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Background Proximal humeral fractures are commonly encountered in the emergency department (ED). These injuries are often associated with significant pain, with patients often receiving multiple doses of opiate medications while awaiting definitive management. The interscalene nerve block has been efficacious as perioperative analgesia for patients undergoing operative shoulder repair. The utilization of the interscalene nerve block in the ED for proximal humeral fractures is largely unexplored. Discussion We report the use of an ultrasound-guided interscalene nerve block in the ED for a patient presenting with significant pain from a proximal humerus fracture. The procedure provided excellent regional anesthesia with no additional need for intravenous or oral opiates during the rest of her ED course. With the significant risks associated with pain medication, particularly opiates, regional anesthesia may be an excellent option for the appropriate patient in the ED. Conclusions As documented in this report, the ultrasound-guided interscalene block, in particular, may be utilized as a means to provide adequate pain control for patients with proximal humerus fractures in the ED.

To compare the efficacy of a subacromial injection (SAI) with a single-shot interscalene block (ISB) for immediate postoperative pain relief after outpatient arthroscopic rotator cuff repair (ARCR).We performed a retrospective chart review of consecutive patients who underwent ARCR. Patients received either an ISB before the procedure or an SAI after the procedure. Preoperative baseline patient characteristics were collected and compared. Visual analog scale (VAS) pain scores were recorded preoperatively, at 15-minute intervals over a 120-minute period in the postanesthesia care unit (PACU), and at discharge. Differences in VAS scores between groups were compared with known values of the minimal clinically important difference, and the percentage of patients with VAS scores below the patient acceptable symptom state was tabulated. Differences between preoperative characteristics were assessed using the Mann-Whitney U, Fisher exact, or χThe median VAS score was significantly lower in the ISB group at PACU admission, at all intervals throughout the PACU stay, and at discharge (P.0001). The median total time in the PACU was 107 minutes (25th percentile-75th percentile, 90-120 minutes) and 210 minutes (25th percentile-75th percentile, 175-274 minutes) in the ISB and SAI groups, respectively (P.0001). Between-group differences in VAS scores were greater than the values of the minimal clinically important difference at each measured interval. A total of 98% and 67% of patients in the ISB and SAI groups, respectively, were discharged with VAS scores below the patient acceptable symptom state of 3.Patients receiving an ISB experience significantly less pain than those receiving an SAI. In addition, they are discharged home from the PACU in half the time as patients receiving an SAI. On the basis of the comparative efficacy, an SAI cannot replace an ISB after ARCR. The ISB should therefore remain the standard of care as an adjunct to postoperative analgesia for patients who undergo outpatient ARCR.Level III, retrospective, comparative therapeutic trial.

Interscalene brachial plexus block has been widely used in shoulder surgery. We report one case of long-term phrenic palsy following ultrasound-guided interscalene brachial plexus block and we will discuss the possible etiology and mechanism of this disability. For painful shoulder surgery, ultrasound-guided interscalene brachial plexus block remains topical. Alternative blocks, such as suprascapular and axillary blocks, may be reserved for patients with pre-existing respiratory pathology.

Resumen Introduccion La paralisis diafragmatica es un efecto indeseable clasicamente asociado al bloqueo interescalenico. De forma reciente ha sido introducido en clinica el indice del grosor del musculo diafragma (grosor inspiratorio/grosor espiratorio) obtenido mediante ecografia como herramienta diagnostica en la paralisis cronica y atrofia del musculo diafragma. Nuestro objetivo fue evaluar este indice para el diagnostico de paresia frenica aguda asociada al bloqueo interescalenico. Pacientes y metodos Disenamos un estudio observacional descriptivo en 22 pacientes programados para artroscopia de hombro. Se les realizo una espirometria forzada (se considero paresia frenica un descenso del FVC y FEV1 ≥20%), se identifico la zona de aposicion en la linea axilar anterior y se evaluo el desplazamiento diafragmatico en inspiracion y espiracion maximas (n.° de espacios intercostales; se considero paresia frenica una reduccion ≥25%) y el grosor del musculo diafragma (se considero paresia frenica un indice Resultados Veintiun pacientes (95%) presentaron bloqueo del nervio frenico segun alguno o varios de los metodos empleados. Un paciente no manifesto ningun sintoma ni signo sugestivo de paralisis frenica y fue excluido del analisis posterior. Todos los pacientes presentaron paresia frenica con base en el indice del grosor diafragmatico, con un indice prebloqueo de 1,8 ± 0,5 y posbloqueo de 1,05 ± 0,06 (p Conclusion El indice del grosor diafragmatico en inspiracion/espiracion

