lateral pain index (LPI) was checked at 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively. Results: Group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours compared with group 2 (5.1 < 7.6, 4.4 < 6.3, 3.7 < 5.3, 3.2 < 4.5, 2.7 < 4.0, and 2.7 < 3.4, respectively). A significantly high mean SAT and low mean LPI was observed in group 1 at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (4.9 > 2.4, 5.9 > 3.7, 6.3 > 5.0, 6.8 > 5.7, 7.3 > 6.2, 7.5 > 6.6, and 7.7 > 7.0, respectively), (1.1 < 3.0, 0.8 < 2.5, 0.7 < 2.0, 0.7 < 1.6, 0.6 < 1.3, 0.6 < 1.0, and 0.4 < 0.7, respectively). The frequency of rebound pain decreased in group 1 compared with group 2 (P ¼ .032). In addition, rebound phenomenon showed a correlation with ANB on univariate logistic regression (P ¼ .034; odds ratio, 0.246). Conclusions: Ultrasonographically guided ANB combined with SSNB in arthroscopic rotator cuff repair showed an improved mean VAS in the first 24 hours after surgery compared with SSNB alone. The mean SAT and LPI of the combined blocks were better than those of the single block within the first 36 hours. Ultrasonographically guided ANB combined with SSNB also decreased the rebound phenomenon. Level of Evidence: Level I, randomized controlled trial.
T
he incidence of severe postoperative pain after shoulder surgery is 30% to 70%.1,2 The postoperative pain should be relieved for early rehabilitation and recovery.1,2 Patient-controlled analgesia (PCA) with opiate therapy may control some of the postoperative
From Department of Anesthesiology and Pain Medicine (J.J.L., S.M.H., G.H.K.) and Orthopedic Surgery (D-Y.K., J-T.H., S-S.L., Y-G.J.), Chuncheon Sacred Heart Hospital, and the Institute for Skeletal Aging and Orthopedic Surgery (D-Y.K., J-T.H., S-S.L.), College of Medicine, Hallym University, Chuncheon-si, Gangwon-do, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. ClinicalTrials.gov Identifier: NCT02060812. J.J.L. and D-Y.K. contributed equally to this work. Received November 1, 2013; accepted March 20, 2014. Address correspondence to Jung-Taek Hwang, M.D., Ph.D., Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, 153, Gyo-dong, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13772/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.03.014
pain, but it has several side effects such as nausea, vomiting, and dizziness, which can prevent early discharge.3 Conversely, there are several regional blocks to control postoperative pain. Interscalene brachial plexus block (ISB) is known as one of the most effective regional blocks for shoulder surgery, but it sometimes causes complications such as phrenic nerve palsy.4,5 Suprascapular nerve block (SSNB) is one of the most widely used methods for relieving the pain of shoulder surgery.1,6,7 Axillary nerve block (ANB) is one of the newly adopted methods for shoulder pain control.1,6-8 There are several comparative studies that have showed the effects of SSNB.9-11 There are 2 studies that showed the effects of ANB combined with SSNB.1,6,7 However, to our knowledge, there is no comparative study between ANB combined with SSNB and SSNB alone. The suprascapular nerve is responsible for 70% of the sensory nerve supply to the shoulder joint, including the superior and posterior regions of the shoulder, capsule, acromioclavicular joint, subacromial
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bursa, coracoacromial ligament, and the overlying skin.6,12 The axillary nerve supplies the deltoid muscle and the teres minor muscle; therefore, it is mainly associated with the sensation of the lateral side of the shoulder.6 The aim of this study was to compare the results of ultrasonographically guided ANB combined with SSNB with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. Our hypothesis was that SSNB combined with ANB would provide more effective anesthesia for arthroscopic rotator cuff repair compared with SSNB alone up to 48 hours.
