regional anesthetic options in shoulder arthroscopy operations (techniques, doses, advantages and disadvantageous)

1. Regional anesthesia
techniques in shoulder
arthroscopy
By/ Ahmed Tarek
MSc, DESA, DHA
Ass. Lecturer, Anesthesia and ICU department,
Zagazig university.

2. • A 66 years old male patient arrive to the
operative theater for shoulder arthroscopy,
his BMI is 42, he has history of being a
heavy smoker and suggesting history of
COPD.
• He is anxious about his
operation and his post-
-operative pain control.

3. What is the benefit of choosing a
certain technique instead of the
other??

5. • Cutaneous innervation is supplied by the axillary nerve
(C5-C6), suprascapular nerve (C5-C6) and
supraclavicular nerve of the cervical plexus (C3-C4).
• Bony and capsular components are supplied by the
suprascapular nerve, axillary nerve, subscapular nerve,
musculocutaneous nerve (C5-C7), lateral pectoral nerve
(C5-C7), and long thoracic nerve (C5-C7).
• Other sensory contributions to the muscles from ventral
rami of (C3-C4), pectoral nerves, dorsal scapular nerve
(C5) and upper and lower subscapular nerve (C5-C6).

7. • General anesthesia
• Regional anesthesia
• Combined general and regional
anesthesia
• Combined regional and local
anesthesia

8. • Less hemodynamic and respiratory affection.
• Better postoperative analgesia.
• Better rehabilitation ex: frozen shoulder.
• More economic (pharmaceuticals, hospital stay)
But beware of the phrenic

9. • Transient paralysis
• Persistent paralysis
• Assessment of severity
(clinically, US guided)

10. • Cervical epidural.
• Cervical paravertebral.
• Interscalene approach for the brachial plexus block
combined with superficial cervical plexus block.
• Supraclavicular approach for brachial plexus block
combined with superficial cervical block.
• Combined axillary nerve and supracapular nerve
block.
• Combined omohyoid and subscapularis plane block.
Regional anesthesia in shoulder
surgeries

11. • Would you prefer this block in such an
operation?
• This block provides anesthesia and
continuous postoperative analgesia
• Would this option be our favorite?

12. • Koom et al. 2016* described a case of cervical
paravertebral block usage in shoulder surgery in a
cardiac and COPD patient with favorable results.
• Need more trials and mainly described for analgesia.
* The use of cervical paravertebral block as the sole anesthetic for shoulder surgery in a morbid patient:
a case report. Reg Anesth Pain Med. 2004 May-Jun;29(3):227-9.

13. Brachial
plexus
blocks

14. • Most common technique
• Good coverage, need no or little supplemental doses.
• 15–20 mL of LA is usually sufficient for the ISB while 5-10
mL used for SCB.
• Carry almost always the risk of phrenic affection*.
* Bergmann L., Martini S., Kesselmeier M. et al. Phrenic nerve block caused by interscalene brachial
plexus block: breathing effects of different sites of injection. BMC Anesthesiol. 2016; 16: 45.

15. • All the terminal nerves supplying the shoulder arise distal
to the origin of the superior trunk and hence analgesic
efficacy is not compromised.
• A meta-analysis carried out by Ryu et al. 2015*
comparing ISB vs. SCB in shoulder surgeries showed
satisfying results for both although they found that
interscalene block achieves better sensory block.
* Ryu T., Tae Kil B. and Hae Kim J. Comparison Between Ultrasound-Guided Supraclavicular and
Interscalene Brachial Plexus Blocks in Patients Undergoing Arthroscopic Shoulder Surgery. Medicine
(Baltimore). 2015 Oct; 94(40): e1726.

16. • Needs an extra volume of 20-25 mL of LA.
• All the studies made have shown no significant phrenic
affection
• Incomplete blockade of the suprascapular nerve, which
has left the brachial plexus at this point so it need
supplemental local doses or analgesia.

17. The suprascapular nerve provides sensory fibers to
approximately 70% of the shoulder joint capsule. The
suprascapular nerve can either be blocked in the
suprascapular fossa or in the root of the neck distal to
where it arises from the superior trunk of the brachial
plexus.

18. • Axillary nerve arises from the posterior cord of the
brachial plexus. It can be identified and blocked below
the deltoid muscle on the back of the upper shaft of the
humerus.
• Least likely to produce phrenic affection
• Less effective especially in open surgeries due to
sparing of some of the shoulder innervation, so it can
be preserved to arthroscopic operations or in cases
where the ISB is contraindicated.

19. • The sparing of some of the innervation made the
axillary-suprascapular nerve blocks inferior to the
ISB.
• In a study carried out by Sandekoppam et al.
2016*, they relied in the fact that Innervation to
the shoulder joint usually travels through various
intermuscular planes before reaching the
shoulder identified by US.* Sondekoppam R., Lopera-Velasquez L., Naik L. et al. Subscapularis and sub-omohyoid plane
blocks: an alternative to peripheral nerve blocks for shoulder analgesia. BJA, Volume 117, Issue
6, December 2016, Pages 831–832.

20. • Applying this fact helped us to perform a plane block
below the inferior belly of omohyoid and the
subscapularis muscle that achieves better block than the
selective nerve block and also doesn’t affect the phrenic
nerve.
• The suprascapular nerve leaves the superior trunk close
to the supraclavicular fossa and travels in the posterior
triangle of the neck parallel to the inferior belly of the
omohyoid muscle to enter the suprascapular notch.

21. • The axillary nerve bifurcates into anterior
and posterior branches while traversing the
subscapularis muscle before winding
around the humerus. The plane block is
achieved by -5-10 mL of LA.

22. • Regional anesthesia is a good and reliable
alternative to general anesthesia in shoulder
surgeries especially in patients at risk.
• There are different options in regional anesthesia
in shoulder surgeries.
• Every choice has it’s advantages and
disadvantages regarding accessibility, efficacy and
side effects esp. phrenic nerve affection.
• After all we should remember that anesthesia and
airway are the closest friends, so if you feel
unsafe, save your airway.