22 Perioperative Pain Management for Shoulder Surgery

Ian S. Patten and Uma Srikumaran


Adequate management of pain after shoulder surgery is paramount to post-operative recovery. Regional anesthesia has proven to provide superior pain control and recovery. Several brachial plexus blocks have been described with intrascalene being the most common employed. A full knowledge of anatomy as well as the indications and potential complications associated with regional anesthesia is required by the physician.

22 Perioperative Pain Management for Shoulder Surgery

I. General overview

  1. First peripheral block was performed by William Halsted with cocaine in 1885

  2. Over the past 30 years there has been an increasing trend in the use of peripheral nerve blocks for postoperative pain management

  3. Adequate pain control via peripheral block:

    1. Decreases hospital length of stay

    2. Allows transition from traditional inpatient surgery to outpatient

    3. Decrease opioid use and associated opioid side effects

    4. Enhances participation in rehabilitation

    5. Improve functions and patient satisfaction outcomes

    6. Enhance cost-effectiveness.

  4. Vital to understand the indications and potential complications associated with regional anesthesia.

II. Anatomy

  1. Brachial plexus (▶ Fig. 22.1 ):

    1. Five roots: C5, C6, C7, C8, and T1

      1. Level of intrascalene block.

    2. Three trunks: Upper, middle, and lower

      1. Level of supraclavicular block.

    3. Six divisions: Anterior and posterior divisions of three trunks

    4. Three cords: Posterior, lateral, and medial

      1. Level of intraclavicular block.

    5. Five branches: Median, axillary, radial, musculocutaneous, and ulnar nerves

      1. Level of axillary block.

        Fig. 22.1 Brachial plexus anatomy. Areas within borders represent anatomic locations of common regional blocks for upper extremity surgery. From proximal to distal: interscalene, supraclavicular, infraclavicular, and axillary.

  2. Shoulder sensory innervation:

    1. Superior region:

      1. Superficial cervical plexus (C3–C4):

        • i. Supraclavicular nerve.

    2. Axillary region:

      1. T2 nerve root.

    3. Shoulder capsule, subacromial bursa, acromioclavicular joint, cutaneous tissue:

      1. Suprascapular nerve—primarily C5, C6 with some C4.

  3. Four anatomic regions pertinent to peripheral nerve blocks (▶ Fig. 22.2 ):

    1. Intrascalene:

      1. Potential space between anterior and middle scalenes

      2. Targets brachial plexus at root-trunk level

      3. Most commonly preformed

      4. Effective for shoulder, proximal humerus, and distal clavicle

      5. Ulnar sparing:

        • i. C8 frequently not covered

        • ii. Additional block required for surgery around the elbow.

          Fig. 22.2 Anterior and posterior distribution of common regional blocks. (a) Interscalene. (b) Supraclavicular. (c) Infraclavicular. (d) Axillary.

    2. Supraclavicular:

      1. Superior to clavicle at the level of plexus trunks

      2. Between anterior and middle scalenes at the first rib

      3. Apical lung vulnerable

      4. Suitable for shoulder; theoretically does not cover superior aspect of shoulder, arm, and elbow: forearm hand adequately covered.

    3. Infraclavicular:

      1. Boarders consist of:

        • i. Superior—posterior aspect of clavicle

        • ii. Inferior—soft tissues of axilla

        • iii. Anterior—pectoralis minor

        • iv. Posterior subscapularis.

      2. Level of the cords before axillary and musculocutaneous nerves exit

      3. Shoulder not covered; arm, elbow, and forearm hand adequately covered.

    4. Axillary and suprascapular:

      1. In combination similar shoulder coverage compared with intrascalene block

      2. Axillary:

        • i. Located beneath glenohumeral joint between the chest wall and medial upper arm

        • ii. In isolation may be adequate for elbow surgery.

      3. Suprascapular:

        • i. Level of the suprascapular notch.

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Feb 6, 2021 | Posted by in ORTHOPEDIC | Comments Off on 22 Perioperative Pain Management for Shoulder Surgery
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