Introduction Dexmedetomidine prolongs sensory block of ropivacaine. Our objective was to study whether this extension would produce better postoperative pain control compared to that produced by clonidine in patients undergoing arthroscopic shoulder. Materials and methods A comparative, longitudinal, controlled, randomised study into 3 groups. Control group I: ropivacaine 0.75% clonidine, group II: 0.75% ropivacaine plus clonidine 1 mg/kg, group III dexmedetomidine: 0.75% ropivacaine plus dexmedetomidine 1 mg/kg. Interscalene block single dose ultrasound-guided. Sensory and motor blockade, pain intensity, sedation level, heart rate, respiratory rate, blood pressure at 6, 12 and 24 h were measured. Results Pain intensity at 6 h in groups I and II showed moderate to severe pain, and mild pain in group III. At 12 h the groups I and II showed moderate to severe pain by more than 60% of patients, and in group III only 10%. At 24 h groups I and II showed 20% of patients continued with moderate pain. Conclusion The prolonged interscalene block produced by dexmedetomidine provided better postoperative pain control during the first 24 h.

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.

Idiopathic adhesive capsulitis, or primary frozen shoulder syndrome, is a fairly common orthopaedic problem characterized by shoulder pain and loss of motion. In most cases, conservative treatment (6-month physical therapy program and intra-articular steroid injections) improves symptoms and restores shoulder motion. In refractory cases, arthroscopic capsular release is indicated. This surgical procedure carries several advantages over other treatment modalities. First, it provides precise and controlled release of the capsule and ligaments, reducing the risk of traumatic complications observed after forceful shoulder manipulation. Second, release of the capsule and the involved structures with a radiofrequency device delays healing, which prevents adhesion formation. Third, the technique is straightforward, and an oral postoperative steroid program decreases pain and allows for a pleasant early rehabilitation program. Fourth, the procedure is performed with the patient fully awake under an interscalene block, which boosts the patient's confidence and adherence to the physical therapy protocol. In patients with refractory primary frozen shoulder syndrome, arthroscopic capsular release emerges as a suitable option that leads to a faster and long-lasting recovery.

Resume Le bloc interscalenique est la technique de reference pour l’analgesie postoperatoire apres chirurgie de l’epaule. La liste des effets indesirables comprend : ponction pleurale et pneumothorax, introduction de l’aiguille dans un trou de conjugaison cervical avec risque de bloc neuroaxial, lesions traumatiques des racines cervicales, insuffisance respiratoire sur paralysie diaphragmatique par anesthesie du phrenique, voix enrouee, bradycardie et hypotension. Ce bloc est contre-indique chez les patients ayant une atteinte de la fonction pulmonaire. La reduction des doses d’anesthesique local constitue une adaptation du bloc. Les alternatives sont le bloc supraclaviculaire, le bloc suprascapulaire ± axillaire et l’analgesie intra-articulaire sur catheter. Le bloc supraclaviculaire a les memes limites que le bloc interscalenique, avec un risque de paresie phrenique. L’injection intra-articulaire ne peut pas etre recommandee en raison d’un effet analgesique faible et d’un risque de chrondrolyse gleno-humerale.

