Treatment Following Brachial Plexus Block
Start with oral NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) as first-line therapy, adding acetaminophen 650mg every 4-6 hours (maximum 4g/day) if needed, and apply heat therapy to the affected shoulder and upper arm region for 15-20 minutes several times daily. 1, 2
Acute Phase Management (First 6-8 Weeks)
First-Line Pharmacologic Approach
- Maximize NSAIDs before considering other options, using either oral or topical formulations as the primary analgesic strategy 1, 2
- Add acetaminophen as an adjunct to NSAIDs if pain control remains inadequate, being careful to monitor total daily acetaminophen dose across all medications to prevent exceeding 4g/day 1, 2
- Avoid opioid prescriptions entirely, as they increase risk of long-term opioid dependence without improving outcomes compared to NSAIDs 1, 2
Non-Pharmacologic Interventions
- Apply heat therapy to the affected shoulder and upper arm region for 15-20 minutes several times daily, as heat is more effective than ice for muscle-related pain 2
Interventional Management (After 6-8 Weeks)
Indications for Peripheral Nerve Blocks
Consider peripheral nerve blocks only if pain persists beyond 6-8 weeks despite maximal conservative management AND the patient has failed to achieve adequate analgesia without intolerable side effects. 1, 3
- Nerve blocks are indicated when pain occurs in the field of one or more peripheral nerves 3
- All nerve blocks must be performed with ultrasound guidance to minimize complications and reduce local anesthetic systemic toxicity risk 4, 5
Specific Block Considerations for Cancer-Related Pain
- For neoplastic brachial plexopathy, single-shot brachial plexus blocks with bupivacaine 0.25% plus methylprednisolone 20-120mg can provide sustained pain relief lasting 2 weeks to 10 months 6
- Brachial plexus neurolysis is reserved for upper extremity pain in cancer patients, but should be used cautiously as it can lead to neuritis in patients with good prognosis 3
Critical Safety Requirements and Contraindications
Absolute Contraindications
- Active P2Y12 inhibitor therapy (clopidogrel, prasugrel, ticagrelor) without appropriate discontinuation periods: clopidogrel requires 5-day discontinuation, prasugrel requires 7-day discontinuation, ticagrelor requires 5-day discontinuation 4
- Therapeutic anticoagulation unless appropriately reversed 4
- Coagulopathy or bleeding disorders that cannot be corrected 4, 3
- Patient refusal 4
- Active infection at the injection site 4
- Very short life expectancy 4, 3
Mandatory Safety Measures
- Ultrasound guidance is required for all nerve blocks 4, 5
- Experienced operator must perform the technique 4
- Calculate safe dose of local anesthetic based on patient weight 4
- Immediate resuscitation equipment must be available 4
Common Pitfalls to Avoid
Medication-Related Errors
- Do not combine multiple acetaminophen-containing products, as this is the most common cause of acetaminophen overdose 3
- Avoid prescribing opioids for brachial plexus-related pain, as they provide no benefit over NSAIDs and significantly increase addiction risk 1
Technical Complications
- Interscalene brachial plexus blocks carry substantial risk of peripheral neurologic injuries (most common), central nervous system complications, respiratory complications, and cardiovascular complications, with some complications causing permanent disability 7
- Less experienced anesthesiologists have higher complication rates with brachial plexus blocks 7
- Neurolytic agents on peripheral nerves can lead to neuritis that may be more difficult to control than the original pain 3