e197(1) C OPYRIGHT Ó 2013
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Exhibit Selection
Upper-Extremity Peripheral Nerve Blocks in the Perioperative Pain Management of Orthopaedic Patients AAOS Exhibit Selection Umasuthan Srikumaran, MD, Benjamin E. Stein, MD, Eric W. Tan, MD, Michael T. Freehill, MD, and John H. Wilckens, MD Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
Background: Over the past twenty-five years, peripheral nerve blocks have become increasingly common for the management of perioperative pain of the upper extremity. Several factors have led to increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on decreasing the duration of hospital stays and associated costs. Methods: We present a review of peripheral nerve blocks for procedures involving the upper extremity, including indications, contraindications, anatomy and technique, expected clinical outcomes and the associated levels of evidence, cost-effectiveness, and complications. We reviewed the scientific literature for studies on the effectiveness of peripheral nerve blocks for orthopaedic procedures involving the upper extremity. Particular attention was directed at the most commonly used nerve blocks, the levels of evidence supporting their use, and emerging technologies such as ultrasonographic guidance. Results: Peripheral nerve blocks for upper-extremity procedures improve postoperative pain control and patient satisfaction, can be administered safely, and have a low complication rate. They are also associated with enhanced participation in postoperative rehabilitation, decreased hospital stays, and decreased costs. There are increasingly higher levels of evidence in the literature to support the use of peripheral nerve blocks in a wide variety of orthopaedic procedures ranging from the shoulder to the hand. Conclusions: The use of peripheral nerve blocks in upper-extremity surgery is common. To actively participate with the patient and anesthesiologist to ensure the best possible outcomes, the orthopaedic surgeon must be well informed regarding the benefits and limitations of this modality.
O
ver the past twenty-five years, peripheral nerve blocks of the upper extremity have become increasingly common for the management of perioperative pain.
Several factors have led to the increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2013;95:e197(1-13)
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decreasing the duration of hospital stays and associated costs. This increased focus on the evaluation and management of pain is shown by the distinction of pain as the fifth vital sign by the American Pain Society in 19951,2. In addition, The Veterans Health Administration made this concept the central component of their pain management strategy in 1998-19993, and the Joint Commission on Accreditation of Healthcare Organizations4 made appropriate pain assessment and management the standard of care in 2000, mandating compliance with this initiative by all health-care providers. The prevalence and severity of postoperative pain after orthopaedic procedures are higher than those after nonorthopaedic procedures5-8, making adequate pain control difficult. Traditional pain management includes general anesthesia and narcotic medication for surgery, followed by oral and intravenous pain medications, including patient-controlled analgesia, after surgery. The use of peripheral nerve blocks for upperextremity procedures has led to improved postoperative pain control, decreased narcotic use, and decreased narcotic-associated side effects such as nausea and vomiting9-20. Accordingly, the duration of hospital stays has been reduced, and procedures previously performed in an inpatient care setting are being performed on an outpatient basis20. Peripheral nerve blocks also allow enhanced participation in postoperative rehabilitation, improving overall patient satisfaction and functional outcomes21,22. Conversely, the use of peripheral nerve blocks
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introduces an additional set of potential complications and concerns, such as a pneumothorax or peripheral neuropathy. However, patients are becoming increasingly aware of these pain management options, and they often have related questions for the orthopaedic surgeon. A well-informed surgeon will be able to address these questions and actively participate with the patient and anesthesiologist to ensure the best possible outcomes. To provide such information, we review the relative anatomy, techniques, indications, contraindications, expected clinical outcomes, and potential complications of the four major peripheral nerve blocks for procedures involving the upper extremity. General Brachial Plexus Anatomy he brachial plexus innervates all of the muscles of the upper extremity and is responsible for most, but not all, of its sensory function (Fig. 1). Although the superior aspect of the shoulder receives sensory innervation by the superficial cervical plexus (C3-C4) via the supraclavicular nerves (Figs. 2-A and 2-B) and the axilla is innervated by the second thoracic nerve root, the brachial plexus provides the remaining sensory innervation to the upper extremity. Cervical nerve roots C5 through T1 join to form the upper, middle, and lower trunks. The anterior and posterior divisions of these trunks form the medial, lateral, and posterior cords, which ultimately branch and terminate in the peripheral nerves of the upper extremity
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Fig. 1
Brachial plexus anatomy. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.)