Estimation of cerebral perfusion pressure during elective shoulder surgery in the beach chair position is regularly performed by noninvasive brachial blood pressure (NIBP) measurements. The relationship between brachial mean arterial pressure and estimated temporal mean arterial pressure (eTMAP) is not well established and may vary with patient positioning. Establishing a ratio between eTMAP and NIBP at varying positions may provide a more accurate estimation of cerebral perfusion using noninvasive measurements.This prospective study included 57 patients undergoing elective shoulder surgery in the beach chair position. All patients received an interscalene block and general anesthesia. After the induction of general anesthesia, values for eTMAP and NIBP were recorded at 0°, 30°, and 70° of incline.A statistically significant, strong, and direct correlation between NIBP and eTMAP was found at 0° (r = 0.909, P ≤ .001), 30° (r = 0.874, P .001), and 70° (r = 0.819, P .001) of incline. The mean ratios of eTMAP to NIBP at 0°, 30°, and 70° of incline were 0.939 (95% confidence interval [CI], 0.915-0.964), 0.738 (95% CI, 0.704-0.771), and 0.629 (95% CI, 0.584-0.673), respectively. There was a statistically significant decrease in the eTMAP/NIBP ratio as patient incline increased from 0° to 30° (P .001) and from 30° to 70° (P .001).The eTMAP-to-NIBP ratio decreases as an anesthetized patient is placed into the beach chair position. Awareness of this phenomenon is important to ensure adequate cerebral perfusion and prevent hypoxic-related injuries.

Purpose This study was conducted to test whether blocking the serotonin receptors by intravenous [IV] ondansetron; can help in reducing the hypotensive bradycardic events [HB events] associated with shoulder arthroscopy done in the sitting position under interscalene plexus block [ISB]. Methods One hundred and fifty patients, scheduled for shoulder arthroscopy in the sitting position under ISB, were randomly assigned to one of three groups receiving either: 4 mg ondansetron, or 8 mg ondansetron or saline. Results IV injection of ondansetron 4 mg or 8 mg significantly reduced the incidence of HB events from 20.4% in the saline group to 6.1% after injection of 4 mg ondansetron and 6% after injection of 8 mg ondansetron; p value [0.030]. Conclusion IV ondansetron either 4 mg or 8 mg reduces the HB events during shoulder arthroscopy in the sitting position under ISB.

Background Pain after shoulder surgery is often treated with interscalene nerve blocks. Single-injection blocks are effective, but time-limited. Adjuncts such as dexamethasone may help. We thus tested the hypothesis that adding dexamethasone significantly prolongs the duration of ropivacaine and bupivacaine analgesia and that the magnitude of the effect differs among the two local anaesthetics. Methods In a double-blinded trial utilizing single-injection interscalene block, patients were randomized to one of four groups: (i) ropivacaine: 0.5% ropivacaine; (ii) bupivacaine: 0.5% bupivacaine; (iii) ropivacaine and steroid: 0.5% ropivacaine mixed with dexamethasone 8 mg; and (iv) bupivacaine and steroid: 0.5% bupivacaine mixed with dexamethasone 8 mg. The primary outcome was time to first analgesic request after post-anaesthesia care unit discharge. The Kaplan–Meier survival density estimation and stratified Cox's proportional hazard regression were used to compare groups. Results Dexamethasone significantly prolonged the duration of analgesia of both ropivacaine [median (inter-quartile range) 11.8 (9.7, 13.8) vs 22.2 (18.0, 28.6) h, log-rank P Conclusions Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that of bupivacaine, the combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia.

