A reply

Abstract

Listen

Translate article

We thank Drs Subash and Hilton for sharing 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 durations have not been compared in a prospective randomised manner, but if data are 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 quite exceptional – 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 Drs 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 were as good as suggested, this would contradict the aforementioned evidence. Further elaboration of their regional anaesthetic technique might then be warranted, which could be of great value to the anaesthetic community. MF has received support for research from Surgical Synergies Ltd. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.