Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention

Tran, John; Peng, Philip; Agur, Anne

doi:10.1136/rapm-2018-100152

Cited by 71 publications

(74 citation statements)

References 34 publications

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“…innervation. Contrary to earlier belief that the suprascapular nerve innervates 70% of the shoulder joint, 11 recent anatomical studies 4,12 indicated that its contribution is modest and confined to the posterior superior quadrant of the joint. The C5 and C6 nerve roots that form the brachial plexus superior trunk (C5-C6) are major contributors to all of the axillary, subscapular, and suprascapular nerves.…”

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confidence: 72%

Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery

et al. 2020

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Background: Interscalene brachial plexus block, the pain relief standard for shoulder surgery, is an invasive technique associated with important complications. The subomohyoid anterior suprascapular block is a potential alternative, but evidence of its comparative analgesic effect is sparse. The authors tested the hypothesis that anterior suprascapular block is noninferior to interscalene block for improving pain control after shoulder surgery. As a secondary objective, the authors evaluated the success of superior trunk (C5-C6 dermatomes) block with suprascapular block. Methods:In this multicenter double-blind noninferiority randomized trial, 140 patients undergoing shoulder surgery were randomized to either interscalene or anterior suprascapular block with 15 ml of ropivacaine 0.5% and epinephrine. The primary outcome was area under the curve of postoperative visual analog scale pain scores during the first 24 h postoperatively. The 90% CI for the difference (interscalene-suprascapular) was compared against a -4.4-U noninferiority margin. Secondary outcomes included presence of superior trunk blockade, pain scores at individual time points, opioid consumption, time to first analgesic request, opioid-related side-effects, and quality of recovery.Results: A total of 136 patients were included in the analysis. The mean difference (90% CI) in area under the curve of pain scores for the (interscalene-suprascapular) comparison was -0.3 U (-0.8 to 0.12), exceeding the noninferiority margin of -4.4 U and demonstrating noninferiority of suprascapular block. The risk ratio (95% CI) of combined superior trunk (C5-C6 dermatomes) blockade was 0.98 (0.92 to 1.01), excluding any meaningful difference in superior trunk block success rates between the two groups. When differences in other analgesic outcomes existed, they were not clinically important.conclusions: The suprascapular block was noninferior to interscalene block with respect to improvement of postoperative pain control, and also for blockade of the superior trunk. These findings suggest that the suprascapular block consistently blocks the superior trunk and qualify it as an effective interscalene block alternative. What We Already Know about This Topic• Interscalene brachial plexus block is a commonly used procedure for shoulder surgery, but it can be associated with important complications What This Article Tells Us That Is New• Subomohyoid anterior suprascapular block is noninferior to interscalene block in providing analgesia for the first 24 h after shoulder surgery • Subomohyoid anterior suprascapular block does not appear to differ significantly from interscalene block in terms of superior trunk blockade or overall quality of recovery T he ongoing quest for effective alternatives to the interscalene block of the brachial plexus for postoperative analgesia after shoulder surgery 1 has been prompted by the interscalene block's invasiveness 2,3 and undesirable respiratory side effects related to phrenic nerve block, 4 which restrict its use in certain population...

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confidence: 72%

Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery

et al. 2020

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“…The remaining shoulder joint areas are innervated by the SSN, which must be blocked in combination with the AN if complete anesthesia of the shoulder is to be achieved (see Aszmann et al, for the shoulder innervation and Price, for the clinical basis of the combined approach). The LPN, which lies in the interpectoral space (Blanco, ), contributes to the innervation of both the shoulder joint capsule and the acromioclavicular joint (Wrete, ; Aszmann et al, ; Tran et al, ). The injection of anesthetic drugs into the interpectoral space, called the Pecks blockade, is a safe technique for pain control in breast surgery and some of its variants can reach the LPN with minimal involvement of other nerves (Blanco, ; Pérez et al, ; Versyck et al, ).…”

Section: Discussionmentioning

confidence: 99%

“…The estimated contribution of the AN to the totality of the shoulder joint innervation is variable. Near the quadrangular space, the main trunk gives direct articular branches to the inferior area (see also Tran et al, ) of the shoulder joint capsule, with other articular branches arising from the branch to the teres minor or appearing in the posterolateral aspect of the capsule after piercing the connective tissue of the tendon of the BB (Nasu et al, ; Eckmann et al, ). Some authors mention a single articular branch (Duparc et al, ), which they call the joint nerve (JN), while others use more general terms such as articular branch or capsular branch.…”