Methods All procedures described in the present study were approved by the institutional review board of our hospital, and all patients gave written informed consent to participate in the study. Between November 2012 and July 2013, 42 patients with rotator cuff tears who had undergone arthroscopic rotator cuff repairs were enrolled in this study. Rotator cuff tears were diagnosed by preoperative magnetic resonance imaging, and the size of the rotator cuff was confirmed at the time of arthroscopic operation. Indication for surgery was a symptomatic full-thickness rotator cuff tear or a partialthickness rotator cuff tear of more than 50% thickness in case of failed conservative therapy. Twenty-one patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL of ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL of ropivacaine and ANB with 10 mL of normal saline. The inclusion criteria for enrollees were (1) a definite rotator cuff tear that needed repair seen on preoperative magnetic resonance imaging, (2) acceptance of arthroscopic surgery including rotator cuff repair, (3) age more than 20 years, and (4) acceptance of preemptive regional block and PCA. Some patients were excluded for the following reasons: (1) they did not undergo arthroscopic rotator cuff repair, (2) they stopped PCA before 48 hours postoperatively because of associated side effects, (3) there was a history of a previous shoulder operation or fracture, or (4) there was a concomitant neurologic disorder around the shoulder. Fifty patients who were scheduled for arthroscopic rotator cuff repair were enrolled in the present study, and all of them satisfied the inclusion criteria. Before the surgery, one patient was excluded because of previous greater tuberosity fracture of the affected shoulder. Another patient declined to participate and was excluded. Power analysis indicated that a total sample size of 34 patients (17 patients in each cohort) would provide a statistical power of 99% with a 2-sided a level of 0.05 to detect significant differences in the visual analog scale (VAS) score at 6 hours
postoperatively, assuming an effect size of 1.56 (mean difference, 2.5, standard deviation, 1.6). This was based on the mean and standard deviation of the VAS at 6 hours postoperatively observed in a pilot study of 20 patients. Double-blinded randomization was performed as follows. The remaining 48 patients were randomly assigned to 1 of 2 groups depending on the additional ANB. Randomization was performed with a computerized random-sequence generator by an independent nurse who prepared a syringe for combined ANB according to the assignment. The patients and all the medical staff who participated in the operation were blinded of the assignment. After the surgery, 2 patients with no rotator cuff tears and 3 patients with only rotator cuff fraying who underwent arthroscopic debridement alone were excluded from this study. One patient was also excluded because PCA had been removed because of hypotension at 1 hour postoperatively. In the end, 42 patients were included in this study. Among them, 21 patients belonged to group 1, and the other 21 patients belonged to group 2 (Fig 1). VAS pain score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, height, and weight were checked preoperatively. All the regional blocks were performed pre-emptively under ultrasonographic guidance. PCA was set at a fixed dose (fentanyl, 0.05 mg/kg loading dose and 0.03 mg/min/kg continuous dose) to remove the effect of a variable amount of PCA. VAS pain score, patient satisfaction (SAT), the percentage of lateral pain in the affected shoulder, and lateral pain index (LPI: VAS the percentage of lateral pain of shoulder O 100) was checked 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively. VAS pain score was selected from 0 to 10, with 0 being no pain and 10 being the most severe pain that the patient had ever experienced.1 SAT was also selected from a scale of 0 to 10, with 0 being unsatisfactory and 10 being very satisfactory.6 The percentage of lateral pain was determined as a value between 0 and 100. One orthopaedic resident blinded to the group assignment and patient information asked the patient, “What is the percentage of lateral pain in the operated shoulder?” while indicating the lateral area of the shoulder as the distribution of the deltoid muscle. LPI was determined as VAS pain score the percentage of lateral pain of the shoulder O 100. Rebound of postoperative pain was confirmed if there had been an increase in the VAS pain score between 1 and 48 hours postoperatively.1,9 All the regional blocks were performed preemptively. When the patient was positioned in the beach chair position (Fig 2), SSNB and ANB were performed by one anesthesiologist under ultrasonographic guidance (S-Nerve; SonoSite, Bothell, WA). A 23-gauge spinal needle was used. Just after skin preparation using povidone-iodine solution, a thin layer of
AXILLARY AND SUPRASCAPULAR NERVE BLOCK
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Fig 1. Flowchart of patient enrollment. ANB, axillary nerve block; PCA, patientcontrolled analgesia; SSNB, suprascapular nerve block.
