الفهرس 
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Abstract
Severe intraoperative and postoperative pain associated with arthroscopic shoulder surgery has high incidence reaching up to 45%; it is often significant enough to interfere with initial recovery and rehabilitation. This pain is difficult to manage without large dose opioids.
Opioids have many adverse effects including nausea, vomiting, sedation, and/or failure to control pain. Adding regional nerve block to general anesthesia (GA) may improve the quality of postoperative pain relief. Interscalene brachial plexus block (ISB) is the most commonly used approach, as it provides effective postoperative analgesia for 6 to 12 hours.
This block is associated with infrequent but potentially serious complications such as diaphragmatic paralysis, hoarseness of voice, Horner’s syndrome, and pneumothorax. These may be because of inadvertent injection of local anesthetic into the cerebrospinal fluid, the epidural space, or the vertebral artery. Its associated side effects are more common because of unpredictable spread of local anesthetic to important adjacent structures such as the phrenic and vagus nerves and the stellate ganglion.
The suprascapular nerve supplies sensation for most of the posterior, medial, and superior part of the shoulder joint capsule. It also supplies the supraspinatous and infraspinatous 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 axillary nerve, which also supplies the deltoid muscle and gives some fibers to the teres minor. The axillary nerve also supplies the skin overlying the deltoid muscle.
Combined suprascapular nerve and Axillary nerve blocks (Shoulder Block) can provide a safe effective alternative to the interscalene block, with adequate postoperative pain relief after arthroscopic shoulder surgeries and with viable diaphragmatic sparing.
Using ultrasound-guided brachial plexus block has many advantages than other techniques as it allows direct visualization of the nerve roots, decreases the number of the attempts, decreases the total dose of the used local anaesthetic, improves the quality of the block and allows for faster onset with longer duration of the block.
The study is aimed to compare Interscalene brachial plexus block ISB with the selective blockade of suprascapular and axillary nerves (ShB) for postoperative analgesia after shoulder arthroscopic surgery guided with ultrasound and nerve stimulator.
This is a prospective, randomized, comparative study, was carried out in Ain Shams University Educational Hospitals, through a period of one year.
The main results of the study revealed that:
45(90%) were male, 5(10%) were female, Mean ± SD of age is 37.32 ± 10.13 years, Mean ± SD of Weight is 77.40 ± 11.07 Kg.
the type of surgery was 13(26%) as diagnostic, 23(46%) as Sub acromial decompression and 14(28%) as Shoulder dislocation with anchor application. Mean ± SD of Duration of surgery was 1.83 ± 0.63 hours; Mean ± SD of Time to perform the block was 15.62 ± 5.00 min; Mean ± SD of MAC (ISO) was 1.19 ± 0.16 %; Mean ± SD of Total dose of opioids (Fent) was 103.50 ± 13.37 µg; Mean ± SD of Dose of hypnotics (propofol) was 132.20 ± 20.63 mg.
Mean ±SD of Duration of surgery at group (A) was 1.80 ± 0.63 hours while in group (B) was 1.86 ± 0.64 hours. Mean ±SD of Time to perform the block at group (A) was 14.00 ± 4.33 min while in group (B) was 17.24 ± 5.17 min.
There were no statistically significant differences between groups as regarding Type of surgery and Duration of surgery. But there were statistically significant differences between groups as regarding Time to perform the block.
Mean ±SD of MAC (ISO) at group (A) was 1.14 ± 0.14 % while in group (B) was 1.23 ± 0.16 %. Mean ±SD of Total dose of opioids (Fent) at group (A) was 99.00 ± 8.78 µg while in group (B) was 108.00 ± 15.68 µg; Mean ±SD of Total dose of opioids (Fent) at group (A) was 125.20 ± 20.64 mg while in group (B) was 139.20 ± 18.47 mg.
There were no statistically significant differences between groups as regarding MAC (ISO) (%). But there were statistically significant differences between groups as regarding Total dose of opioids (Fent) and Dose of hypnotics (propofol).
The pain threshold score using VAS score at different times postoperatively showed non-significant difference between the ISB and ShB groups in all times, with p-values at 0.071, 0.28, 0.378, 0.358, 0.451 for VAS 2, VAS 4, VAS 8, VAS 16, VAS 24 respectively except at VAS 0 a significant difference at p value 0.029 was found but still the VAS score was less than 3, So, no pain killers were given. Surprisingly a reported improvement in expression of postoperative pain was noticed later on. This is may be due to the very dense block offered by interscalene brachial plexus block unlike the selective shoulder block.
there is non-significant difference in total patients needed analgesics postoperatively in the two different groups, with total 7 out of 25 patients in ISB group and 11 patients out of 25 in ShB group, with p-value 0.239.
The table also shows non-significant difference between the two groups in time of 1st analgesic with p-value 0.941.
Also the total dose of pethidine consumed in 24 hour is also non-significant between the two groups with p-value 0.865.
So, the ISB and ShB are with the same efficacy for postoperative analgesia after shoulder arthroscopy done for different purposes.
non-significant difference in patient satisfaction assessed 24-hour post-operative, with p-value 0.054.
PONV was reported in one case received ShB and in 6 patients received ISB making a significant difference with p-value 0.042.
This might be explained with the associated hypotension with ISB because this complaint was noticed in patients experienced post-operative hypotension and tachycardia, and also resolved with isotonic solution infusion and antiemetics, and the complaint resolved after normalization of blood pressure.
The table also shows significant difference between the two groups regarding the reported complications, with p-value 0.017.
Based on our results we recommend for further studies on larger patients and longer period of follow up to emphasize our conclusion.