A randomized controlled trial evaluating the impact of selective axillary nerve block after arthroscopic subacromial decompression

Abstract

Background: The sensory innervation of the shoulder is complex and there are variations in the branching patterns of the sensory fibres. Articular branches from the axillary nerve to the subacromial bursa are described in more than 50% of investigated shoulders but the isolated contribution of sensory input from the axillary nerve has never been investigated clinically. We hypothesized that a selective block of the axillary nerve would reduce morphine consumption and pain after arthroscopic subacromial decompression.

Methods: We included 60 patients in a randomized, blinded, placebo-controlled study. Patients were randomized to a preoperative selective ultrasound-guided axillary nerve block with 20 mL ropivacaine (7.5 mg/mL) or 20 mL saline. Primary outcome was intravenous morphine consumption 0-4 h postoperatively. Secondary outcome was postoperative pain evaluated by a visual analogue scale (VAS) score (0-100).

Results: We analysed data from 50 patients and found no significant difference in 0-4 h postoperative morphine consumption between the two groups (ropivacaine 14 mg, placebo 18 mg (P = 0.12)). There was a reduction in postoperative pain: VAS 0-4 h (area under the curve) (ropivacaine 135, placebo 182 (P = 0.03)), VAS after 8 h (ropivacaine 9, placebo 20 (P = 0.01)) and VAS after 24 h (ropivacaine 7, placebo 18 (P = 0.04)). Eight out of 19 patients with a successful selective axillary nerve block needed an interscalene brachial plexus escape block.

Conclusions: Selective block of the axillary nerve has some pain relieving effect, but in this setting the effect was unpredictable, variable and far from sufficient in a large proportion of the patients.

Trial registration: ClinicalTrials.gov (NCT01463865). Registered: November 1, 2011.

Keywords: Anatomy; Axillary nerve; Regional anesthesia; Selective nerveblocks.

Fig. 1

CONSORT Flow diagram of patients enrolled in the study

Fig. 2

a Surface anatomy and transducer position of selective axillary nerve block. The acromion (AC) and the scapular spine (SS) are marked. b Ultrasonographic image of the shoulder region with the transducer positioned as in Fig. 1. a Important landmarks are the deltoid muscle (DM), the humeral bone (HB), the teres minor muscle (TMM) in transverse section and the triceps muscle (TM) in longitudinal section. The axillary nerve (arrow) is cranial to the posterior circumflex humeral artery (*) in the neurovascular space (dotted triangle)