• Users Online: 392
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 281-287

Interscalene versus combined supraclavicular with suprascapular ultrasound-guided nerve blocks in arthroscopic rotator cuff surgery with levobupivacaine


Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission07-Apr-2019
Date of Decision20-May-2019
Date of Acceptance01-Sep-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Ahmed G.S El Sawy
5240 Andrya Street, Mokattam, Cairo, 11571
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_66_19

Rights and Permissions
  Abstract 


Background In recent years, shoulder arthroscopy has been used as a diagnostic and therapeutic maneuver. With the introduction of ultrasound, peripheral nerve block has increasingly been performed by the anesthesiologist, because it increases the success rate of the block. Interscalene block is suitable for arthroscopic shoulder surgery, but many complication may affect the respiratory system. Ultrasound-guided supraclavicular with suprascapular nerve block may be a safe alternative for arthroscopic shoulder surgery. Levobupivacaine is a local anesthetic. It is the S enantiomer of bupivacaine with long duration of action, motor block, and onset time.
Aims The primary outcome of the study is the quality of the block (sensory and motor), whereas the postoperative analgesia and patient satisfaction are the secondary outcomes in arthroscopic rotator cuff surgery.
Settings and design This was a prospective randomized comparative clinical study.
Patients and methods A total of 60 patients between 25 and 55 years were included in this study. The patients scheduled for elective arthroscopic rotator cuff surgery were randomized into two groups: group A patient received ultrasound-guided interscalene brachial plexus block with levobupivacaine, and group B patient received ultrasound-guided supraclavicular with suprascapular brachial plexus block with levobupivacaine.
Results The mean age of all arthroscopy patients was 43.1±8.8 years, and most patients were males (60%), whereas 40% were females. On comparing the two groups, we found no statistically significant difference regarding basic preoperative, hemodynamic, and intraoperative data. Regarding the primary outcome, there was a significant increase in success rate (block quality) in group B (93.3%) compared with group A patients (70%) (P=0.02) and nonsignificant difference regarding sensory and motor block onset (P>0.05). Regarding secondary outcomes, there was a highly significant decrease in rescue analgesia in B group (average 1.9±0.7 ampoules) compared with group A patients (average 2.5±0.7 ampoules) (P=0.008), a significant decrease in complications rate in group B (0%) compared with group A patients (26.7%) (P=0.026), and a highly significant increase in patient satisfaction rate in group B (100%) compared with group A patients (70%) (P=0.004).
Conclusions Suprascapular brachial plexus block can be performed as an alternative to interscalene brachial plexus block in patients undergoing arthroscopic shoulder surgery.

Keywords: interscalene, supraclavicular, levobupivacaine, rotator cuff, suprascapular


How to cite this article:
El Sawy AG, El-Garhy AM, Abd-Elmegeed MM. Interscalene versus combined supraclavicular with suprascapular ultrasound-guided nerve blocks in arthroscopic rotator cuff surgery with levobupivacaine. Al-Azhar Assiut Med J 2019;17:281-7

How to cite this URL:
El Sawy AG, El-Garhy AM, Abd-Elmegeed MM. Interscalene versus combined supraclavicular with suprascapular ultrasound-guided nerve blocks in arthroscopic rotator cuff surgery with levobupivacaine. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 6];17:281-7. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/281/271683




  Introduction Top


Shoulder arthroscopy has been used effectively in the treatment of different injuries and diseases of the shoulder, one of them being rotator cuff injury on an ambulatory basis [1],[2]. Arthroscopic shoulder surgery is minimally invasive but associated with severe pain both intraoperatively and postoperatively, so it requires strong analgesia and adequate muscle relaxation. Regional anesthesia is preferred than general anesthesia because it is associated with good analgesia, adequate muscle relaxation, and rapid recovery with early discharge [3],[4]. Ultrasound-guided brachial plexus block has been associated with higher success, better visualization of spread of local anesthetic, decreasing total volume of local anesthetic, and lesser incidence of complications [5],[6]. Interscalene brachial plexus block (ISBPB) is a suitable block for rotator cuff surgery. It targets the roots and proximal trunks in the neck at the interscalene groove between the anterior and middle scalene muscles. Complications of the interscalene block may be serious [7],[8]. ISBPB can provides anesthesia of the shoulder joint by blocking the lower nerve roots of the cervical plexus (C5, C6), which gives most of the nerve supply to the shoulder [9]. Ultrasound-guided supraclavicular brachial plexus block (SCBPB) may be safe for arthroscopic shoulder surgery [10]. Large volumes of local anesthetic may be needed to block the lower roots of the cervical plexus, which may not be blocked by the usual volume of local anesthetic. The suprascapular nerve (C5–C6) supplies sensory to the superior, medial, and posterior part of the shoulder joint capsule and the infraspinatus and supraspinatus muscles of the rotator cuff [11]. The suprascapular nerve can be blocked in the suprascapular fossa by ultrasound. Levobupivacaine is a local anesthetic drug and is one of the amino amides [12]. Levobupivacaine has less vasodilation and long duration, motor block, and onset time than bupivacaine [13].

