Ultrasound-Guided Out-of-Plane vs. In-Plane Interscalene Catheters: A Randomized, Prospective Study

Abstract

Background: Continuous interscalene blocks provide excellent analgesia after shoulder surgery. Although the safety of the ultrasound-guided in-plane approach has been touted, technical and patient factors can limit this approach. We developed a caudad-to-cephalad out-of-plane approach and hypothesized that it would decrease pain ratings due to better catheter alignment with the brachial plexus compared to the in-plane technique in a randomized, controlled study.

Objectives: To compare an out-of-plane interscalene catheter technique to the in-plane technique in a randomized clinical trial.

Patients and methods: Eighty-four patients undergoing open shoulder surgery were randomized to either the in-plane or out-of-plane ultrasound-guided continuous interscalene technique. The primary outcome was VAS pain rating at 24 hours. Secondary outcomes included pain ratings in the recovery room and at 48 hours, morphine consumption, the incidence of catheter dislodgments, procedure time, and block difficulty. Procedural data and all pain ratings were collected by blinded observers.

Results: There were no differences in the primary outcome of median VAS pain rating at 24 hours between the out-of-plane and in-plane groups (1.50; IQR, [0 - 4.38] vs. 1.25; IQR, [0 - 3.75]; P = 0.57). There were also no differences, respectively, between out-of-plane and in-plane median PACU pain ratings (1.0; IQR, [0 - 3.5] vs. 0.25; IQR, [0 - 2.5]; P = 0.08) and median 48-hour pain ratings (1.25; IQR, [1.25 - 2.63] vs. 0.50; IQR, [0 - 1.88]; P = 0.30). There were no differences in any other secondary endpoint.

Conclusions: Our out-of-plane technique did not provide superior analgesia to the in-plane technique. It did not increase the number of complications. Our technique is an acceptable alternative in situations where the in-plane technique is difficult to perform.

Keywords: Brachial Plexus Block; Nerve Block; Peripheral Nerve; Regional Anesthesia; Shoulder Pain.

Figure 1.. A) In-Plane Approach, B) Out-of-Plane Approach. The Skin Has Been Peeled Away to Show The Underlying Brachial Plexus and Possible Spatial Relationship Between The Catheter After it is Inserted and The Superior Portions of The Plexus

Figure 2.. Consort Flow Diagram

Figure 3.. Notched Dox Plot Illustrating the Median VAS Pain Scores on a 10-cm Scale at 24 Hours for the In-Plane and Out-of-Plane Groups