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 Table of Contents  
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 308-313

Analgesic efficacy of preoperative ultrasound-guided interscalene block versus intravenous morphine on postoperative pain relief after shoulder surgeries

Lecturer of Anesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan, Egypt

Date of Submission23-Jan-2019
Date of Decision18-Mar-2019
Date of Acceptance22-Apr-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Huda Fahmy
Lecturer of Anesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_11_19

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Background Postoperative pain relief is a major concern for the anesthesiologist after shoulder surgeries.
Aim The aim of the study was to compare the efficacy of preoperative ultrasound-guided interscalene brachial plexus block (ISPB) and postoperative intravenous morphine for postoperative analgesia in shoulder surgeries.
Patients and methods This prospective, randomized study was performed on 40 patients who were scheduled for different types of shoulder surgery under general anesthesia, with ASA physical status between I and II. The patients were divided equally and randomly into two groups to receive ISPB or intravenous morphine.
Results Patient demographic characteristics, operative data, and ASA classification were similar between the groups. The mean pain score was significantly lower in ISPB compared with the intravenous morphine group at 3, 6, and 12 h postoperatively (P<0.05). Additionally, the ISPB group was associated with statistically significant lower morphine consumption (P<0.001) and the number of patients who required additional analgesia 3 h postoperatively was 3 (20%) versus 17 (75%) in the morphine group (P=0.000).
Conclusion The present randomized trial shows that ultrasound-guided ISPB provides better postoperative analgesia and reduces the need for postoperative morphine than opioids alone among patients scheduled for open shoulder surgery.

Keywords: postoperative pain, ultrasound-guided block, shoulder surgeries

How to cite this article:
Fahmy H. Analgesic efficacy of preoperative ultrasound-guided interscalene block versus intravenous morphine on postoperative pain relief after shoulder surgeries. Al-Azhar Assiut Med J 2019;17:308-13

How to cite this URL:
Fahmy H. Analgesic efficacy of preoperative ultrasound-guided interscalene block versus intravenous morphine on postoperative pain relief after shoulder surgeries. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 6];17:308-13. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/308/271672

  Introduction Top

Postoperative pain is a common complication of shoulder surgery that was reported to be inadequately treated in approximately one-half of all shoulder surgical procedures [1]. Although different pain management modalities have been extensively studied within the published literature, the currently established modalities have several limitations. For example, the adverse events of opioids, such as vomiting and intestinal ileus, may limit its use in a considerable proportion of patients. On the other hand, local anesthetic injections alone might not be enough to reduce pain. Moreover, the efficiency of local anesthetic or morphine remains controversial [2].

Throughout the past two decades, regional anesthesia has been proposed as an effective analgesic modality for the control of postoperative pain. It was demonstrated that regional anesthesia reduces the incidence of postoperative pain, opioid consumption, and its related side effects such as nausea and vomiting [3]. These beneficial roles have become more evident with the introduction of ultrasound-guided pain management procedures; real-time ultrasound use, while performing the block may reduce the complications, performance time, and local anesthetic requirements. It also provides reappraising the older techniques with potential complications [4]. Ultrasound-guided interscalene brachial plexus block (ISPB) is a well-established procedure to provide optimal postoperative shoulder surgery analgesia and reduce postoperative demand for opioids [5]. However, it has multiple side effects that provoked the researchers to find alternatives [6],[7].

  Patients and methods Top

After receiving approval from the Aswan Faculty of Medicine Ethics Committee, 40 patients, ASA physical status I or II with their age range from 18 to 65 years and treated with different varieties of open shoulder surgeries under general anesthesia were included in the study. All patients were randomly allocated into two groups using a table of random sampling numbers.

Anesthetic technique

The patients were taken to the operating room 45 min before the surgery, intravenous vascular access was established on the arm opposite to the diseased shoulder; they were monitored noninvasively with an ECG, noninvasive arterial blood pressure, and pulse oximetry. Skin cleansing with betadine was carried out on the location at which the block would be performed.

