|Year : 2019 | Volume
| Issue : 3 | Page : 175-178
Comparison between Supraclavicular and Interscalene Brachial Plexus Block in Patients Undergoing Shoulder Surgery
Roona Singh, Amol Singam
Department of Anaesthesiology, AVBRH Affiliated to Jawaharlal Nehru Medical College, Wardha, Maharashtra, India, India
|Date of Submission||10-Mar-2019|
|Date of Decision||25-Jul-2019|
|Date of Acceptance||15-Aug-2019|
|Date of Web Publication||2-May-2020|
Dr. Amol Singam
Department of Anaesthesiology, AVBRH Affiliated to Jawaharlal Nehru Medical College, Sawangi, Wardha - 442 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Interscalene approach of the brachial plexus block is considered the gold standard for shoulder anesthesia. However, this method is associated with a high incidence of side effects such as Horner's syndrome, phrenic nerve palsy and hoarseness of voice. The supraclavicular approach of the brachial plexus block is associated with a high success rate and provides anesthesia of the entire upper extremity in the most consistent, time-efficient manner. However, there is little information regarding its efficacy for providing analgesia for shoulder surgeries. This study was carried out to compare the success rate and complications associated with each technique. Materials and Methods: After the approval of Ethics Committee, this prospective, randomized comparative study was carried out on 60 American Society of Anesthesiologists Class I and II patients posted for elective and emergency shoulder surgeries. Sixty patients were randomly divided into two groups of 30 each, namely interscalene block (ISB) group and supraclavicular block (SCB) group. Both the blocks were given with 30 ml of 0.375% injection bupivacaine. Success rate, block performance time, patient requiring fentanyl, duration of analgesia and complications were noted. Results: The success rate and duration of analgesia were comparable in both the groups. Block performance time was significantly longer in SCB group as compared to ISB group. The requirement of intraoperative fentanyl was more in the SCB group. Complications such as Horner's syndrome, phrenic nerve palsy and hoarseness of voice were significantly higher in ISB group as compared to SCB group. Conclusion: SCB technique has an equal success rate and provides similar analgesic efficacy and duration of analgesia as ISB for shoulder surgeries. It is also associated with a lesser incidence of complications. SCB can thus be considered as a safe alternative to ISB for shoulder surgeries.
Keywords: Brachial plexus technique, Horner's syndrome, phrenic nerve palsy, shoulder surgery
|How to cite this article:|
Singh R, Singam A. Comparison between Supraclavicular and Interscalene Brachial Plexus Block in Patients Undergoing Shoulder Surgery. J Datta Meghe Inst Med Sci Univ 2019;14:175-8
|How to cite this URL:|
Singh R, Singam A. Comparison between Supraclavicular and Interscalene Brachial Plexus Block in Patients Undergoing Shoulder Surgery. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 May 28];14:175-8. Available from: http://www.journaldmims.com/text.asp?2019/14/3/175/283594
| Introduction|| |
There are several techniques for blocking the nerves of the brachial plexus such as supraclavicular, interscalene, axillary and infraclavicular approaches. Various surgeries on the shoulder such as total shoulder arthroplasty, hemiarthroplasty, shoulder arthroscopy, subacromial decompression and procedures such as rotator cuff repair are done either under general anesthesia or brachial plexus block. The interscalene approach for brachial plexus block is the gold standard for shoulder anesthesia and the most commonly used block for shoulder procedures. This approach blocks the brachial plexus at the nerve root or trunk level. Local anesthetic is directed toward C5–C6 nerve roots or the superior trunk. The block is especially useful for procedures involving the shoulder, including the lateral two-thirds of the clavicle, proximal humerus and shoulder joint. The supraclavicular approach for brachial plexus block is often called the “spinal anesthesia of the upper extremity“. The high success rate of this block can be attributed to its anatomic characteristics. The block is performed at the level of the distal trunks and origin of the divisions where the brachial plexus is confined to its smallest surface area. This compactness may explain the reason for the block's historical reputation for providing anesthesia of the entire upper extremity in the most consistent, time-efficient manner of any brachial plexus block technique. This study aimed to compare both the approaches for brachial plexus in patients posted for surgeries around the shoulder. The primary outcome measured was the comparison of success rate, whereas secondary outcomes measured were block performance time, duration of analgesia and complications associated with each technique.
| Materials and Methods|| |
After obtaining the Ethics Committee approval and written informed consent, this prospective, randomized, comparative study was carried out in the Department of Anaesthesiology AVBRH affiliated to JNMC Sawangi (Meghe), Wardha, Maharashtra, India, during the period between August 2016 and August 2017.
