The Use of Interscalene Block Prior to Shoulder Arthroscopy: Implications for Postoperative Pain Management

OVERVIEW OF BRACHIAL PLEXUS BLOCKS The development of the brachial plexus block began in 1884 when Halsted performed the first brachial plexus by injecting exposed roots of the brachial plexus with cocaine 1. It was not until 1911 that Hirschel and Kulenkampff reported a percutaneous brachial plexus block. The axillary technique was developed first, followed by a supraclavicular approach 2,3. In 1919, Mully developed the interscalene approach to brachial plexus block in order to avoid pneumothorax 4. The modern interscalene approach was developed by Winnie using the level of the sixth cervical transverse process as the reference point for needle insertion 5. The interscalene brachial plexus block is ideal for the proximal upper extremity but less reliable for neural blockade of the wrist and hand. Most patients have readily identifiable landmarks, allowing easy access to the brachial plexus via the interscalene approach. The use of a nerve stimulator to guide proper needle placement rather than relying solely on paresthesias, can increase the rate of a safe and successful block. In an effort to initiate early postoperative physical therapy, our Acute Pain Management Service was asked to provide brachial plexus blocks for all patients having shoulder surgery at a newly opened orthopedic specialty hospital. The block was performed prior to surgery. While our pain management service had been in existence for four years providing epidural analgesia and IV PCA at a large teaching hospital, we had almost no experience with brachial plexus blocks for postoperative pain. Therefore, a Continuous Quality Improvement (C.Q.I.) monitor was initiated to determine the efficacy, effectiveness and efficiency of this new procedure on our patient population. Indicators were established to capture possible complications (see CQI monitor). In addition, a follow-up patient satisfaction survey was done.