What regional block techniques are effective for pain management in shoulder posterior labrum repair?

Regional Block Techniques for Shoulder Posterior Labrum Repair

Continuous interscalene brachial plexus block is the first-choice regional analgesic technique for pain management in shoulder posterior labrum repair surgery, with single-shot interscalene block as an acceptable alternative if continuous technique is not feasible. 1, 2

Primary Recommended Regional Block Techniques

Interscalene Brachial Plexus Block

• Continuous interscalene block provides superior analgesia over single-shot technique with lower pain scores and reduced opioid consumption on postoperative days 1,2, and 7 2
• Continuous technique significantly reduces postoperative pain scores at 6h, 24h, and 72h as well as during physiotherapy compared to IV patient-controlled analgesia 2
• For continuous interscalene block, ropivacaine 0.2-0.3% is effective, with higher concentrations potentially providing better opioid-sparing effects 2, 3
• Single-shot interscalene block is an acceptable alternative but has limited duration (6-8 hours) with potential for rebound pain at 24 hours 1, 2

Alternative Regional Techniques

• If interscalene block is contraindicated, a suprascapular nerve block with or without axillary nerve block is recommended over no block or suprascapular nerve block alone 1, 2
• Supraclavicular block has been shown to be noninferior to interscalene block for postoperative opioid consumption and acute pain, with reduced odds of respiratory dysfunction 4
• Subomohyoid anterior suprascapular block has demonstrated noninferiority to interscalene block for postoperative pain control in shoulder surgery 5

Optimizing Block Efficacy

Adjuncts and Multimodal Approach

• Intravenous dexamethasone is recommended to increase the analgesic duration of interscalene block and decrease supplemental analgesia requirements 1, 2
• Regular administration of paracetamol and NSAIDs or COX-2 inhibitors should be initiated pre-operatively or intra-operatively and continued postoperatively 1
• Opioids should be reserved for rescue analgesia only 1

Technical Considerations

• For continuous interscalene block, patient-controlled bolus capability may provide better analgesia than fixed-rate infusion alone 2
• For single-shot interscalene block, ropivacaine 0.5-0.75% is typically used with volumes of 10-40 mL depending on concentration 3
• Ultrasound guidance improves accuracy and potentially reduces complications 2

Novel Combination Approaches

• A combination of superficial cervical plexus block, suprascapular nerve block, and infraclavicular brachial plexus block has shown promise as an alternative to interscalene block for arthroscopic shoulder surgery 6
• This combination approach allowed 95% of patients to undergo surgery with only light propofol sedation, without opioids or artificial airway 6

Potential Complications and Considerations

• Interscalene block is associated with phrenic nerve blockade and respiratory complications in up to 100% of cases 4
• Supraclavicular block reduces the odds of respiratory dysfunction compared to interscalene block while maintaining similar analgesic efficacy 4
• When using continuous interscalene block, caution should be exercised when administering ropivacaine for prolonged periods (>70 hours) in debilitated patients 3
• The smallest dose and concentration of local anesthetic required to produce the desired result should be administered to minimize risk of toxicity 3

Surgical Considerations

• Arthroscopic approach for posterior labrum repair is recommended as it is associated with reduced postoperative pain compared to open procedures 1, 7
• Knotless suture anchor fixation techniques for arthroscopic posterior labral repair have shown positive patient-reported outcomes and low risk of recurrence 7

The evidence strongly supports interscalene brachial plexus block as the gold standard for pain management in shoulder posterior labrum repair, with several viable alternatives when interscalene block is contraindicated or not feasible. A multimodal approach including systemic analgesics should always accompany regional techniques to optimize pain control.