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prascapular nerve, with most of the contributions being from the C5 and C6 nerve roots and some from the C4 nerve root23. The sensory innervation to the skin is variable because the axillary nerve, originating from C4, C5, and C6 via the posterior cord and superior lateral brachial cutaneous nerve, supplies most of the skin over the lateral upper arm. Brachial plexus blockade is most commonly performed at four distinct levels: the space between the anterior and middle scalene muscles (interscalene block), the areas above and below the clavicle (supraclavicular and infraclavicular blocks), and the axilla (axillary block). An understanding of brachial plexus anatomy and the level of the peripheral nerve block can help the surgeon determine whether the surgical field will be adequately covered by a particular block. In turn, decisions can be made regarding whether additional local anesthetic infiltration is indicated. Localization Techniques for Upper-Extremity Nerve Blocks he methods used for accurate localization of a nerve or plexus to successfully administer an upper-extremity nerve block have been a topic of much controversy. Early methods used for localization involved elicitation of paresthesias from the patient to guide needle placement and a tactile response on the part of the operator. Over time, new technologies emerged, including neurostimulation and ultrasonographic guidance, which have improved the accuracy of localization. In the recent literature, there has been an increasing focus on comparing ultrasonographic guidance and neurostimulation. A number of randomized and double-blinded studies involving infraclavicular and axillary nerve blocks have shown that ultrasonographic guidance is superior in terms of faster performance of the block, faster block onset, and improved block success24-26. In a meta-analysis of randomized studies comparing ultrasonographic guidance and neurostimulation, fifteen of nineteen studies showed that ultrasonographic guidance had significant benefits for supraclavicular nerve, infraclavicular nerve, and axillary nerve blocks 27 . Another meta-analysis of thirteen randomized controlled studies comparing ultrasonographic guidance with neurostimulation found that the ultrasonographically guided blocks took less time to perform, were more successful, and had a lower risk of vascular puncture28. Despite this mounting evidence of the superiority of ultrasonographic over neurostimulation guidance, however, one recent metaanalysis found that the data were insufficient for drawing this conclusion29. Ultimately, there remains a large variability in the localization techniques used in different centers. The associated operative delay remains largely contingent on the operative setting (ambulatory center versus hospital) and experience level of the operator. Whether or not a dedicated block physician or room is available, time savings are often achieved at the end of the case because the patient can be gradually awakened without affecting surgical wound closure.
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Fig. 2-A
Fig. 2-B
Figs. 2-A and 2-B The cervical plexus. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 2-A The dermatomes anesthetized are shown in dark blue. Fig. 2-B Surface anatomy of the neck showing the relative midpoint (x) of the posterior border of the sternocleidomastoid muscle (solid line).
(Fig. 1). Seventy percent of the sensory innervation to the shoulder capsule, subacromial bursa, acromioclavicular joint, and overlying skin comes from the superior trunk via the su-
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Fig. 3-A
Fig. 3-B
Figs. 3-A, 3-B, and 3-C Interscalene nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 3-A The dermatomes anesthetized are shown in dark blue. Fig. 3-B The highlight shows the region of the brachial plexus (nerve roots and root-trunk transition) targeted by an interscalene nerve block.
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TABLE I Level of Evidence, Anesthesia Type, and Identified Complications for Studies Involving Upper-Extremity Peripheral Nerve Blocks* Study
Level of Evidence (Study Design) 39
Bishop et al. 40
Brull et al.
9
Borgeat et al.
42
Misamore et al.
Block Type
Complications
IV
ISB
2.3% sensory neuropathy
III (meta-analysis)
ISB
2.84% sensory neuropathy
II (RCT)
CISB
Decreased diaphragmatic excursion
III (prospective)
ISB
Immediate paresthesias in 16%; persistent neuropathy in 4.4%; long-term neuropathy in 0.8%
41
Liu et al.
III (prospective)
ISB, SCNB
Hoarseness: 31% (ISB), 22% (SCNB).
III (prospective)
ICNB
0.7% prevalence pneumothorax
III (prospective)
SCNB
50% complete hemidiaphragmatic paresis;
Dyspnea: 10% (ISB), 7% (SCNB) 37
Desroches
38
Mak et al.
17% partial hemidiaphragmatic paresis *ISB = interscalene nerve block, RCT = randomized controlled trial, CISB = continuous interscalene nerve block, SCNB = supraclavicular nerve block, and ICNB = infraclavicular nerve block.