Previous studies have demonstrated that lower local anaesthetic (LA) volumes can be used for ultrasound (US)-guided interscalene brachial plexus block (ISB). However, no study has examined whether US can reduce the volume required when compared with nerve stimulation (NS) for ISB. Our aim was to do this by comparing the minimum effective analgesic volumes (MEAVs).After ethics approval and informed consent, patients undergoing shoulder surgery were recruited to this randomized, double-blind, up-down sequential allocation study. The volume used for both US and NS was dependent upon the success or failure of the previous block. Success was defined as a verbal rating score of 0/10, 30 min after surgery. Ten needle passes were allowed before defaulting to the opposite group. Patients received general anaesthesia. Pain scores and analgesic consumption were assessed by a blinded observer. Statistical comparisons of continuous variables were performed using Student's t-test and Mann-Whitney U-test as appropriate. Categorical variables were analysed using χ² test. MEAV values were estimated using log-transformed up-down independent pairs analysis and probit regression. Significance was assumed at P0.05 (two-sided).The MEAV required to provide effective analgesia was significantly (P=0.034) reduced to 0.9 ml [95% confidence interval (CI) 0.3-2.8] in the US group from 5.4 ml (95% CI 3.4-8.6) in the NS group. Fewer needle passes were needed to identify the brachial plexus with US (1 vs 3; P0.0001) and patients had less pain at 30 min after surgery (P=0.03).US reduces the number of attempts, LA volume, and postoperative pain when compared with NS for ISB.

Resume Objectifs La region interscalenique presente de nombreuses variations anatomiques. L’objectif principal de cette etude est d’evaluer la mise en evidence de ces variations en echographie par l’anesthesiste. L’objectif secondaire est de comparer la reussite du bloc interscalenique (BIS) en presence ou non d’une variation. Type d’etude Etude retrospective, descriptive, conduite dans deux hopitaux universitaires. Patients et methodes Cent quarante-six echographies de cou realisees chez 27 volontaires et 46 patients etaient relues, a posteriori, a la recherche de variations anatomiques de la region interscalenique. Les 46 patients, operes de l’epaule, ont eu un BIS analgesique en une injection. Durant les 30 premieres minutes, les blocs sensitifs et moteurs etaient compares en presence ou non d’une variation. Resultats Quarante-neuf pour cent (71/146) des regions presentaient une variation visible en echographie. Trente-trois pour cent (48/146) presentaient un passage intramusculaire d’une racine, 8 % (12/146) possedaient une racine C5 anterieure au muscle scalene anterieur et 23 % (33/146) une artere passant entre les racines ou troncs. Trente-sept pour cent (54/146) presentaient un vaisseau au contact du plexus pouvant gener l’approche de l’aiguille. Sur les 46 BIS realises, la presence d’une variation n’a pas entraine de difference significative sur les blocs sensitifs et moteurs a la trentieme minute (p > 0,05). Conclusion L’echographie a permis de mettre en evidence de nombreuses variations anatomiques de la region interscalenique. Ces variations ne semblaient pas avoir d’influence sur l’extension anesthesique du BIS en une injection.

Study Objective To report the results of single and continuous interscalene blocks (ISB) performed using ultrasound (US) guidance only. Design Prospective, observational study. Setting Operating room of a university-affiliated orthopaedic hospital. Patients 200 ASA physical status I, II, and III patients undergoing shoulder or elbow surgery. Interventions Single or continuous ISB were placed using US guidance only. All blocks were performed by anesthesiology residents and supervised by faculty anesthesiologists. Measurements Success rate and frequency of untoward events such as needle paresthesia, vessel puncture, infection, and persistent neurologic deficits were prospectively recorded. Main Results 99% of patients reported sensory and motor changes in the distribution of the brachial plexus and postoperative pain scores ≤ 2. The rates of needle paresthesia and vessel puncture were 6% and 1%, respectively. Two patients (1%) reported transient neurologic deficits. No signs or symptoms of infection or intravascular injection were noted. There were also no permanent neurologic deficits. Conclusions In this group of 200 consecutive patients, the success rate for postoperative analgesia using US guidance only was 99%. Untoward events such as needle paresthesia and persistent neurologic deficits were lower than existing data on nerve stimulation and paresthesia techniques. Ultrasound can be successfully used as a "stand alone" method to perform ISB.