The study has been conducted to assess quality of the block, success rate, postoperative analgesia, and patient satisfaction between ISBPB and SCBPB combined with suprascapular nerve block in patients undergoing rotator cuff surgery.


  Patients and methods Top


This prospective randomized comparative clinical study was done in Al-Azhar University Hospital (Al-Hussein) from May 2018 to October 2018 after obtaining the local ethics committee approval from the hospital and informed written consent from the patients.

A total of 60 patients between 25 and 55 years of age, with American Society of Anesthesiologists status I and II, scheduled for elective arthroscopic rotator cuff surgery were included in this study.
  • Exclusion criteria were as follows:
  • Patients with coagulopathy.
  • Patients with mental retardation.
  • Patients with airway problems.
  • Patients with sleep apnea syndrome.
  • Patients with American Society of Anesthesiologists status III or IV.
    1. The patients scheduled for elective arthroscopic rotator cuff surgery were randomly divided by closed envelopes into two equal groups.
    2. Group A (N=30) received ultrasound-guided ISBPB, with 25-ml levobupivacaine 0.5% (chirocaine).
    3. Group B (N=30) received combination of ultrasound-guided supraclavicular and SCBPB, with 25 ml and 5 ml levobupivacaine 0.5% (chirocaine).


In all patients, ultrasound was used (Sonosite M Turbo Fujifilm, Bothell, Washington, USA) with high-frequency linear probe (6 : 15 MHz) and a 22-G spinal needle (BD Quink spinal needle 22 G×3 1/2 in/l; 8.9 cm) for local anesthetic injection, which was 0.5% levobupivacaine (chirocaine abb vie Italy) solution.


  Methods Top


Procedure

  1. Preoperative investigations (complete blood count, coagulation profile, liver function, kidney function, ECG, and chest radiography) were done. Details of anesthetic procedure were explained to the patients. An intravemous line was inserted and secured in the contralateral limb. All patients were monitored for heart rate (beat/min), oxygen saturation, noninvasive mean arterial blood pressure (mmHg) using GE datex ohmeda (Ghafont St Giles, Buckinghamsire, UK), and oxygen supply 3 l/min via nasal cannula. Sterilization of the site of the block must be done, and sterile gel for the probe should be used.
  2. For interscalene block, the patient was positioned in the supine position with his/her neck in the neutral position with slightly turned to the opposite side. The skin over the site of the block was sterilized, and the linear probe of the ultrasound was placed in a sterile sheath and sterile gel was used. The was probe placed at the level of cricoid cartilage and moved laterally to visualize the carotid artery and internal jugular vein and then moved in latero-posterior direction until the plexus was visualized between the middle and anterior scalene muscles as distinct hypoechoic circles. Absence of vascular structure was confirmed by color Doppler. After skin infiltration by 2 ml lidocaine, the needle was inserted using in-plane technique through the middle scalene muscle to reach the brachial plexus roots, and then 25 ml of levobupivacaine 0.5% was injected, with aspiration every 5 ml to avoid inadvertent injection, with real-time visualization of the spread of local anesthetic solution.
  3. For supraclavicular block, the block was performed in supine position with the patient arm at the side and the head slightly turned to the other side. After skin sterilization, the linear probe of the ultrasound was placed in sterile sheath and the probe was placed in the supraclavicular fossa. Pulsation of the subclavian artery will appear as pulsatile hypoechoic round structure, and the plexus will appear as several hypoechoic circles superior and lateral to the artery. After skin infiltration by 2-ml lidocaine, the needle was inserted using in-plane technique. The needle was advanced until the tip of the needle enters the sheath of the plexus, and the needle is redirected to block the plexus superior to the artery. Overall, 25 ml of levobupivacaine 0.5% was injected with aspiration technique to avoid intravascular injection, with visualization the spread of local anesthetic solution.
  4. Regarding suprascapular nerve block, the block was performed in the sitting position. After skin sterilization, the linear probe was placed in sterile sheath and placed parallel to the scapular spine and moved cephalad to the suprascapular fossa, and then moved laterally to identify the suprascapular notch. The nerve was seen as a hyperechoic circle structure. The needle was inserted along the longitudinal axis of the probe until the tip of the needle was visualized in proximity to the suprascapular nerve, and then 5 ml of levobupivacaine was injected and the spread of the solution was visualized.


