الفهرس 
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Abstract
Shoulder arthroscopy is a minimally invasive, ambulatory surgery useful for treating a variety of shoulder pathologies. But it is associated with severe post-operative pain, which causes significant discomfort to the patient and hence interferes with recovery and rehabilitation of the shoulder. Of all blocks, employed for postoperative pain after shoulder surgery, the ISB is the most widely used block. It has been reported to provide excellent post-operative analgesia but can produce side effects like phrenic nerve blockade resulting in diaphragmatic paresis causing respiratory distress to the patient. Other common complications associated with ISB are weakness of arm, hoarseness of voice and Horner’s syndrome. This necessitates the search for other nerve blocks which has similar analgesic efficacy as the ISB but without any associated complications. So, instead of the ISB, targeting selective blockade of nerves supplying to the shoulder may be a better alternative. The SSN supplies about 60–70% of the shoulder joint and AN supplies about 25–30% of the shoulder joint. The SSN supplies sensation for most of the posterior, medial and superior part of the shoulder joint capsule. It also supplies the supraspinatus and infraspinatus muscles of the rotator cuff and some branches to the teres minor, the glenoid, acromion and the posterior surface of the scapula. The anterior, lateral and inferior structures of the shoulder joint are supplied by the AN, which also supplies the deltoid muscle and gives some fibres to the teres minor. The AN also supplies the skin overlying the deltoid muscle. The use of ultrasound and nerve stimulator in performing the blocks provided better visualisation and localisation of the nerves, resulting in successful blockade with fewer complications. So instead of the ISB, combined blockade of these two nerves can be useful for providing analgesia in surgeries of the shoulder joint. But there is a conflicting view in the literature regarding the efficacy of combined blockade of SSN and AN when compared with ISB. This study aimed to compare efficacy of intra and post operative analgesia of ISB, SHB and SSNB for shoulder arthroscopic surgeries This prospective randomized controlled double blinded clinical trial was conducted on 90 adult patients aged 20-55 years of both sex, ASA physical status I and II admitted for shoulder arthroscopic surgery. Patients were equally randomized into three groups 30 patints each to receive either: • group I: Ultrasound guided Interscalene Block (ISB), brachial plexus was blocked by 20ml of levobupivacaine 0.5%. • group II: Ultrasound guided SHB, 10 ml of levobupivacaine 0.5% was injected below the supraspinatus fascia and another 10 ml was injected at AN. • group III: Ultrasound guided SSNB, 10 ml of levobupivacaine 0.5% was injected below the supraspinatous fascia. Summary of our results: • Demographic data (age, gender, BMI and ASA physical status) duration of surgery and onset of the block were insignificantly different among the three groups. • Intraoperative HR and MAP were significantly different at at skin incision, 20, 30, 40, 50 min and at the end of surgery among the three groups (P<0.05) but the preoperative measurements were insignificantly different. Intraoperative HR and MAP at skin incision, 20, 30, 40, 50 min and at the end of surgery were significantly higher in group SSNB compared to groups ISB and SHB (P <0.05) and were insignificantly different between groups ISB and SHB • Postoperative HR and MAP were insignificantly different at preoperative, PACU and 30 min among the three groups and was significantly different at 2, 4, 6, 12, 18 and 24 h among the three groups. Postoperative HR and MAP at 2, 4, 6, 12, 18 and 24 h were significantly higher in group SSNB compared to groups ISB and SHB (P<0.05) and was insignificantly different between groups ISB and SHB. • VAS was insignificantly different at PACU and 30 min among the three groups and was significantly diffirent at 2, 4, 6, 12, 18 and 24 hr (P< 0.05). VAS at 2, 4, 6, 12, 18 and 24 hr was significantly higher in group SSNB compared to groups ISB and SHB (P value < 0.05) and was insignificantly different between ISB and SHB. • Number of patients required rescue analgesia was significantly higher in group SSNB compared to groups ISB and SHB (P< 0.001). • Time to first rescue analgesic requirement was significantly earlier in group SSNB compared to groups ISB and SHB (P value <0.001) and was insignificantly different between groups ISB and SHB. • Number of patients required fentanyl intraoperatively was significantly higher in group SSNB compared to groups ISB and SHB (P < 0.001) and was insignificantly different between groups ISB and SHB. Intraoperative fentanyl consumption was significantly higher in group SSNB compared to groups ISB and SHB (P < 0 .001) and was insignificantly different between groups ISB and SHB. • Postoperative meperidine consumption was significantly higher in group SSNB compared to groups ISB and SHB (P < 0.001) and was insignificantly different between groups ISB and SHB. • Regarding the adverse effects in group ISB, HDP occurred in 23 (76.67%) patients, bradycardia occurred in 3 (10%) patients, hypotension occurred in 2 (6.67%), PONV occurred in 2 (6.67%), Horner syndrome occurred in 3 (10%) patients and Hoarseness occurred in 2 (6.67%) patients. • Regarding the adverse effects in group SHB, bradycardia occurred in 2 (6.67%) patients, hypotension occurred in 1 (3.33%), PONV occurred in 2 (6.67%), Horner syndrome and Hoarseness didn’t occur in any patient. regarding the adverse effects in group SSNB, bradycardia occurred in 1 (3.33%) patient, hypotension occurred in 3 (10%), PONV occurred in 8 (26.67%), Horner syndrome and Hoarseness didn’t occur in any patient. Bradycardia, hypotension, hoarseness, failed block and LAST were insignificantly different among the three groups. • PONV was significantly higher in group SSNB compared to groups ISB and SHB (P= 0.031), HDP and Horner syndrome were significantly higher in group ISB compared to groups SHB and SSNB (P<0.001). • Patients’ satisfaction was significantly higher in group ISB and SHB compared to group SSNB.