Randomized comparison between interscalene and costoclavicular blocks for arthroscopic shoulder surgery

Abstract

BackgroundThis randomized trial compared ultrasound-guided interscalene block (ISB) and costoclavicular brachial plexus block (CCB) for arthroscopic shoulder surgery. We hypothesized that CCB would provide equivalent analgesia to ISB 30 min after surgery without the risk of hemidiaphragmatic paralysis.MethodsAll 44 patients received an ultrasound-guided block of the intermediate cervical plexus. Subsequently, they were randomized to ISB or CCB. The local anesthetic agent (20 mL of levobupivacaine 0.5% and epinephrine 5 µg/mL) and pharmacological block adjunct (4 mg of intravenous dexamethasone) were identical for all study participants. After the block performance, a blinded investigator assessed ISBs and CCBs every 5 min until 30 min using a composite scale that encompassed the sensory function of the supraclavicular nerves, the sensorimotor function of the axillary nerve and the motor function of the suprascapular nerve. A complete block was defined as one displaying a minimal score of six points (out of a maximum of eight points) at 30 min. Onset time was defined as the time required to reach the six-point minimal composite score. The blinded investigator also assessed the presence of hemidiaphragmatic paralysis at 30 min with ultrasonography.Subsequently, all patients underwent general anesthesia. Postoperatively, a blinded investigator recorded pain scores at rest at 0.5, 1, 2, 3, 6, 12, and 24 hours. Patient satisfaction at 24 hours, consumption of intraoperative and postoperative narcotics, and opioid-related side effects (eg, nausea/vomiting, pruritus) were also tabulated.ResultsBoth groups displayed equivalent postoperative pain scores at 0.5, 1, 2, 3, 6, 12, and 24 hours. ISB resulted in a higher incidence of hemidiaphragmatic paralysis (100% vs 0%; P < 0.001) as well as a shorter onset time (14.0 (5.0) vs 21.6 (6.4) minutes; p<0.001). However, no intergroup differences were found in terms of proportion of patients with minimal composite scores of 6 points at 30 min, intraoperative/postoperative opioid consumption, side effects, and patient satisfaction at 24 hours.ConclusionCompared to ISB, CCB results in equivalent postoperative analgesia while circumventing the risk of hemidiaphragmatic paralysis. Further confirmatory trials are required. Future studies should also investigate if CCB can provide surgical anesthesia for arthroscopic shoulder surgery.Clinical Trials RegistrationNCT03411343.

Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study

“…For example, randomized controlled trials of patients undergoing the interscalene brachial plexus block [3,5,6] showed that the incidence of HDP in patients who were administered 5 mL of local anesthetic was 27%-45%, about half that of patients who were administered larger volumes of local anesthetic. Studies using a relatively small volume of local anesthetic (20 mL) reported an incidence of HDP of 0%-9% in patients undergoing SCB [8,32] and a 0% incidence in patients undergoing CCB [22]. The present study also showed that administration of < 25 mL of local anesthetic in CCB resulted in a 0% incidence of HDP.…”

“…A randomized control trial using 35 mL of local anesthetic for the CCB and a paracoracoid infraclavicular approach reported that the rates of HDP were 8.9% in both groups [30]. Moreover, a recent study using 20 mL of local anesthetic for the CCB and interscalene brachial plexus block in 44 patients found that the rates of HDP were 0% and 100%, respectively [22]. The logistic regression model described in this study showed that the likelihood of HDP is 30-fold lower for the CCB than for the SCB.…”

“…The optimal volume of local anesthetic for the CCB has not yet been determined. Due to the anatomical advantages of the costoclavicular space [21,33], a relatively small Oh, et al volume of local anesthetic was administered compared with the conventional infraclavicular brachial plexus block and the results were successful [19,20,22]. In contrast, a dose-finding study for ultrasound-guided CCB with 1.5% lidocaine revealed that the minimum effective volume in 90% of patients was 34 mL [10].…”

“…Cords in this space are located more superficially than with the classical approach at the lateral infraclavicular fossa and are clustered, while maintaining a consistent anatomical relationship with each other [20,21]. In addition, the costoclavicular space is considered a retrograde channel to the supraclavicular area, enabling reliable anesthesia, including anesthesia to the suprascapular nerve during shoulder surgery [22], and providing additional stability in catheter placement for a continuous brachial plexus block [23]. Because of these anatomical advantages, the CCB is emerging as a promising infraclavicular approach, with several studies showing that the CCB can provide a successful and rapid onset of the blockade with a single injection of a relatively small volume of local anesthetic [18][19][20].…”

Does the Serratus Plane Block Added to the Interscalene Block Improve the Quality of Anesthesia in Arthroscopic Shoulder Surgery? A Prospective Randomized Study

“…Therefore, regional anesthetic methods are frequently preferred as part of multimodal analgesia to provide better pain control and to reduce the side effects associated with opioids [3]. In shoulder arthroplasty, isolated nerve blocks such as suprascapular and axillary nerve blocks for postoperative analgesia are frequently applied as well as the brachial plexus blocks from the costoclavicular, supraclavicular, and interscalene regions [1,[4][5]. Interscalene brachial plexus block (ISBPB) is accepted as the gold standard in shoulder surgery.…”