In group I (ISPB), ISPB was performed under the guidance of ultrasonography with the use of ultrasound machine (Philips; Model: OTD020, AcBel Polytech Inc., Taiwan); hypoechoic nerve roots on short-axis view in between anterior scalene muscle and middle scalene muscle were visualized in a round-oval honeycomb form with a 5–10 MHz linear probe.

The best point of view for C5/6/7 roots was determined; local skin anesthesia was provided for the area to be operated upon with 1 ml 2% lidocaine; 22 G peripheral nerve block needle was inserted with the in-plane method. The needle tip was directed into the C5/6 roots, then 20 ml 0.25% bupivacaine (10 ml 0.5% bupivacaine+10 ml 0.9% NaCl prepared) preoperatively was injected and the block was completed. All ISPB maneuvers were done by the same anesthetist and all surgical operations were carried out by the same surgeon.

Sensory block level was evaluated by a gauze soaked with iced saline on the shoulder using a three-point scale: 0=normal sensation, 1=loss of cold sensation (analgesia), and 2=loss of sensation of touch (anesthesia). Motor block evaluation by a modified Bromage scale for shoulder abduction using a three-point scale: 0=normal abduction, 1=decreased movement of the shoulder, 2=complete motor block with an inability to abduct the shoulder. Evaluation of the sensorial and motor block was performed after 30 min and a score of 1 or more was accepted as a sufficient block and included in the study result analysis.

Group II (morphine) received only intravenous morphine immediately postoperatively with a dose of 0.1 mg/kg.

Anesthesia induction was provided intravenously with 1 μg/kg fentanyl, 2–3 mg /kg propofol, and muscle relaxation was provided with 0.5 mg/kg atracurium; tracheal intubation was performed and respiration continued with controlled ventilation; anesthesia maintenance was continued using 50% oxygen in 50% air with 1–2% isoflurane inhalation anesthesia.

Each type of surgery performed on our patients was recorded. At the end of operation, the patients were extubated after reversing the neuromuscular block with 0.04 mg/kg neostigmine and 0.02 mg/kg atropine and then taken to the postanesthetic care unit where heart rate (HR), noninvasive blood pressure, and oxygen saturation were measured.

Visual analog score (VAS) with a 10 point scale (ranging from 0=no pain to 10=worst pain imaginable) was carried out by an anesthetist, who was blinded to the groups for the evaluation of pain with the shoulder in a resting position at baseline 0, 3, 6, 12, 24 h postoperatively. Patients with VAS scores of 4 or more were received 0.1 mg/kg, intravenously, morphine as a bolus therapy. Additional analgesia in the form of 30 mg ketorolac was given intravenously to patients with VAS scores of 4 or more despite being given morphine bolus.

Morphine consumption and additional analgesic requirements of our patients were estimated at 3, 6, 12, and 24 h, postoperatively.

Postoperative patient satisfaction scores in 24 h were evaluated using a five-point scale (1=very unsatisfactory, 2=rather unsatisfactory, 3=fair, 4=rather satisfactory, and 5=very satisfactory) and any observed side effects during the study were recorded.

The primary outcome of this study was the postoperative 24-h VAS scores and postoperative morphine consumption. The secondary outcome was the number of patients who required additional analgesia in the first 24 h postoperatively, total additional analgesic requirements, and the 24-h patient satisfaction scores.

Data analysis

All analyses were performed with the IBM SPSS 20.0 software produced by SPSS Inc., Chicago. The data were tested for normality using the Anderson–Darling test and for homogeneity variances prior to further statistical analysis. Categorical variables were described as number and percent, while continuous variables were described as mean±SD. Comparison between categorical variables was done by χ2-test and Fisher’s exact test, while independent-sample t-test was used to compare continuous variables. A P value less than 0.05 was considered statistically significant. Pearson’s correlation was used to detect the association between variables.

