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Combined ultrasound-guided infraclavicular & suprascapular nerve block in a patient with advanced lung disease and neck contracture for analgesia after total shoulder arthroplasty
Interscalene blockade (ISB) is a commonly utilized and effective technique for analgesia after total shoulder arthroplasty. Safe and successful block can be challenging in patients with poor neck motion. Additionally, the risk of ipsilateral phrenic nerve paralysis, with a reported incidence up to 100%, may be detrimental to patients with poor pulmonary reserve1. We report successfully combining infraclavicular and suprascapular nerve blocks under ultrasound guidance in a patient with advanced lung disease and neck contracture for total shoulder arthroplasty.
Materials and methods
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A 67 year old man presented for right-sided total shoulder arthroplasty with multiple medical issues, including right-sided hemiparesis, neck contractures and limb spasticity, as a result of a traumatic brain injury. His pulmonary history included chronic obstructive pulmonary disease, restrictive lung disease from thoracic kyphosis, bronchiectasis, neuromuscular weakness and obstructive sleep apnea. Prior to surgery, intensity of pain in his right shoulder was rated 9/10 on the numeric rating scale (NRS), treated with acetaminophen and tramadol. Given the limitations of performing an ISB, ultrasound-guided infraclavicular and suprascapular nerve blocks were opted for preoperatively. After appropriate monitoring and sedation, paracoracoid infraclavicular block was performed with single injection of 15 milliliters 0.5% bupivacaine with epinephrine and 25 micrograms dexmedetomidine (image 1). Next, suprascapular nerve block was performed at the suprascapular notch with single injection of 10 milliliters 0.5% bupivacaine with epinephrine and 25 micrograms dexmedetomidine (image 2). The patient subsequently underwent the procedure under general anesthesia uneventfully. The incision site was infiltrated with 0.25% ropivacaine during wound closure. The patient was extubated and transported to the postanesthesia care unit requiring minimal oxygen, where he reported an NRS score of 0/10 and received no additional pain medication. Blockade in the infraclavicular distribution from ipsilateral deltoid to fingers was evident and persisted 24 hours postoperatively. The patient resumed his regimen of tramadol and tylenol postoperative day 1, rating discomfort in his right shoulder as 4-6/10. No respiratory events or complications occurred throughout hospitalization, and the patient was discharged postoperative day 2.
Due to limitations of ISB, alternative techniques for analgesia after shoulder surgery have been described, including “diaphragm-sparing” blocks. Strategies include using low concentration and/or volume of local anesthetic for brachial plexus block, selective nerve root blockade, local infiltration analgesia, and combining brachial plexus blocks with suprascapular nerve block2. Combining selective axillary and suprascapular nerve blocks are well-described, but result in sparing other neural contributors to the shoulder capsule3. Selectively targeting posterior and lateral cords of the brachial plexus with low volume, in combination with suprascapular block, may provide greater analgesic benefit while mitigating the risk of phrenic nerve blockade. Future investigations should be directed at comparing postoperative analgesic efficacy between ultrasound-guided ISB and the combination of infraclavicular plus suprascapular nerve blocks for total shoulder arthroplasty.