Study Objective To determine whether interscalene brachial plexus block (ISB) provides adequate anesthesia for surgery on or about the elbow. Study Design Case series. Setting Operating room of an academic teaching hospital. Patients 78 patients scheduled for elective elbow surgery. Interventions All patients received an ISB using a low approach technique. A stimulating needle was inserted in the interscalene groove two cm above the clavicle. A volume of 35-45 mL of mepivacaine 1.5% or ropivacaine 0.5% was administered after obtaining a motor response of any component of the brachial plexus with a current intensity of 0.2-0.4 mA (0.1 msec). Measurements Block success rate, defined as the ability to complete surgery without use of intraoperative opioids or general anesthesia, was assessed. Verbal rating scores for pain (0 = no pain, 10=worst pain imaginable) were obtained in the recovery room. Main Results Low ISB resulted in successful surgical anesthesia in 75 (96%) of the study patients. Verbal rating scores were low (0-2) for all patients postoperatively. Conclusions The low interscalene block can be used to provide surgical anesthesia in the majority of patients having surgery on or about the elbow.

Winnie first described the technique of interscalene block more than thirty years ago. Percutaneous electrode guidance (PEG) of the block needle is a recently published technique that incorporates transcutaneous stimulation of an underlying nerve or plexus to prelocate the targeted nerve or nerves. PEG has been used to perform interscalene block. PEG has the potential to simplify or narrow the search for the brachial plexus during interscalene block. Transcutaneous stimulation of the most superficial nerve roots, C5 and C6, are easy to perform at the interscalene level. The block needle is subsequently guided through the cutaneous electrode. PEG has the potential to help prevent complications such as pneumothorax, phrenic nerve injury, or spinal cord injury. The technique for PEG-assisted interscalene block is presented in detail. © 2003 Elsevier Inc. All rights reserved.

Early and efficient rehabilitation is necessary for improving outcome after shoulder surgery. Pain, which is severe to very severe in this condition, is the major factor which compromises early physical therapy. Interscalene block is a well recognized and efficient technique for controlling pain after major open shoulder surgery. Among the different approaches which have been described, the modified lateral technique is the safest to perform and the most suitable for insertion of an interscalene catheter. A number of different techniques have been tried to control pain after shoulder surgery. However, the application of a continuous infusion of local anaesthetics through an interscalene catheter is actually the best technique available to achieve pain relief at rest and on movement after this type of surgery. This chapter emphasizes the advantages of the modified lateral approach, the use of patient-controlled interscalene analgesia and the traps and tricks of the interscalene block. Thus, this chapter demonstrates why interscalene anaesthesia and analgesia are the most appropriate techniques for shoulder surgery.

Management of acute post-operative pain due to shoulder surgery may be successfully and consistently achieved in ambulatory patients by using continuous interscalene block. This chapter outlines the anterior and posterior approaches to the proximal brachial plexus and describes a method of precisely placing a catheter along the brachial plexus by stimulating the plexus through the needle used for placing the catheter as well as through the catheter itself. A technique for securing the catheter by subcutaneous tunneling to prevent dislodgement is also described. Suggested drugs and dosages for initial boluses, continuous infusions and patient controlled interscalene analgesia are discussed. Sedation for block placement, and special precautions, are outlined.

The case of a 43 year-old woman who underwent successful right interscalene brachial plexus block for arthroscopic shoulder surgery is presented. During the surgery, she subsequently exhibited signs of neuraxial spread of local anesthetic. Bilateral motor block was noted postoperatively. Spontaneous ventilation was maintained throughout the case, and she was successfully discharged home several hours after the procedure with no residual symptoms.

