Common shoulder surgical procedures include hemiarthroplasty, total shoulder arthroplasty, shoulder arthroscopy, subacromial decompression, shoulder instability procedures including rotator cuff repair and frozen shoulder procedures.

Postoperative painaftershouldersurgery can be severe and may be exacerbated by movement during rehabilitation. Effective control of postoperative shoulder pain requires blockade of the nerve supply to the synovium, capsule, articular surfaces, periostium, ligaments, and muscles of the shoulder joint.

Evidence-based treatment recommendations specific to the condition

Preoperative

Interscalene bocks are more effective than systemic analgesia. Administer at least a single interscalene injection with long acting local anaesthesia. German guidelines 4.6.2.2,p 61.

Interscalene blocks are more effective than suprascapular and subacromial blocks and intra-articular injections. They provide better analgesia, higher level of satisfaction and fewer side- effects. German guidelines 4.6.2.2,p 61.

Intraoperative

Continuous infusion of a local anaesthetic through a sub-acromial catheter. The catheter can be placed subcutaneously at the end of surgery for open surgery. Plexus block is however more efficacious French, section 9.2, p 407.

Postoperative

For operations that are expected to result in longer lasting (> 12h), moderate to severe pain, continuous catheter analgesic with a long-acting local anaesthetic is recommended. If not possible, a strong opioid should be administered intraveneously. German guidelines 4.6.2.3., p 61.

Continuous interscalene analgesia provides better pain relief, reduced opioid-related side effects and improved patient satisfaction compared with i.v PCA after open shoulder surgery. Intra-articular local anaesthetics reduce pain to a limited extent only. However, intra-articular bupivacaine infusions have been associated with chondrolysis and their use has been cautioned against ANZCA chapter 7.5.1., p 195-196.

Minor shoulder procedures may be managed with a single-injection nerve block; however, major shoulder procedures such as rotator cuff repair and total shoulder arthroplasty that produce intense pain lasting for days should be treated with perineural catheters. ¹

Multimodal systemic analgesia. Whenever possible, patients should be given multimodal pain management therapy.

• COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.

• Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.

Non-pharmacological

There is some evidence that cooling, TENS, acupuncture or continuous passive motion can reduce pain after surgery of the shoulder. German section 4.6.2.3., p 62

Ambulatory shoulder surgeryPerineural catheters are now being used to treat pain at home after ambulatory shoulder surgery. However, because of safety issues and the financial and logistic aspects perineural techniques are currently used in selected institutions only (see suggested reading).

Summary

Single injectioninterscaleneblocks with long acting LA can provide prolonged postoperative analgesia.

In institutions where perineural techniques are not routine, the general practice guidelines for multimodal analgesia should be applied.

Supplementary reading:

1. Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home. A review. Anesth Analg 2005;100:1822-1833
2. Rawal N. Perineural catheter analgesia as a routine method after ambulatory surgery-effective but unrealistic.Reg Anesth Pain Med 2012;37:72-78
3. Richman JM et al Does continuous peripheral nerve block provide superior pain control to opioids? A metaanalysis. Anesth Analg 2006;102:248-257.