We read with interest the review article by Dr Fredrickson and colleagues and the accompanying editorial about postoperative analgesia for shoulder surgery [1-2].

We were extremelysurprised that, in both these articles, no mention was made of ultrasound-guided supraclavicular brachial plexus blockade for both arthroscopic and open shoulder surgery. This block is easy to learn and perform and has been successfully used in our shoulder centre for over 2000 shoulder procedures. Complete analgesia lasting up to 24 hours with a single injection is normal and local anaesthetic infusions are rarely required.

Complications include one pneumothorax (after a block performed by a trainee under supervision) and one case of bronchospasm in a patient with severe pre-existing respiratory disease.

We feel that recommendations for optimal postoperative pain relief following shoulder surgery cannot be made without considering this widely used block.

F Subash

P Hilton 

Morriston Hospital,

Swansea, UK

References

1     Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia 2010; 65: 608-24.

2     Hadzic A, Gadsden J, Shariat AN. Local and nerve block techniques for analgesia after shoulder surgery. Anaesthesia 2010; 65: 547-8.

We thank Drs Subash and Hilton forsharing their collective shoulder surgery experience with the readership.

As described in our review, analgesia for shoulder surgery requires blockade of the suprascapular, axillary and lateral pectoral nerves. If the objective is blockade of these nerves, the logical site to deposit local anaesthetic along the brachial plexus is at the level of the sixth-seventh cervical vertebrae (i.e. interscalene level): placement further distally potentially spares the origin of the suprascapular nerve at the proximal superior trunk. Although the supraclavicular approach may be associated with a reduction in phrenic nerve block related side effects (dyspnoea) [1], problematic distal motor block (hand paralysis) has been observed, possibly due to the tightly grouped nature of the supraclavicular brachial plexus at this location; and accumulating evidence points to an inverse relationship between motor block and patient satisfaction [2-3]. Furthermore, the authors correctly acknowledge a theoretically higher risk of pneumothorax with the supraclavicular approach. Interscalene and supraclavicular block duration have not been compared in a prospective randomised manner, but if data is extrapolated from other brachial plexus locations [4], any difference is unlikely to be of clinical relevance for postoperative analgesia.

Subash and Hilton’s experience with single injection supraclavicular block is quiteexceptional – in particular that “local anaesthetic infusions are rarely required” for procedures presumably including (painful) open rotator cuff repair. Their practice highlights how protocols can be strikingly different between centres: continuous interscalene analgesia has been used in Auckland (population 1.5 million) since 2003, and is now the standard of care here for rotator cuff repair, which is in keeping with the nine identified randomised trials comparing continuous with single injection techniques for this surgery [5]. The move, where possible, from single injection blocks to continuous techniques, was the main conclusion drawn from the evidence reviewed [5].

We would urge Subash and Hilton to perform a prospective study in patients having rotator cuff repair at their institution, specifically questioning patients for pain during postoperative days one and two. If the analgesia is as good as suggested, this would contradict th eaforementioned evidence. Further elaboration of their regional anaesthetic technique might then be warranted, which may be of great value to the anaesthetic community.

M. Fredrickson

S. Krishnan

C. Chen

University of Auckland, New Zealand

Competing interests (MF, research support –Surgical Synergies Ltd). 

References

1.           DiMeoC, Cameron A, Cook C, Zayas V, Marcello D. Supraclavicular vs. interscalene brachial plexus block for shoulder surgery. ASRA Spring Meeting 2010; A12(http://www.asra.com/display_spring_2010.php?id=314).

2.           Fredrickson MJ, Price DJ. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. British Journal of Anaesthesia 2009; 103: 434-9.

3.           Fredrickson MJ, Smith KR, Wong AC. Importance of volume and concentration for ropivacaine interscalene block in preventing recovery room pain and minimizing motor block after shoulder surgery. Anesthesiology; 112: 1374-81.

[4]            Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia:essentials of our current understanding, 2008. Regional Anesthesia and Pain Medicine 2009; 34:134-70.

[5]            Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia 65: 608-24.