are common complications of the procedure. This study presents 9 cases of unusual complications of shoulder arthroscopy: 8 from the senior authors (M.G.H. and A.D.S.), whose experience includes more than 4000 shoulder arthroscopies, and 1 referral from another institution. Some of these complications are difficult to attribute to the surgical procedure. They are, however, undesirable sequelae, and we believe that they should be reported. Our standard practice in all cases of shoulder arthroscopy, unless there are specific contraindications, is to administer a general anesthetic and, frequently, an interscalene block. We perform shoulder arthroscopy with the patient in the lateral decubitus position, supported by a deflated bean bag. The arm is suspended by means of a 4-kg weight through use of single overhead traction applied through nonadhesive forearm skin traction. Our irrigation fluid is water in 1000-mL bags, 0.5 mL of 1:1000 adrenalin being added to each bag. We use a hand pump to assist in distension when it is required. Our 3 standard portals are the posterior, anterior, and lateral portals. We routinely perform electrosurgery with a diathermy unit (Valleylab Inc, Boulder, Colo). There was no deviation from our standard practice in any of the cases described in this article, except as specifically noted in the individual case histories.

We present two cases in which an ultrasound-guided interscalene block was immediately effective for severe postthoracotomy ipsilateral shoulder pain. The block resulted in no related complications, and it provided long-lasting relief and a high degree of patient satisfaction.

Summary A persistent phrenic palsy after interscalene block is a rare but possibly severe complication particularly in patients with previous lung function impairment or co-morbidities. We report the case of a patient, with a past history of post-traumatic diaphragmatic eventration, who presents a persistent respiratory insufficiency leading to long term non-invasive ventilation following interscalene block for rotator cuff shoulder surgery. A preoperative careful evaluation of patients addressed to interscalene block could avoid such long term complications.

The interscalene block (ISB) of the brachial plexus is a common technique for anaesthesia and the treatment of postoperative pain in shoulder surgery. Despite the well-known advantages of this technique, it is not without risks that need to be identified and taken into account. The most frequent complications associated with it are of a neurological nature and most are transient. It has been shown that the use of nerve stimulation does not guarantee a safe block. Ultrasound guidance now makes it possible to visualise potentially dangerous structures, thus allowing us to reduce the risk of associated complications. We present the case of a patient with transient dysphonia secondary to recurrent laryngeal nerve palsy. We also discuss briefly the most common complications associated with the technique.

A case study is presented involving a 22-year-old male who developed total spinal anesthesia after interscalene blockade for an arthroscopic procedure of the shoulder. An understanding of the anatomical structures of the brachial plexus, autonomic nervous system function, and side effects of local anesthetics is presented to assist the perianesthetic nurse in assessing and anticipating patient needs and in clinical decision making.

A prospective study of 43 patients undergoing day case open shoulder surgery under general anaesthesia was performed. All patients received an interscalene block for post-operative analgesia. Pre and post-operative pain scores, time to first dose of analgesia and patient satisfaction were recorded. Interscalene blockade provided good pain relief for up to 12 h in the majority of patients. Two patients were admitted due to inadequate pain relief and one complication of interscalene block was recorded.

Resume Un cas de penetration accidentelle dans l'espace peridural cervical d'un catheter plexique, mis en place par voie interscalenique pour l'analgesie postoperatoire, apres cure chirurgicale d'une rupture de la coiffe des rotateurs, est rapporte. Aucun signe de penetration peridurale d'anesthesique local n'est apparu a la premiere injection, car celle-ci avait ete faite a travers l'introducteur du catheter. L'opacification de celui-ci avant la deuxieme injection permit d'objectiver la position peridurale de son extremite et d'eviter un accident. Deux des trois moyens de prevention de cette complication n'avaient pas pu etre respectes : a) mise en place du catheter avant l'induction de l'anesthesie generale, lorsque les conditions de ponction sont les meilleures (patient conscient, donc capable de signaler douleurs et dysesthesies, absence de gene par le pansement) ; b) orientation correcte de l'aiguille lors de la ponction (vers l'arriere, le dedans et surtout vers le bas) ; c) opacification systematique avant la premiere injection a travers le catheter et surveillance clinique attentive durant les 30 min suivant chaque injection.