Single-Injection Blocks Versus Continuous Perineural Catheters he single-injection nerve block for improved postoperative pain control is currently the most commonly used modality for regional anesthesia in upper-extremity surgery. The duration of analgesia provided by these blocks ranges from twelve to twenty-four hours13,16. As technology has advanced, the use of indwelling continuous nerve catheters to provide primary anesthesia and prolonged management of postoperative pain has increased. In two comparison studies of singleinjection compared with continuous interscalene nerve blocks, the results showed that a continuous interscalene nerve block provided better pain relief, better sleep quality, and lower narcotic requirements18,30. Several studies have also suggested that the use of continuous nerve catheters may lead to shorter hospital stays and improved postoperative shoulder mobilization14,31,32. Furthermore, the authors of one pilot study reported the successful use of nerve catheters for total shoulder arthroplasties performed in an outpatient setting33. However, to implement models involving nerve catheters in the ambulatory setting, there has to be a great deal of focus on patient education and a safe and effective follow-up system. With the growing emphasis on costeffectiveness in the surgical setting, there will undoubtedly be a continued focus on studying the use of continuous nerve catheters to allow for earlier patient discharge.
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Peripheral Nerve Blocks Interscalene Nerve Block he interscalene nerve block, the most commonly performed nerve block, targets the brachial plexus at the roottrunk level (Figs. 3-A, 3-B, and 3-C). The localization of this block makes it effective for procedures involving the shoulder, proximal aspect of the humerus, and distal aspect of the clavicle. The supraclavicular and suprascapular nerves are affected
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by the block, and therefore the superior aspect of the shoulder is adequately covered34. However, the C8 dermatome and inferior trunk are often incompletely covered, an effect that is called ulnar sparing. Procedures at or distal to the elbow are not adequately covered with an interscalene nerve block alone and require an additional ulnar nerve block. Since the first description of the direct anterior technique for interscalene nerve blockade by Winnie35 in 1970, several modifications have enhanced its safety and effectiveness. Meier et al.36 and Borgeat et al.9 described a lateral approach with a more caudal trajectory to help avoid central neuraxial complications. The use of nerve stimulation or ultrasonography for guidance has further increased its safety (Table I9,37-42). However, complications can occur.
Fig. 3-C
Surface anatomy. The typical needle entry point (x) for an interscalene nerve block is shown in relation to the sternocleidomastoid muscle and its clavicular and sternal heads (solid lines) as well as the course of the external jugular vein (dotted line) and the ends of the clavicle.
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Fig. 4-A
Fig. 4-B
Figs. 4-A, 4-B, and 4-C Supraclavicular nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 4-A The dermatomes anesthetized are shown in dark blue. Fig. 4-B The highlight shows the region of the brachial plexus (trunks) targeted by a supraclavicular nerve block.
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TABLE II Anesthesia Type, Level of Evidence, and Outcome Parameters for Studies Involving Open and Arthroscopic Shoulder Surgery*
Study 10
Brown et al.
16
Kinnard et al.
19
Singelyn et al.
12
Ciccone et al. 17
Lee et al.
13
Gohl et al.
20
Wu et al.
Level of Evidence (Study Design)
Anesthesia†
Patient Satisfaction
Pain
Duration of Stay
Rehabilitation
II (RCT)
CISB
Y
Y
II (RCT)
ISB
Y
Y
Y
Y
—
) /
—
II (RCT)
ISB
Y
YY
—
Y
—
SSNB
) /
—
Y
) /
—
—
Adverse Effects
IA
) /
) /
) /
—
—
II (RCT)
ISB
—
Y
) /
) /
—
II (RCT)
ISB
—
Y
Y
) /
) /
III
ISB
Y
Y
) /
—
—
IV
ISB
—
Y
) /
Y
—
*CISB = continuous interscalene nerve block, RCT = randomized controlled trial, ISB = interscalene nerve block, SSNB = suprascapular nerve block, and IA = intra-articular analgesia. Arrows indicate whether the outcome is no different () /), better (Y), or worse ([). Multiple arrows (YY) indicate a better outcome compared with the other listed peripheral nerve block modalities for the same study. Dashes indicate not reported. †Each group was compared with intravenous patient-controlled analgesia.