sterile ultrasonographic transmission gel (Sung Heung, Pucheon, Kyungki-do, Republic of Korea) was placed between the ultrasonographic transducer and the skin. SSNB was performed first, and the entry site was the
Fig 2. Pre-emptive suprascapular nerve block (SSNB) and axillary nerve block (ANB) with patient in beach chair position. White arrow is the entry point of SSNB, which is located at the midpoint between the anterolateral angle of the acromion and the medial end of the scapular spine. The white star is the entry point of the ANB, which is located at a point 1.5 cm medial and 2 cm inferior to the posterolateral angle of the acromion.
midpoint between the anterolateral angle of the acromion and the medial end of the scapular spine. With the linear probe parallel to the scapular spine, the suprascapular notch was identified and the block was performed by penetrating the transverse scapular ligament with 10 mL of 0.75% ropivacaine, because the scapular nerve and artery were located at the suprascapular notch (Fig 3A).13,14 ANB was performed just after the SSNB, and the entry site was a point 1.5 cm medial and 2 cm inferior to the posterolateral angle of the acromion. With the linear probe parallel to the longitudinal axis of the humerus, the posterior circumflex artery was identified and the block was performed just above the artery with 10 mL of 0.75% ropivacaine or 10 mL of normal saline (Fig 3B).8 Color Doppler ultrasonography may be helpful for identifying the arterial structures; they were sometimes undetectable but could be identified by detecting a pulsatile motion. In group 1, the mean patient age was 54.0 8.0 years (range, 43 to 69 years), and the mean body mass index (BMI) was 24.6 3.0 kg/m2 (range, 19.0 to 29.0 kg/ m2). In the control group, the mean age was 55.8 8.0 years (range, 39 to 72 years) and the mean BMI was 24.4 3.1 kg/m2 (range, 17.0 to 30.0 kg/m2). The symptom duration was defined as the duration of symptoms before surgery. The overall demographic data such as the mean age, BMI, and symptom duration
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Fig 3. Ultrasonographically guided suprascapular nerve block (SSNB) and axillary nerve block (ANB). (A) Suprascapular nerve block (SSNB). The transverse view of the scapular fossa and the suprascapular notch. The ultrasound transducer was parallel to the scapular spine. White arrow is spinal needle and white star is suprascapular notch. The block was performed by penetrating the transverse scapular ligament. (B) Axillary nerve block (ANB). The ultrasound transducer was parallel to the longitudinal axis of the humerus. White arrow is spinal needle and white star is posterior circumflex artery. The block was performed just above the artery. CP, coracoid process; DM, deltoid muscle; HS, humeral shaft; LT, lateral head of triceps brachii muscle; SM, supraspinatus muscle; TM, teres minor muscle; TM, teres minor muscle; TSL, transverse scapular ligament.