After performing the block, each patient was evaluated for the following:
  1. Onset time of sensory block: it is defined as the time between the end of the last injection and complete absence of pinprick response in all nerve distribution (pinprick method, with 22 G hypodermic needle at an interval of every 3 min to a maximum of 30 min in the sensory distribution of radial, ulnar, median and musculocutaneous nerves) [elbow and wrist extension (radial nerve), finger abduction (ulnar nerve), wrist flexion (median nerve), and elbow flexion (musculocutaneous nerve)] on a scale of 0–6 (6: normal muscle force; 5: slightly reduced muscle force; 4: greatly reduced muscle force; 3: slightly impaired mobility; 2: greatly impaired mobility; 1: near complete paralysis; and 0: complete paralysis).
  2. Onset time of motor block: it is defined as the time between the end of the last injection and complete paralysis (Lovett rating scale=0) in all nerve distributions (6-normal muscular force, 0-complete paralysis).
  3. Duration of sensory block: it is defined as the time interval between the complete sensory block (complete absence of pinprick response) and first experience with postoperative pain.
  4. Duration of motor block: it is defined as the time interval between complete paralysis (Lovett rating scale=0) and complete recovery (Lovett rating scale=6).
  5. Severity of postoperative pain: it is measured by visual analog scale where 0 equals no pain and 10 indicates the worst possible pain till the time of first analgesic rescue dose.
  6. Time of first analgesic request: first need for rescue opioid after surgery.
  7. The adverse effects of the block (Horner’s syndrome, hoarseness, and subjective dyspnea, which can be caused by ipsilateral stellate ganglion, recurrent laryngeal nerve, and phrenic nerve block, respectively) and the procedural time (time between insertion and removal of the nerve-stimulating needle) were also recorded.
  8. Patient satisfaction was noted.



  Results Top


In this study, 60 patients scheduled for arthroscopy between 25 and 55 years of age were included in the study. [Table 1] presents the basic preoperative data, where the mean age of all patients undergoing arthroscopy was 43.1±8.8 years; for group A was 44±7 years, whereas for group B was 42.2±10.4 years. Regarding sex, most patients were males (60%), whereas 40% were females. In groups A and B, 60% were males and 40% were females, as shown in [Table 1].
Table 1 Comparison between groups A and B regarding basic preoperative and hemodynamic data

Click here to view


Regarding basic preoperative data, we found no significant statistical difference between the two groups (P>0.05). Regarding basic hemodynamic data, we also found no significant statistical difference between the two groups (P>0.05), as shown in [Table 1].

Regarding intraoperative data, we found the following:
  1. There was no significant difference regarding duration and onset of surgery, along with the need of general anesthesia, local infiltration, and intravenous fentanyl (P>0.05), as shown in [Table 2].
    Table 2 Comparison between groups A and B regarding intraoperative data

    Click here to view


Regarding primary outcomes (sensory and motor block onset and success rate), follow-up period revealed the following:
  1. There was significant increase in success rate (block quality) in group B (93.3%) compared with group A patients (70%), with a significant statistical difference (P=0.02), as shown in [Table 3] and [Figure 1].
    Table 3 Comparison between groups A and B regarding primary outcome

    Click here to view
    Figure 1 Comparison between the two groups of patients regarding success rate (block quality).

    Click here to view
  2. A nonsignificant difference was found regarding sensory and motor block onset (P>0.05), as shown in [Table 3].


