Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea.
Korea University College of Medicine, Anam Hospital, Seoul, Korea.
Pain Physician. 2021 May;24(3):235-242.
Interscalene block is the most commonly used nerve block for shoulder surgery, and superior trunk block has been investigated as a phrenic-sparing alternative. This randomized controlled trial compared ultrasound-guided interscalene block and superior trunk block as anesthesia for arthroscopic shoulder surgery.
Our aims were to determine the superiority of anesthesia quality and compare the risk of hemidiaphragmatic paralysis between these 2 blocks.
A randomized, controlled trial.
Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital.
Forty-eight patients undergoing elective arthroscopic shoulder surgery under an ultrasound guided brachial plexus block were randomized to receive either an interscalene block (ISB group, n = 24) or a superior trunk block (STB group, n = 24) for surgery. Ten milliliters of 2% lidocaine and 10 mL of 0.75% ropivacaine were used as local anesthesia in both brachial plexus block groups (total 20 mL). In the ISB group, the local anesthesia was injected between the C5-C6 root and at the upper part of C5 with equally divided doses. In the STB group, the local anesthesia was injected into the anterior and posterior parts of the superior trunk with equally divided doses. Sensory blockade of each trocar's insulting site (supraclavicular, axillary, and suprascapular nerve areas) and motor blockade of the axillary nerve (shoulder abduction) and the suprascapular nerve (shoulder external rotation) were assessed by a blinded observer at 5-minute intervals for 30 minutes after the block. Anesthesia quality was assessed using 3 grades (excellent/insufficient/failure). The blinded investigator also assessed the grade of hemidiaphragmatic paralysis (normal/partial/complete) by comparing pre- and postoperative chest radiographs. Primary outcome variables were anesthesia grade and rate of hemidiaphragmatic paralysis. Secondary outcome variables were performance time and anesthesia onset time.
The anesthetic grade was significantly different between the 2 groups (22/2/0 in the ISB group vs. 16/3/5 in the STB group, P = 0.046). Both groups displayed equivalent incidence of hemidiaphragmatic paralysis (12/6/6 in the ISB group vs. 7/14/3 in the STB group, P = 0.063). No intergroup differences were found in terms of performance time and anesthesia onset time.
Our sensory and motor function test was not applied to the subscapular nerve, which serves internal rotation of the humeral head so may be difficult to evaluate in patients with rotator cuff tears. We assessed the diaphragmatic movement by chest radiographs instead of by ultrasound.
The superior trunk block provided lower quality of surgical anesthesia than the interscalene block and did not effectively decrease the risk of hemidiaphragmatic paralysis during arthroscopic shoulder surgery for rotator cuff syndrome.
经斜角肌间隙阻滞是肩部手术最常用的神经阻滞方法，而高位肌间沟阻滞已被研究为一种膈神经保留的替代方法。本随机对照试验比较了超声引导下经斜角肌间隙阻滞和高位肌间沟阻滞作为关节镜下肩部手术的麻醉方法。
我们的目的是确定这两种阻滞方法的麻醉质量优势，并比较它们之间膈神经麻痹的风险。
随机对照试验。
韩国大学安岩医院麻醉与疼痛医学系。
48 例行择期关节镜下肩部手术的患者在超声引导下臂丛神经阻滞下随机分为接受经斜角肌间隙阻滞（ISB 组，n = 24）或高位肌间沟阻滞（STB 组，n = 24）进行手术。两组均使用 2%利多卡因 10 毫升和 0.75%罗哌卡因 10 毫升作为局部麻醉（总剂量 20 毫升）。在 ISB 组中，将局部麻醉药等量分配于 C5-C6 神经根和 C5 上部之间。在 STB 组中，将局部麻醉药等量注入高位肌间沟的前、后部分。在阻滞后 30 分钟内，盲法观察者每隔 5 分钟评估一次每个套管穿刺部位（锁骨上、腋窝和肩胛上神经区域）的感觉阻滞和腋神经（肩关节外展）和肩胛上神经（肩关节外旋）的运动阻滞。麻醉质量采用 3 级（优/不足/失败）进行评估。盲法研究者还通过比较术前和术后的胸部 X 线片来评估膈神经麻痹的程度（正常/部分/完全）。主要观察指标为麻醉分级和膈神经麻痹发生率。次要观察指标为操作时间和麻醉起效时间。
两组的麻醉分级差异有统计学意义（ISB 组 22/2/0 与 STB 组 16/3/5，P = 0.046）。两组膈神经麻痹的发生率相当（ISB 组 12/6/6 与 STB 组 7/14/3，P = 0.063）。两组操作时间和麻醉起效时间无差异。
我们的感觉和运动功能测试未应用于肩胛下神经，肩胛下神经负责肱骨头内旋，因此在肩袖撕裂患者中可能难以评估。我们通过胸部 X 线片评估膈的运动，而不是通过超声。
与经斜角肌间隙阻滞相比，高位肌间沟阻滞提供的手术麻醉质量较低，不能有效降低肩袖综合征关节镜下肩部手术中膈神经麻痹的风险。
