Shoulder pain is frequently encountered in the medical field. Rotator cuff tears are the most common cause. Shoulder pain affects quality of life and delay rehabilitation programs.
Effective control of post operative pain is a cornerstone in the success of these surgeries. Regional anaesthesia is often favoured for shoulder surgery as it could effectively provide anaesthesia and postoperative analgesia. Additionally, the upper limb has multiple nerve targets that can be blocked. Ultrasound combined SSNB-ANB were described as an alternative to interscalene nerve block for shoulder surgeries equipotent pain relief and patient satisfaction as well as fewer complications due to the location of injection.
Ultrasound guided SHAC block is a motor sparing block which targets all nerves supplying shoulder consistently at two sites. It was validated in chronic shoulder pain patients. However, there is no sufficient evidence for this block in postoperative pain after shoulder surgery.
Patients acceptance
Age: 21-60 years
Sex: both sexes (males or females).
Physical status: ASA 1& II.
Patient with any contraindications of regional blocks (as coagulopathy or local infection at injection site)
Patients with known history of allergy to the study drugs.
patients with neuropathy involving the limb undergoing surgery
Advanced hepatic, renal, cardiovascular, and neurologic diseases.
Parallel
(SHAC) block
Procedure/SurgeryThe shoulder anterior capsular block targets interfacial and pericapsular space. A 25-gauge 80-mm insulated stimulating needle will be used for injections and in-plane needling will be from lateral to medial side. After aspiration is negative, 10 ml of 0.5 % bupivacaine plus dexamethasone 4 mg as adjuvant will be injected in the interfacial plane. Once the injection into the fascial space is achieved, the operator can proceed towards the glenohumeral pericapsular space by crossing the subscapularis muscle with the needle and the second injection after negative aspiration will be 10 ml 0.5 % bupivacaine plus dexamethasone 4 mg in pericapsular space.
(SSNB-ANB) block
Procedure/SurgerySuprascapular Nerve Block (SNB): Using an in-plane ultrasound guidance from the medial side, 10 mL of 0.5% bupivacaine plus dexamethasone 4 mg as adjuvant will be injected after contacting the lateral aspect of the supraspinous fossa and negative aspiration confirmed. The LA should spread beneath the supraspinatus, lifting up the muscle. Axillary Nerve Block (ANB): The ANB is performed from behind the patient with the patient seated. The axillary nerve will be identified within the quadrilateral space by placing high frequency linear probe (Sono site M turbo) parallel to the long axis of the humeral shaft. The nerve was identified next to the circumflex artery. The skin will be anesthetized with 1% lidocaine (3mL). 10 mL of 0.5% bupivacaine plus dexamethasone 4 mg will be injected against the surface of the humerus, just posterior and lateral to the artery after confirming negative aspiration.
The total postoperative pethidine consumption (in milligrams) during the first 24-h after surgery.
Postoperative pain assessment by Numeric rating scale (NRS) at rest and on passive movements in the recovery room and at 2,4,8,16 and 24 hours after surgery.
The patients will be instructed to use numeric rating scale (NRS) for pain. The numeric rating scale will be explained using a 0-10 scale, with the left-most end (zero) meaning "no pain" and the right-most end (10) meaning "the worst pain imaginable". Patients will be instructed to circle the number that represents the amount of pain that they are experiencing at the time of the evaluation
The time to first request of rescue analgesia (pethidine).
3. The total number of patients requiring additional dose of intraoperative fentanyl.
The block performance time
defined by the sum of scanning time and needle time. Scanning time is the time from ultrasound probe is placed on the skin until a satisfactory image is obtained. Needle time is taken from the time needle tip penetrated the skin and exited after block placement.
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