Sixty adult patients of either sex belonging to the American Society of Anesthesiologists (ASA) physical status I and II in the age range of 20–70 years scheduled to undergo surgeries of the shoulder either elective or emergency were included in the study. The patients were explained about the procedure and the advantages of postoperative pain relief with this technique. Patients with known hypersensitivity to the study drug, obstetric population, patients on anticoagulants or altered coagulation profile, patients with infection at the site of block and local bony deformity, patients with documented evidence of preoperative hemidiaphragmatic paresis, ptosis and preoperative hoarseness of voice were excluded from the study. Informed consent was obtained and local anesthetic sensitivity testing was done.
Patients were randomly allocated into two equal groups of 30 each. Randomization was done by computer-generated random number table and allocation of the same by the sealed envelope technique. These envelopes were opaque with the patient's registration number mentioned outside. A paper slip inside them indicating either interscalene block (ISB) group or supraclavicular block (SCB) group. After the patient arrived in the OT complex, the numbered envelope was handed over to an anesthesiologist performing the block who was not taking part in the study. He/she opened the envelope and administered either of the blocks to the patients.
There were two groups, namely ISB group and SCB group. Both the blocks were given with 30 ml of 0.375% injection bupivacaine using a 22 G 5 cm insulated needle. The nerve locator used was B Braun Stimulpex Dig Rc. After arrival in operation theater, an intravenous (IV) line with 18 G cannula was secured in the opposite upper limb. Monitors were attached and preoperative pulse rate, respiratory rate, and blood pressure were noted. Preoperative sedation was deliberately avoided to minimize interference during the assessment of the quality of block and postoperative pain relief.
For the SCB, the patients were placed supine and the lateral border of the sternocleidomastoid was identified, the fingers were slowly moved laterally to feel the anterior and medial scalene muscles and the groove between them was appreciated. A point 1.5–2 cm above the clavicle was marked in the groove where the anterior scalene could be palpated; pulsation of the subclavian artery was identified; and the Stimuplex needle was inserted in a backward, medial and posterior direction. Flexion and extension movement at the wrist at 0.4 mA was taken as the endpoint and local anesthetic was injected.,
For ISB, the patients were placed in the supine position and cricoid cartilage was located. A horizontal plane extending laterally from the cricoid cartilage and intercepting the posterior border of sternocleidomastoid was established which indicates the transverse process of the sixth cervical vertebra. The fingers were then rolled back until they fell into the interscalene groove. The stimuplex needle was inserted perpendicular to the skin with a 45° caudate and slightly posterior angle. Movements at the tricep at 0.4 mA were taken as the endpoint and the local anesthetic solution was injected.,
Ten minutes after giving the block, sensory block assessment was done over four major nerve distribution area (radial, ulnar, median and musculocutaneous) on a three-point scale (0 – normal sensation; 1 – analgesia, blunt sensation; and 2 – anesthesia, no sensation). Motor blockade was evaluated by rating the muscle contraction forces corresponding 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). Block success was defined as sensory score of 2 in all the four nerve dermatomes and motor block score of 1, i.e. complete paralysis of muscles supplied by all the four nerves. After injection, the block was assessed and the surgery was allowed to proceed. If 30 min after giving the block, the sensory and motor block were inadequate and had to be supplemented with general anesthesia, then the block was considered to have failed. Block performance time was defined as the time from sterile skin preparation to the termination of injection and removal of nerve stimulator needle. Intraoperatively if patient complained of pain, it was managed by giving injection fentanyl 2 μg/kg IV. Duration of surgery was defined as the time from incision till closure of the skin. Ten minutes after giving the block, all the patients were evaluated for any complication related to the block. Horner's syndrome was checked by looking for ptosis, miosis and anhidrosis; phrenic nerve palsy was evaluated by looking for bilateral excursion of the chest wall; vascular puncture was confirmed if there was visible blood in the syringe or any hematoma at the site of the block and hoarseness of voice was checked by talking to the patient.
The severity of postoperative pain was evaluated on the basis of the Visual Analog Scale (VAS) (0–10), where 0 indicates no pain and 10 indicates worst possible pain. When the VAS >4 rescue analgesia was given in the form of injection diclofenac 1.5 mg/kg/im. The duration of analgesia was taken as time from the onset of sensory block till the patient required first rescue analgesic.