Section: Introduction and Aimsmentioning

confidence: 99%

Ultrasonography‐guided anterior approach for axillary nerve blockade: An anatomical study

et al. 2019

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Combined ultrasound (US)-guided blockade of the suprascapular and axillary nerves (ANs) has been proposed as an alternative to interscalene blockade for pain control in shoulder joint pathology or postsurgical care. This technique could help avoid respiratory complications and/or almost total upper limb palsy. Nowadays, the AN blockade is mostly performed using an in-plane caudal-to-cephalic approach from the posterior surface of the shoulder, reaching the nerve immediately after it exits the neurovascular quadrangular space (part of the spatium axillare). Despite precluding most respiratory complications, this approach has not made postsurgical pain relief any better than an interscalene blockade, probably because articular branches of the AN are not blocked.Cephalic-to-caudal methylene blue injections were placed in the first segment of the AN of six Thiel-embalmed cadavers using an US-guided anterior approach in order to compare the distribution with that produced by a posterior approach to the contralateral AN in the same cadaver. Another 21 formalin-fixed cadavers were bilaterally dissected to identify the articular branches of the AN.We found a good spread of the dye on the AN and a constant relationship of this nerve with the subscapularis muscle. The dye reached the musculocutaneous nerve, which also contributes to shoulder joint innervation. We describe the anatomical landmarks for an ultrasonography-guided anterior AN blockade and hypothesize that this anterior approach will provide better pain control than the posterior approach owing to complete blocking of the joint nerve. Clin. Anat. 33:488-499, 2020.

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“…Anatomically, it is classically believed that 70% of shoulder glenohumeral joint innervation is provided by the suprascapular nerve; hence, blocking this nerve provides partial pain relief following shoulder surgery [34,35]. The remaining 30% of the joint is innervated by the axillary and subscapular nerves [34][35][36]. However, shoulder surgery is not only limited to the joint per se but it also involves the surrounding muscular and cutaneous tissues which derive additional innervation from the supraclavicular and pectoral nerves [37].…”

Section: Discussionmentioning

confidence: 99%

Analgesic benefits and clinical role of the posterior suprascapular nerve block in shoulder surgery: a systematic review, meta‐analysis and trial sequential analysis

Cho¹,

Kang

McCartney³

et al. 2019

Anaesthesia

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The posterior suprascapular nerve block has been proposed as an analgesic alternative for shoulder surgery based on the publication of several comparisons with interscalene block that failed to detect differences in analgesic outcomes. However, quantification of the absolute treatment effect of suprascapular nerve block on its own, in comparison with no block (control), to corroborate the aforementioned conclusions has been lacking. This study examines the absolute analgesic efficacy of suprascapular nerve block compared with control for shoulder surgery. We systematically sought electronic databases for studies comparing suprascapular nerve block with control. The primary outcomes included postoperative 24-h cumulative oral morphine consumption and the difference in area under the curve for 24-h pooled pain scores. Secondary outcomes included the incidence of opioid-related side-effects (postoperative nausea and vomiting) and patient satisfaction. Data were pooled using random-effects modelling. Ten studies (700 patients) were analysed; all studies examined landmark-guided posterior suprascapular nerve block performed in the suprascapular fossa. Suprascapular nerve block was statistically but not clinically superior to control for postoperative 24-h cumulative oral morphine consumption, with a weighted mean difference (99%CI) of 11.41 mg (À21.28 to À1.54; p = 0.003). Suprascapular nerve block was also statistically but not clinically superior to control for area under the curve of pain scores, with a mean difference of 1.01 cm.h. Nonetheless, suprascapular nerve block reduced the odds of postoperative nausea and vomiting and improved patient satisfaction. This review suggests that the landmarkguided posterior suprascapular nerve block does not provide clinically important analgesic benefits for shoulder surgery. Investigation of other interscalene block alternatives is warranted.

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Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention

Cited by 71 publications

References 34 publications

Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery

Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery

Ultrasonography‐guided anterior approach for axillary nerve blockade: An anatomical study

Analgesic benefits and clinical role of the posterior suprascapular nerve block in shoulder surgery: a systematic review, meta‐analysis and trial sequential analysis

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