Title: Should We Block the Intercostobrachial Nerve: Incidence of Axillary Pain After Shoulder Surgery
Authors: Abhinav V. Raju1,2; John-Paul J. Pozek, MD2
1Kansas City University College of Osteopathic Medicine, Kansas City, Missouri
2Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
Background:
•Shoulder surgery has been performed to treat and relieve pain, but many arthroscopies have been reported to be associated with chronic postsurgical pain.
•Interscalene block à lower pain criteria scores (visual analog scale + morphine intake) [1].
•Sensory innervation of the axilla comes from the intercostobrachial (ICB) nerve.
•Axillary pain after shoulder surgery can occur even with well-working interscalene blocks [2] – potential links with anterior port placement [3] and can increase opioid use [4].
•Postoperative ICB nerve block performance may be difficult.
Purpose/Aims/Hypothesis:
•Retrospective, single-institution study that seeks to find the incidence of axilla pain after shoulder surgery.
•Hypothesis: Incidence for axillary pain post-shoulder surgery will be very low, at 1-5%.
Methods:
•Chart review in EPIC on all patients who had undergone shoulder surgery at the University of Kansas Health System between 1/1/22 and 12/31/22.
•Data analyzed included date of surgery, surgical intervention, age, postoperative pain, and analgesic use.
•The primary outcome was the presence of pain in the axilla immediately after surgery.
•The patients were then grouped into patients with pain in the axilla and patients without.
•Patients who had a failed brachial plexus block that was repeated were excluded.
•The secondary outcome is milligram morphine equivalent (MME) of opioids in the PACU for patients with axilla pain and those without.
Results:
•Out of 147 patients, there were 11 patients with axilla pain (7.4%) in the immediate postoperative period.
•The patients who had axillary pain used a mean of 3.59 MME in the PACU while those who had axilla pain used 21.36 MME (p < .05).
Discussion:
•The results indicate a 7.4% incidence of axillary pain in the immediate postoperative period after shoulder surgery.
•Does not provide an adequate justification to modify current anesthetic practice for all shoulder surgeries.
•ICB nerve block may be considered in the preoperative period if the patient is undergoing arthroscopic surgery with an anterior port placement, if the patient is opioid tolerant, has a history of opioid use disorder, or any other reason to minimize opioid use in the postoperative period.
Conclusion:
•Higher incidence of post-shoulder surgical axillary pain at our institution given the lack of information in literature.
•Prospective, randomized controlled trials comparing brachial plexus and ICB nerve blocks against brachial plexus blocks alone for patients undergoing shoulder surgery are needed.
References:
1. Stiglitz Y, Gosselin O, Sedaghatian J, Sirveaux F, Molé D. Pain after shoulder arthroscopy: A prospective study on 231 cases. Orthopaedics & Traumatology: Surgery & Research 2011;97(3):260- 266.
2. Şahin A, Baran O, Çetin MÜ, Gültekin A, Arar MC. Combined suprascapular nerve block and axillary nerve block approach vs. peri-articular infiltration analgesia for postoperative pain management following arthroscopic shoulder surgery: a randomized clinical trial. Eur Rev Med Pharmacol Sci. 2022
3. Neal JM, Gurkan Y. Cutaneous blocks for the upper extremity – landmarks and nerve stimulator technique. NYSORA, Inc. https://www.nysora.com/cutaneous-blocks-upper-extremity/
4. Martin S. Angst, J David Clark; Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570–587