Complications of the interscalene nerve block include phrenic blockade, spinal cord damage, sympathetic chain blockade, recurrent laryngeal nerve blockade, and peripheral neuropathy34. The reported rates of neuropathy after an interscalene nerve block vary: the neuropathy most commonly takes the form of a sensory neuropathy (in
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Exhibit Selection
Upper-Extremity Peripheral Nerve Blocks in the Perioperative Pain Management of Orthopaedic Patients AAOS Exhibit Selection Umasuthan Srikumaran, MD, Benjamin E. Stein, MD, Eric W. Tan, MD, Michael T. Freehill, MD, and John H. Wilckens, MD Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
Background: Over the past twenty-five years, peripheral nerve blocks have become increasingly common for the management of perioperative pain of the upper extremity. Several factors have led to increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on decreasing the duration of hospital stays and associated costs. Methods: We present a review of peripheral nerve blocks for procedures involving the upper extremity, including indications, contraindications, anatomy and technique, expected clinical outcomes and the associated levels of evidence, cost-effectiveness, and complications. We reviewed the scientific literature for studies on the effectiveness of peripheral nerve blocks for orthopaedic procedures involving the upper extremity. Particular attention was directed at the most commonly used nerve blocks, the levels of evidence supporting their use, and emerging technologies such as ultrasonographic guidance. Results: Peripheral nerve blocks for upper-extremity procedures improve postoperative pain control and patient satisfaction, can be administered safely, and have a low complication rate. They are also associated with enhanced participation in postoperative rehabilitation, decreased hospital stays, and decreased costs. There are increasingly higher levels of evidence in the literature to support the use of peripheral nerve blocks in a wide variety of orthopaedic procedures ranging from the shoulder to the hand. Conclusions: The use of peripheral nerve blocks in upper-extremity surgery is common. To actively participate with the patient and anesthesiologist to ensure the best possible outcomes, the orthopaedic surgeon must be well informed regarding the benefits and limitations of this modality.
O
ver the past twenty-five years, peripheral nerve blocks of the upper extremity have become increasingly common for the management of perioperative pain.
Several factors have led to the increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2013;95:e197(1-13)
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http://dx.doi.org/10.2106/JBJS.L.01745
e197(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013 d
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decreasing the duration of hospital stays and associated costs. This increased focus on the evaluation and management of pain is shown by the distinction of pain as the fifth vital sign by the American Pain Society in 19951,2. In addition, The Veterans Health Administration made this concept the central component of their pain management strategy in 1998-19993, and the Joint Commission on Accreditation of Healthcare Organizations4 made appropriate pain assessment and management the standard of care in 2000, mandating compliance with this initiative by all health-care providers. The prevalence and severity of postoperative pain after orthopaedic procedures are higher than those after nonorthopaedic procedures5-8, making adequate pain control difficult. Traditional pain management includes general anesthesia and narcotic medication for surgery, followed by oral and intravenous pain medications, including patient-controlled analgesia, after surgery. The use of peripheral nerve blocks for upperextremity procedures has led to improved postoperative pain control, decreased narcotic use, and decreased narcotic-associated side effects such as nausea and vomiting9-20. Accordingly, the duration of hospital stays has been reduced, and procedures previously performed in an inpatient care setting are being performed on an outpatient basis20. Peripheral nerve blocks also allow enhanced participation in postoperative rehabilitation, improving overall patient satisfaction and functional outcomes21,22. Conversely, the use of peripheral nerve blocks
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introduces an additional set of potential complications and concerns, such as a pneumothorax or peripheral neuropathy. However, patients are becoming increasingly aware of these pain management options, and they often have related questions for the orthopaedic surgeon. A well-informed surgeon will be able to address these questions and actively participate with the patient and anesthesiologist to ensure the best possible outcomes. To provide such information, we review the relative anatomy, techniques, indications, contraindications, expected clinical outcomes, and potential complications of the four major peripheral nerve blocks for procedures involving the upper extremity. General Brachial Plexus Anatomy he brachial plexus innervates all of the muscles of the upper extremity and is responsible for most, but not all, of its sensory function (Fig. 1). Although the superior aspect of the shoulder receives sensory innervation by the superficial cervical plexus (C3-C4) via the supraclavicular nerves (Figs. 2-A and 2-B) and the axilla is innervated by the second thoracic nerve root, the brachial plexus provides the remaining sensory innervation to the upper extremity. Cervical nerve roots C5 through T1 join to form the upper, middle, and lower trunks. The anterior and posterior divisions of these trunks form the medial, lateral, and posterior cords, which ultimately branch and terminate in the peripheral nerves of the upper extremity
T
Fig. 1
Brachial plexus anatomy. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.)