  Results Top

Demographic data of the patients included in our study are summarized in [Table 1]. There was no statistically significant difference between the studied groups as regards age, sex, BMI, and ASA status.
Table 1 Demographic data of patients included in the study

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Values of VAS scores in the ISPB group were significantly lower than that in the morphine group at 3, 6, and 12 h postoperatively. In the ISPB group, the VAS scores had significantly lower values at 3, 6, and 12 h postoperatively, while in the morphine group, there were significantly lower values at 6, 12, and 24 h compared with the baseline as shown in [Figure 1].
Figure 1 Visual analog score (VAS) rest values in interscalene brachial plexus block (ISPB) and morphine groups.

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[Table 2] summarized that the total 24 h postoperative morphine consumption was significantly lower in the ISPB group than the other group (P=0.000).
Table 2 24 h postoperative morphine consumption between the two groups

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There was a considerably large number of patients who required additional analgesia in the morphine group (17) (75%) versus (3) (20%) in the ISPB group at 3 h postoperatively.

Moreover, there was greater doses of the total additional analgesic need (P=0.000) in the morphine group ([Table 3]).
Table 3 Comparison between the two groups regarding the number of patients who required additional analgesia and the doses of the total additional analgesic need in the first 24 h postoperatively

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The 24-h patient satisfaction scores in the ISPB group were significantly higher than the other group at 3 and 6 h, postoperatively (P=0.000; [Figure 2]).
Figure 2 24-h patient satisfaction scores in interscalene brachial plexus block (ISPB) and morphine groups.

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The mean values of HR at 3 h postoperatively were significantly lower in the ISBP group compared with the morphine group (P=0.004). Moreover, in the morphine group, the mean HR was constant all over the study period, while in the other group, it was significantly decreased in the mean HR at 3, 6, and 12 h postoperatively compared with the baseline ([Figure 3]).
Figure 3 Mean heart rate (HR) in interscalene brachial plexus block (ISPB) and morphine groups.

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In the morphine group, the values of the mean arterial pressure (MAP) were constant all over the study period, while in the other group; MAP values were significantly lower at 3, 6, and 12 h postoperatively compared with the baseline ([Figure 4]).
Figure 4 Mean arterial pressure (MAP) in interscalene brachial plexus block (ISPB) and morphine groups.

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Nausea and vomiting were observed among five (25%) patients in the morphine group, and three (15%) patients in the ISPB group, where antiemetic treatment was started in these cases. Ptosis was observed in two patients among the ISPB group (P=0.126).

  Discussion Top

In the present study, we included 40 patients who were allocated to equal groups to receive ISPB or opioid alone. In terms of our primary outcomes, there was a statistically significant reduction in pain score of the ISPB group postoperatively; the pain score remained less than 5 till 12 h postoperatively. Moreover, the total morphine consumption and total additional ketorolac were lower in ISPB compared with the other group.

In agreement with our results, Lee et al. [8] reported that the VAS score of the ISPB group was significantly lower than that of the opioids group alone. Moreover, the total analgesic consumption in the ISPB group was significantly lesser than that of the opioid-alone group. Similarly, in their randomized controlled trial, Borgeat et al. [9] showed that pain relief was significantly better controlled in the ISPB group at 12 and 18 h than the opioid group (P<0.05). Additionally, a systematic review and meta-analysis performed by Ullah et al. [10] showed better pain relief with continuous ISPB following major shoulder surgery and a lower incidence of complications when the ISPB was performed under ultrasound guidance rather than without it. Zanfaly and Aly [11] showed that the total dose of morphine consumption was significantly higher in the opioids-alone group compared with the ISPB group (P<0.001). Another report by So and Kim [12] showed that ISPB was effective for controlling the postoperative pain during 1–12 h after shoulder arthroscopic surgery. Moreover, compared with the control group, the ISPB resulted in significantly reduced additional analgesics.