Regarding secondary outcomes (pain score), follow-up period revealed the following:
  1. There was a highly statistically significant decrease in rescue analgesia in group B (average 1.9±0.7 ampoules) compared with group A patients (average 2.5±0.7 ampoules) (P=0.008), as shown in [Table 4] and [Figure 2].
    Table 4 Comparison between groups A and B regarding secondary outcomes

    Click here to view
    Figure 2 Comparison between the two groups of patients regarding rescue analgesia.

    Click here to view
  2. There was a statistically significant decrease in complication rate in group B (0%) compared with group A patients (26.7%) (P=0.026), as shown in [Table 4] and [Figure 3].
    Figure 3 Comparison between the two groups of patients regarding complications rate.

    Click here to view
  3. There was a highly statistically significant increase in patient satisfaction rate in group B (100%) compared with A group of patients (70%) (P=0.004), as shown in [Table 4] and [Figure 4].
    Figure 4 Comparison between the two groups of patients regarding patient satisfaction rate.

    Click here to view
  4. There was no significant difference regarding duration of analgesia (P>0.05), as shown in [Table 4].



  Discussion Top


In this study, 60 patients scheduled for arthroscopy between 25 and 55 years of age were included in the study. Regarding basic preoperative data, it was found that the mean age of all arthroscopy patients was 43.1±8.8 years. Most of them were males (60%), and 40% were females.

Regarding basic preoperative and hemodynamic data, we found no significant statistical difference between the two groups (P>0.05).

Regarding intraoperative data, we also found nonsignificant difference regarding duration and onset of surgery, along with the need of general anesthesia, local infiltration, and intravenous fentanyl (P>0.05), which came in agreement with Ryu et al. [14], who studied the comparison between ultrasound-guided SCBPB and ISBPB in patients undergoing arthroscopic shoulder surgery.

Regarding primary outcomes (sensory and motor block onset and success rate), follow-up period revealed the following.

There was a significant increase in success rate (blockade quality) in group B (93.3%) compared with group A patients (70%), with significant statistical difference (P=0.02), along with nonsignificant difference regarding sensory and motor block onset (P>0.05), which came in disagreement with Auyong et al. [15], who studied the comparison of anterior suprascapular, supraclavicular, and interscalene nerve block approaches for major outpatient arthroscopic shoulder surgery.

Auyong et al. [15], found that anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared with the interscalene approach for major arthroscopic shoulder surgery.

Our results came in agreement with Ryu et al. [14], who studied the comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery.

However, Ryu et al. [14], reported that there was a highly significant decrease in motor blockade at median in group A compared with group B, whereas nonsignificant difference regarding motor blockade at ulnar nerve between the two groups.

Regarding secondary outcomes (pain score), follow-up period revealed the following.

There was nonsignificant difference regarding duration of analgesia (P>0.05), along with highly significant decrease in rescue analgesia in group B (average 1.9±0.7 ampoules) compared with group A patients (average 2.5±0.7 ampoules), with highly significant statistical difference (P=0.008).

Our results came in agreement with Auyong et al. [15], who studied the comparison of anterior suprascapular, supraclavicular, and interscalene nerve block approaches for major outpatient arthroscopic shoulder surgery and found a less opioid consumption with better preservation of vital capacity in the anterior suprascapular group.

Significant decrease in complications rate in group B (0%) compared with group A patients (26.7%), with significant statistical difference (P=0.026), along with a highly significant increase in patient satisfaction rate in group B (100%) compared with group A patients (70%), with a highly significant statistical difference (P=0.004), which came in agreement with Guo et al. [16], who conducted a meta-analysis of supraclavicular block versus interscalene brachial plexus block for shoulder surgery.Guo et al. [16], reported that the incidence of hoarseness and Horner syndrome was statistically lower in the SCB group than in the ISB group (P=0.0002 and P<0.00001, respectively).

Song et al. [17] also reported that a medially directed needle could increase the possibility of complications such as intravascular injections (the internal jugular vein or even the carotid artery), phrenic nerve block, epidural and spinal anesthesia, Horner’s syndrome, hoarseness, and dysphagia.