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prascapular nerve, with most of the contributions being from the C5 and C6 nerve roots and some from the C4 nerve root23. The sensory innervation to the skin is variable because the axillary nerve, originating from C4, C5, and C6 via the posterior cord and superior lateral brachial cutaneous nerve, supplies most of the skin over the lateral upper arm. Brachial plexus blockade is most commonly performed at four distinct levels: the space between the anterior and middle scalene muscles (interscalene block), the areas above and below the clavicle (supraclavicular and infraclavicular blocks), and the axilla (axillary block). An understanding of brachial plexus anatomy and the level of the peripheral nerve block can help the surgeon determine whether the surgical field will be adequately covered by a particular block. In turn, decisions can be made regarding whether additional local anesthetic infiltration is indicated. Localization Techniques for Upper-Extremity Nerve Blocks he methods used for accurate localization of a nerve or plexus to successfully administer an upper-extremity nerve block have been a topic of much controversy. Early methods used for localization involved elicitation of paresthesias from the patient to guide needle placement and a tactile response on the part of the operator. Over time, new technologies emerged, including neurostimulation and ultrasonographic guidance, which have improved the accuracy of localization. In the recent literature, there has been an increasing focus on comparing ultrasonographic guidance and neurostimulation. A number of randomized and double-blinded studies involving infraclavicular and axillary nerve blocks have shown that ultrasonographic guidance is superior in terms of faster performance of the block, faster block onset, and improved block success24-26. In a meta-analysis of randomized studies comparing ultrasonographic guidance and neurostimulation, fifteen of nineteen studies showed that ultrasonographic guidance had significant benefits for supraclavicular nerve, infraclavicular nerve, and axillary nerve blocks 27 . Another meta-analysis of thirteen randomized controlled studies comparing ultrasonographic guidance with neurostimulation found that the ultrasonographically guided blocks took less time to perform, were more successful, and had a lower risk of vascular puncture28. Despite this mounting evidence of the superiority of ultrasonographic over neurostimulation guidance, however, one recent metaanalysis found that the data were insufficient for drawing this conclusion29. Ultimately, there remains a large variability in the localization techniques used in different centers. The associated operative delay remains largely contingent on the operative setting (ambulatory center versus hospital) and experience level of the operator. Whether or not a dedicated block physician or room is available, time savings are often achieved at the end of the case because the patient can be gradually awakened without affecting surgical wound closure.
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Fig. 2-A
Fig. 2-B
Figs. 2-A and 2-B The cervical plexus. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 2-A The dermatomes anesthetized are shown in dark blue. Fig. 2-B Surface anatomy of the neck showing the relative midpoint (x) of the posterior border of the sternocleidomastoid muscle (solid line).
(Fig. 1). Seventy percent of the sensory innervation to the shoulder capsule, subacromial bursa, acromioclavicular joint, and overlying skin comes from the superior trunk via the su-
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Fig. 3-A
Fig. 3-B
Figs. 3-A, 3-B, and 3-C Interscalene nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 3-A The dermatomes anesthetized are shown in dark blue. Fig. 3-B The highlight shows the region of the brachial plexus (nerve roots and root-trunk transition) targeted by an interscalene nerve block.
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TABLE I Level of Evidence, Anesthesia Type, and Identified Complications for Studies Involving Upper-Extremity Peripheral Nerve Blocks* Study
Level of Evidence (Study Design) 39
Bishop et al. 40
Brull et al.
9
Borgeat et al.
42
Misamore et al.
Block Type
Complications
IV
ISB
2.3% sensory neuropathy
III (meta-analysis)
ISB
2.84% sensory neuropathy
II (RCT)
CISB
Decreased diaphragmatic excursion
III (prospective)
ISB
Immediate paresthesias in 16%; persistent neuropathy in 4.4%; long-term neuropathy in 0.8%
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Liu et al.
III (prospective)
ISB, SCNB
Hoarseness: 31% (ISB), 22% (SCNB).
III (prospective)
ICNB
0.7% prevalence pneumothorax
III (prospective)
SCNB
50% complete hemidiaphragmatic paresis;
Dyspnea: 10% (ISB), 7% (SCNB) 37
Desroches
38
Mak et al.
17% partial hemidiaphragmatic paresis *ISB = interscalene nerve block, RCT = randomized controlled trial, CISB = continuous interscalene nerve block, SCNB = supraclavicular nerve block, and ICNB = infraclavicular nerve block.