In contrast, Chen et al. [13] performed a prospective study to investigate the postoperative analgesic effect of ISPB combined with opioids in comparison to opioids alone after shoulder surgery. They found that the average or worst VAS did not differ significantly between the two groups. However, the ISPB group required less volume of analgesics than the opioids-alone group 24 and 48 h, postoperatively.

The exact causes of such discrepancies between our findings and the Chen and colleagues study regarding the pain score are unclear; however, it can be attributed to many methodological differences. Chen and colleagues compared the postoperative analgesic effect of intravenous patient-controlled analgesia combined with interscalene nerve block in comparison to patient-controlled analgesia alone after shoulder surgery. Moreover, the patients in the above-mentioned study were significantly older than our patients and most of them underwent arthroscopy, and not open surgery.

In terms of patients’ satisfaction, the mean satisfaction score was significantly higher in the ISPB group compared with the opioid group. In harmony with our findings, Lee et al. [8] demonstrated that the degree of satisfaction of the ISPB group was superior in the recovery room than those who received opioids alone. Similarly, Zanfaly and Aly [11] reported that patient satisfaction was significantly higher in the ISPB group compared with the use of opioids alone.

Lee et al. [14] indicated that more stable hemodynamic profiles were reported in patients undergoing ISPB application than in those receiving placebo. In this study, in the ISPB group, the values of mean HR and MAP were significantly declined at 3, 6, and 12 h postoperatively compared with baseline values, while in those receiving morphine alone the values of the MAP and mean HR were constant all over the study period.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Park JY, Bang JY, Oh KS. Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery. Knee Surg Sports Traumatol Arthrosc 2016; 24:3877–3883.  Back to cited text no. 1
Ruiz-Suarez M, Barber FA. Postoperative pain control after shoulder arthroscopy. Orthopedics 2008; 31:1130.  Back to cited text no. 2
Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth 2011; 107(Suppl 1):i90–i95.  Back to cited text no. 3
Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. Ultrasound guidance for upper and lower limb blocks. Cochrane Database Syst Rev 2015; (9):CD006459. doi: 10.1002/14651858.CD006459.pub3  Back to cited text no. 4
Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia 2010; 65:608–624.  Back to cited text no. 5
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. 6
Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and interscalene nerve block for shoulder surgery: a systematic review and meta-analysis. Anesthesiology 2017; 127:998–1013.  Back to cited text no. 7
Lee SM, Park SE, Nam YS, Han SH, Lee KJ, Kwon MJ et al. Analgesic effectiveness of nerve block in shoulder arthroscopy: comparison between interscalene, suprascapular and axillary nerve blocks. Knee Surg Sports Traumatol Arthrosc 2012; 20:2573–2578.  Back to cited text no. 8
Borgeat A, Schappi B, Biasca N, Gerber C. Patient-controlled analgesia after major shoulder surgery patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 1997; 87:1343–1347.  Back to cited text no. 9
Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery. Cochrane Database Syst Rev 2014; (2):CD007080. doi: 10.1002/14651858.CD007080.pub2  Back to cited text no. 10
Zanfaly HE, Aly AA. Shoulder block versus interscalene block for postoperative pain relief after shoulder arthroscopy. Ain Shams J Anaesthesiol 2016; 9:296.  Back to cited text no. 11
So KY, Kim SH. The hemodynamic and postoperative pain control effect of interscalene nerve block and general anesthesia for arthroscopic shoulder surgery: 14AP12–3. Eur J Anaesthesiol 2010; 27:222.  Back to cited text no. 12
Chen HP, Shen SJ, Tsai HI, Kao SC, Yu HP. Effects of interscalene nerve block for postoperative pain management in patients after shoulder surgery. Biomed Res Int 2015; 2015:902745.  Back to cited text no. 13
Lee HY, Kim SH, So KY, Kim DJ. Effects of interscalene brachial plexus block to intra-operative hemodynamics and postoperative pain for arthroscopic shoulder surgery. Korean J Anesthesiol 2012; 62:30–34.  Back to cited text no. 14


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

  [Table 1], [Table 2], [Table 3]


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