Guo et al. [16] reported in their meta-analysis a different trend in adverse events between the SCB group and the ISB group, with the SCB demonstrating a lower incidence of hoarseness and Horner syndrome, and the ISB showing a similar incidence of dyspnea 24 h after surgery. In other studies, Horner syndrome developed following SCB and ISB, with an incidence of 10 and 5%, respectively, and has been considered a factor causing hypotensive bradycardic events.

Despite less potent sensory blockade was provided by SCBPB compared with ISBPB, a better motor blockade profile and lower incidence of Horner’s syndrome might be obtained when using SCBPB.

Despite the discrepancies in the sensory blockade assessment in the early post-block period, neither of the two brachial plexus blocks required conversion to general anesthesia owing to inadequate sensory anesthesia.

In addition, the patients receiving either SCBPB or ISBPB required opioid analgesics, with less frequency in SCBPB group (P=0.0008), and benefited from similar surgical anesthesia and postoperative analgesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beecroft CL, Coventry DM. Anaesthesia for shoulder surgery. Continu Educ Anaesth Crit Care Pain 2008; 8:193–198.  Back to cited text no. 1
    
2.
Chie ED, Tong D, Chung F, Norris AM, Miniaci A, Vairavanathan SD. Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: a new modality?. Anesth Analg 1997; 84:1306–1312.  Back to cited text no. 2
    
3.
Wilson AT, Nicholson E, Burton L, Wild C. Analgesia for day‐case shoulder surgery. Br J Anaesth 2004; 92:414–415.  Back to cited text no. 3
    
4.
Wurm WH, Concepcion M, Sternlicht A, Carabuena JM, Robelen G, Goudas LC, Strassels SA, Carr DB. Preoperative interscalene block for elective shoulder surgery: loss of benefit over early postoperative block after patient discharge to home. Anesth Analg 2003; 97:1620–1626.  Back to cited text no. 4
    
5.
Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2008; 101:549–556.  Back to cited text no. 5
    
6.
Renes SH, Rettig HC, Gielen MJ, Wilder-Smith OH, van Geffen GJ. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med 2009; 34:498–502.  Back to cited text no. 6
    
7.
Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder surgery: continuous versus patient-controlled infusion. Anesth Analg 1999; 89:1216–1220.  Back to cited text no. 7
    
8.
Passannante AN. Spinal anesthesia and permanent neurologic deficit after interscalene block. Anesth Analg 1996; 82:873–874.  Back to cited text no. 8
    
9.
Checcucci G, Allegra A, Bigazzi P, Gianesello L, Ceruso M, Gritti G. A new technique for regional anesthesia for arthroscopic shoulder surgery based on a suprascapular nerve block and an axillary nerve block: an evaluation of the first results. Arthroscopy 2008; 24:689–696.  Back to cited text no. 9
    
10.
Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, Yadeau JT. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg 2010; 111:617–623.  Back to cited text no. 10
    
11.
Price DJ. The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesth Intensive care 2007; 35:575–581.  Back to cited text no. 11
    
12.
Burlacu CL, Buggy DJ. Update on local anesthetics: focus on levobupivacaine. Ther Clin Risk Manag 2008; 4:381.  Back to cited text no. 12
    
13.
Gulec D, Karsli B, Ertugrul F, Bigat Z, Kayacan N. Intrathecal bupivacaine or levobupivacaine: which should be used for elderly patients?. J Int Med Res 2014; 42:376–385.  Back to cited text no. 13
    
14.
Ryu T, Kil BT, Kim JH. Comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery: a prospective, randomized, parallel study. Medicine 2015; 94:e1726.  Back to cited text no. 14
    
15.
Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of anterior suprascapular, supraclavicular, and interscalene nerve block approaches for major outpatient arthroscopic shoulder surgery. a randomized, double-blind, noninferiority trial. Anesthesiology 2018; 129:47–57.  Back to cited text no. 15
    
16.
Guo CW, Ma JX, Ma XL, Lu B, Wang Y, Tian AX, Sun L et al. Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: a meta-analysis of clinical control trials. Int J Surg 2017; 45:85–91.  Back to cited text no. 16
    
17.
Song SY, Roh WS. Hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene brachial plexus blocks. Korean J Anesthesiol 2012; 62:209–219.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Patients and methods
  Methods
  Results
  Discussion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed299    
    Printed19    
    Emailed0    
    PDF Downloaded41    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]