Single-Injection Blocks Versus Continuous Perineural Catheters he single-injection nerve block for improved postoperative pain control is currently the most commonly used modality for regional anesthesia in upper-extremity surgery. The duration of analgesia provided by these blocks ranges from twelve to twenty-four hours13,16. As technology has advanced, the use of indwelling continuous nerve catheters to provide primary anesthesia and prolonged management of postoperative pain has increased. In two comparison studies of singleinjection compared with continuous interscalene nerve blocks, the results showed that a continuous interscalene nerve block provided better pain relief, better sleep quality, and lower narcotic requirements18,30. Several studies have also suggested that the use of continuous nerve catheters may lead to shorter hospital stays and improved postoperative shoulder mobilization14,31,32. Furthermore, the authors of one pilot study reported the successful use of nerve catheters for total shoulder arthroplasties performed in an outpatient setting33. However, to implement models involving nerve catheters in the ambulatory setting, there has to be a great deal of focus on patient education and a safe and effective follow-up system. With the growing emphasis on costeffectiveness in the surgical setting, there will undoubtedly be a continued focus on studying the use of continuous nerve catheters to allow for earlier patient discharge.
T
Peripheral Nerve Blocks Interscalene Nerve Block he interscalene nerve block, the most commonly performed nerve block, targets the brachial plexus at the roottrunk level (Figs. 3-A, 3-B, and 3-C). The localization of this block makes it effective for procedures involving the shoulder, proximal aspect of the humerus, and distal aspect of the clavicle. The supraclavicular and suprascapular nerves are affected
T
by the block, and therefore the superior aspect of the shoulder is adequately covered34. However, the C8 dermatome and inferior trunk are often incompletely covered, an effect that is called ulnar sparing. Procedures at or distal to the elbow are not adequately covered with an interscalene nerve block alone and require an additional ulnar nerve block. Since the first description of the direct anterior technique for interscalene nerve blockade by Winnie35 in 1970, several modifications have enhanced its safety and effectiveness. Meier et al.36 and Borgeat et al.9 described a lateral approach with a more caudal trajectory to help avoid central neuraxial complications. The use of nerve stimulation or ultrasonography for guidance has further increased its safety (Table I9,37-42). However, complications can occur.
Fig. 3-C
Surface anatomy. The typical needle entry point (x) for an interscalene nerve block is shown in relation to the sternocleidomastoid muscle and its clavicular and sternal heads (solid lines) as well as the course of the external jugular vein (dotted line) and the ends of the clavicle.
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U P P E R -E X T R E M I T Y P E R I P H E R A L N E R V E B L O C K S I N P E R I O P E R AT I V E P A I N M A N A G E M E N T
Fig. 4-A
Fig. 4-B
Figs. 4-A, 4-B, and 4-C Supraclavicular nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.) Fig. 4-A The dermatomes anesthetized are shown in dark blue. Fig. 4-B The highlight shows the region of the brachial plexus (trunks) targeted by a supraclavicular nerve block.
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TABLE II Anesthesia Type, Level of Evidence, and Outcome Parameters for Studies Involving Open and Arthroscopic Shoulder Surgery*
Study 10
Brown et al.
16
Kinnard et al.
19
Singelyn et al.
12
Ciccone et al. 17
Lee et al.
13
Gohl et al.
20
Wu et al.
Level of Evidence (Study Design)
Anesthesia†
Patient Satisfaction
Pain
Duration of Stay
Rehabilitation
II (RCT)
CISB
Y
Y
II (RCT)
ISB
Y
Y
Y
Y
—
) /
—
II (RCT)
ISB
Y
YY
—
Y
—
SSNB
) /
—
Y
) /
—
—
Adverse Effects
IA
) /
) /
) /
—
—
II (RCT)
ISB
—
Y
) /
) /
—
II (RCT)
ISB
—
Y
Y
) /
) /
III
ISB
Y
Y
) /
—
—
IV
ISB
—
Y
) /
Y
—
*CISB = continuous interscalene nerve block, RCT = randomized controlled trial, ISB = interscalene nerve block, SSNB = suprascapular nerve block, and IA = intra-articular analgesia. Arrows indicate whether the outcome is no different () /), better (Y), or worse ([). Multiple arrows (YY) indicate a better outcome compared with the other listed peripheral nerve block modalities for the same study. Dashes indicate not reported. †Each group was compared with intravenous patient-controlled analgesia.
Complications of the interscalene nerve block include phrenic blockade, spinal cord damage, sympathetic chain blockade, recurrent laryngeal nerve blockade, and peripheral neuropathy34. The reported rates of neuropathy after an interscalene nerve block vary: the neuropathy most commonly takes the form of a sensory neuropathy (in