showed no statistically significant differences between group 1 and group 2 (Table 1). All patients in this study underwent arthroscopic rotator cuff repair and subacromial decompression. All procedures were performed by one surgeon who specialized in shoulder and elbow surgery and sports medicine. Four routine arthroscopic portals (anterior, posterior, lateral, and posterolateral) were used in the arthroscopic surgery. After bursectomy, arthroscopic subacromial decompression was performed with acromioplasty and spur removal in all patients. A suture bridge technique was mainly used for rotator cuff repair with a 5.0-mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL) and a 4.75-mm Bio-SwiveLock (Arthrex). A tendon-to-tendon suture technique was sometimes used for small to medium tears located around a
musculotendinous junction.15,16 Depending on the concomitant diseases, a long lead of biceps (LHB) tenotomy or tenodesis, distal clavicle resection, and anterior capsulotomy were performed simultaneously. LHB tenodesis was performed at the suprapectoral region of the bicipital groove using a 7-mm SwiveLock for tenodesis using an all-arthroscopic technique. Adhesive capsulitis was defined as passive forward elevation less than 100o and passive external rotation at the side of less than 30o.17,18 Operation time was defined as the duration between symptom onset and operation. Operative data is shown in Table 2. Postoperatively, a shoulder-immobilizing sling with an abduction pillow was prescribed for each patient with instruction to maintain the shoulder at 30o to 40o internal rotation and 20o abduction. The postoperative
Table 1. Demographic Characteristics Factors No. Age (yr)* Sex (male to female) Dominant/nondominant Symptom duration (mo)* Preoperative height (cm)* Preoperative weight (kg)* Preoperative BMI (kg/m2)* Preoperative VAS score* Preoperative ASES score* Preoperative Constant score*
Group 1 21 54.0 8.0 (43-69) 14:7 13/8 14.9 164.7 67.0 24.6 5.6 48.5 56.2
15.9 (3.0-60.0) 8.7 (148.0-176.0) 12.5 (45.0-85.0) 3.0 (19.0-29.0) 2.1 (2.0-8.0) 15.2 (25.0-82.0) 12.6 (35.6-83.6)
Group 2 21 55.8 8.0 (39-72) 14:7 13/8 11.7 162.9 65.1 24.4 6.4 39.0 52.6
28.0 (3.0-132.0) 9.3 (150.0-177.0) 13.1 (49.0-87.0) 3.1 (17.0-30.0) 1.5 (3.0-8.0) 17.4 (13.0-73.0) 9.3 (38.5-72.9)
Confidence Interval of the Difference P Value 6.8-3.2 0.3-0.3 (male ¼ 1, female ¼ 0) 0.3-0.3 (dominant ¼ 1, nondominant ¼ 0) 11.1-17.6 3.9-7.4 6.1-9.9 1.7-2.1 1.9-0.3 0.6-19.7 3.3-10.5
.470 1.000 1.000 .098 .520 .597 .841 .228 .065 .299
This analysis was performed using the Mann-Whitney U test or the t test for independent samples according to the normality of data to evaluate the differences between the mean values of group 1 and group 2 (P < .05). ASES, American Shoulder and Elbow Surgeons; BMI, body mass index, VAS, visual analog scale (pain). *Factors are presented as the mean standard deviation, with the range in parentheses.
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AXILLARY AND SUPRASCAPULAR NERVE BLOCK Table 2. Operative Characteristics Factors No. Operation time (min)* RCT size (cm)* Suture bridge repair Single-row repair Tendon-to-tendon repair SC lesion Debridement Repair using suture anchor Tendon-to-tendon repair LHB lesion Debridement Tenotomy Tenodesis ADCR Anterior capsulotomy
Group 1 21 81 31 (45-145) 2.4 1.1 (1.0-5.0) 18 0 3
Group 2 21 84 30 (40-140) 2.6 1.3 (1.0-5.5) 17 0 4
5 1
3 0
1
0
2 0 1 1 5
4 0 1 1 3
NOTE. Operation time was the duration between symptom onset and operation. Debridement was performed for fraying or spontaneous rupture of LHB. Fraying was defined as an LHB lesion less than 50%. Tenodesis or tenotomy was performed in patients with LHB dislocation, subluxation, or tear involving more than 50%. ADCR was performed for symptomatic AC arthritis. Anterior capsulotomy was performed for adhesive capsulitis. AC, acromioclavicular joint; ADCR, arthroscopic distal clavicle resection; LHB, long head of biceps; RCT, rotator cuff tear; SC, subscapularis. *Factors are presented as the mean standard deviation with the range in parentheses.
rehabilitation was individualized according to the size of the rotator cuff tear and the tissue quality of the torn rotator cuff.15,16 The patients without a rotator cuff tear were allowed passive forward elevation using a pulley at 48 hours postoperatively, just after PCA had been discontinued. A nonsteroidal anti-inflammatory drug (45 mg of diclofenac) was given intramuscularly to patients in combination with intravenous injection of a proton pump inhibitor (40 mg of pantoprazole) just before going to bed on the operative day. From the first postoperative day to the day of discharge (commonly the third postoperative day), a nonsteroidal antiinflammatory drug (100 mg of aceclofenac) was given orally with a drug protective of the gastric mucosa (60 mg of eupatilin) twice daily. The normally distributed data between the groups was analyzed using a t test for independent samples. Otherwise, a nonparametric Mann-Whitney U test was used. Probable factors that might affect rebound of pain were analyzed using univariate logistic regression. In analyzing the relation between the addition of ANB and the rebound pain, the odds ratio represents the odds of rebound pain in patients treated with ultrasonographically guided ANB þ SSNB/the odds of rebound pain with ultrasonographically guided SSNB alone. Statistical analysis was performed using SPSS, version
13.0 (SPSS, Chicago, IL). The significance level was set at P < .05.