A study power 80% and alpha level of 0.05 sample size were calculated for two groups. The sample size aimed was 60 patients, with 30 patients in each group; all the data were entered into the Excel sheet. Quantitative data were expressed as mean ± standard deviation. Qualitative data were expressed as percentage. Statistical analysis was performed by using the descriptive and inferential statistics using the Chi-square test and Student's unpaired t-test. Software used in the analysis was SPSS 22.0 version and Graph Pad Prism 6.0 version and P < 0.05 was considered as the level of statistical significance.
| Results|| |
There was no statistically significant difference among the patients in two groups, with respect to age, weight, duration of surgery, gender and ASA physical status. [Table 1] shows the demographic data.
[Table 2] shows success rate, block performance time, patient requiring fentanyl and duration of analgesia. The success rate was comparable between the two groups. Block performance time was significantly more in the SCB group. The number of patients who required intraoperative fentanyl was more in SCB group compared to ISB group, but it was statistically insignificant. The duration of analgesia was not statistically different between the two groups.(715.32 ± 25.27 min for ISB group and 725.44 ± 15.58 min for SCB group).
|Table 2: Success rate, block performance time, patient requiring fentanyl, and duration of analgesia|
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[Table 3] shows the complications such as Horner's syndrome, phrenic nerve palsy and hoarseness of voice. Horner's syndrome and phrenic nerve palsy were significantly higher in ISB group as compared to SCB group. The incidence of hoarseness of voice was 17.8% and 0% in ISB and SCB group respectively, which was also statistically significant. No vascular puncture was seen in any of the groups.
| Discussion|| |
SCB is indicated in the surgeries below the shoulder, as SCB is performed at more caudal level than ICB, the proximal nerve branches including the suprascapular neve and the cervical plexus which supply the shoulder joint tend to be spared. Recent studies have demonstrated the effectiveness of SCB for shoulder surgeries., The probable explanation for adequate surgical analgesia provided by the SCB for shoulder surgeries is the cephalad migration of the drug between the anterior and middle scalene muscle due to the “chimney effect.“ Abdelhaq et al in their study used 20 ml, 15 ml and 10 ml local anesthetic solution in ultrasonography (USG)-guided ISB and SCB and found that the onset of sensory and motor block and duration of analgesia and motor block were maximum with 20 ml drug. Since we have not used US guidance, a dose of 30 ml was used in our study. The success rate of the blocks was comparable in both the groups which corresponds to the study conducted by Kim et al. Procedural time was found to be more in the SCB group in the study conducted by Ryu et al, which is similar to our findings. The number of patients requiring intraoperative fentanyl was equal in both the groups which was also the outcome of the study conducted by Weisman et al. The duration of analgesia was not statistically different between the groups, with results of 725.44 ± 15.58 min for the SCB group versus 715.32 ± 25.27 min for the ISB group, which is in accordance with previous study Wiesmann et al and Kim et al and Kim et al. compared the SCB and the ISB regarding analgesic quality for shoulder surgery and concluded that both blocks provided comparable pain relief during the first 24 h after surgery. The incidence of Horner's syndrome was significantly higher in ISB group as compared to SCB group. Our findings were confirmed by the results of the studies done by Auyong et al and Koh et al. The phrenic nerve is in close proximity to the brachial plexus at the cricoid cartilage level and separates more anteriorly, moving away from the brachial plexus as it travels caudally. The incidence of hemidiaphragmatic paresis after single SCB is reported to be lower than after ISB which was statistically significant. The incidence of hoarseness of voice was more with ISB group compared to SCB group but was statistically significant, which coincides with the results obtained in the previous study by Liu et al. There was no incidence of vascular puncture in both groups.
This study has various limitations. First, the use of USG may have helped us to use smaller volume of drug and visualization of the diaphragmatic function before and postblock. Second, pulmonary function test could have helped us to quantify the reduction in ventilatory function after the block. Third, the intraoperative fentanyl use was not taken into consideration which could have influenced the duration of analgesia.
| Conclusion|| |
The SCB technique has an equal success rate and provides similar analgesic efficacy and duration of analgesia as ISB for shoulder surgeries. Although SCB requires longer procedural time, but it is associated with a lesser incidence of side effects such as Horner's syndrome, hoarseness of voice and hemidiaphragmatic paralysis compared to ISB. Therefore, SCB can be used as an alternative for shoulder surgeries, especially those with respiratory disease.
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Conflicts of interest
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