Results The mean postoperative VAS showed an overall sequential decrease as time passed in groups 1 and 2, whereas the mean postoperative SAT showed an overall sequential increase. The mean postoperative percentage of lateral pain and LPI showed a sequential decrease in group 2 but did not show a definite sequential decrease in group 1 (Table 3). Twenty-one patients in group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours (P < .001, P < .001, P ¼ .002, P ¼ .007, P ¼ .002, P ¼ .041, respectively) and a significantly high mean SAT at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (P < .001, P < .001, P ¼ .004, P ¼ .013, P ¼ .007, P ¼ .043, and P ¼ .020, respectively) compared with group 2. The mean percentage of lateral pain in group 1 was significantly low at 1, 3, 6, 12, 18 hours compared with that of group 2 (P ¼ .003, P < .001, P ¼ .001, P ¼ .003, P ¼ .008, respectively). The mean LPI of group 1 was significantly low at postoperative 1, 3, 6, 12, 18, 24, and 36 hours compared with that of group 2 (P < .001, P < .001, P < .001, P ¼ .001, P ¼ .004, P ¼ .024, P ¼ .046, respectively) (Table 3). Six patients in group 1 and 13 patients in group 2 showed rebound of pain. The frequency of rebound pain significantly decreased in group 1 compared with group 2 (P ¼ .032), but other factors such as age, sex, and height did not show a statistical difference between groups 1 and 2 (Table 4). In addition, the rebound phenomenon showed a correlation with ANB on univariate logistic regression (P ¼ .034; odds ratio, 0.246), but other factors did not correlate with ANB (Table 5). All the rebound pain occurred between 12 and 48 postoperatively. Nausea was observed in one patient in group 1 and one patient in group 2. However, patients with nausea were not excluded from this study because the nausea was tolerable. There were no other complications, such as paresthesia, until at least 3 months postoperatively on outpatient department follow-up.
Discussion Postoperative pain control in arthroscopic shoulder surgery is a challenging area.19 Such control is important for early rehabilitation and early return to daily activities of life. Pain is one of the major factors that can influence the duration of hospital stay. In one report, when the postoperative pain was controlled, the mean length of hospital stay was reduced by 4.7% after general anesthesia.20 There are several methods to control postoperative pain in shoulder surgery. One is a constant analgesic infusion pump, which has been reported as an effective method in a previous randomized study, but there are
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Table 3. Scores Associated With Pain According to Postoperative Time Postoperative time VAS according to postoperative time 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr SAT according to postoperative time 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr Percentage of lateral pain 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr LPI 1hr 3hr 6hr 12hr 18hr 24hr 36hr 48hr
Group I
Group II
Confidence interval of the difference
p-value
5.1 4.4 3.7 3.2 2.7 2.7 2.3 2.1
1.6 1.4 1.4 1.8 1.6 1.5 1.4 1.4
(1-8) (1-8) (1-7) (1-8) (1-8) (1-7) (0-5) (0-6)
7.6 6.3 5.3 4.5 4.0 3.4 2.9 2.6
1.5 1.4 1.5 1.4 1.4 1.2 1.0 1.2
(4-10) (3-9) (3-8) (2-7) (1-6) (1-6) (2-6) (1-7)
L3.4-(L1.5) L2.7-(L1.0) L2.5-(L0.7) L2.3-(L0.2) L2.2-(L0.4) L1.6-0.2 1.3-0.2 1.3-0.4
