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| Frequently Asked Questions |
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| Category #13 - The shoulder joint |
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| Frozen shoulder and ISB |
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You mention that a relative contraindication to a continuous interscalene block is a "frozen shoulder" having a capsulotomy, and a better choice is the posterior approach. Is this because the interscalene block may be implicated in subsequent EMG studies where in fact, it was probably surgical manipulation or is it some other reason?
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Thank you for this interesting question and the opportunity to clarify the whole issue around frozen shoulder.
Frozen shoulder is an interesting problem in that it is histologically similar to Dupuytren's disease or Peyronie's disease, which is a fibromatosis. The condition itself (apart from in the acute phase), is therefore, like Dupuytren's disease, not painful. Unfortunately, there is very scanty literature available on this condition, but there are some interesting thoughts.
The condition, which is a fibromatosis, shrinks the whole capsule and "fibroses" the whole capsule of the shoulder joint. Thus, as the result of "freezing" of the shoulder joint in the functional or anatomical position the arm is in internal rotation, abduction and forward flexion. If you asked patients with adhesive capsulitis or frozen shoulder how they get rid of the pain in the shoulder, they would immediately place the arm in the anatomical or functional position.
Now, carrying the arm at the side would have the effect of rotation of the scapula and this causes a condition known to shoulder surgeons as "pseudo winging" of the shoulder blade. The effect of this is that the distance from the cervical spine to the coracoid process is slightly lengthened and this applies traction to the brachial plexus. The brachial plexus crosses the first rib and at this area the brachial plexus would be under maximum tension and also undergoes maximum movement. It therefore sounds logical that the pain associated with frozen shoulder or adhesive capsulitis could be due to traction of the brachial plexus. The fact that the placement of the arm in the functional position relieves this pain, underscores this possibility.
Because the pain of frozen shoulder or adhesive capsulitis, most likely does not originate from the shoulder joint but from the brachial plexus, my hesitance to do interscalene blocks for frozen shoulder, should be clear at this stage. If, however, a brachial plexus block is done, (and it should be done), it should be wise not to place a catheter and volume (hat cause further pressure), not to mention epinephrine that cause further ischemia, at the exact place on the brachial plexus where the brachial plexus is under maximum tension and maximum irritation. Out of a personal series of 4700 interscalene catheters following major shoulder surgery, fourteen patients developed neuropathic pain post-operatively that was even diagnosed as complex regional pain syndrome (CRPS) Type II. This burning pain in the arm, in effect, was most probably further irritation to an already irritated brachial plexus by the ISB.
Since we abolished the use of continuous interscalene blocks as a routine block for major shoulder surgery, and replaced it with the cervical paravertebral block - some 3,000 blocks ago, we have not encountered this problem again. It was rather a refreshing new start to my practice, where I did not anymore have to fear telephone calls by surgeons since this is not a problem anymore.
Having said that, we default on cervical paravertebral blocks for all major surgery of the entire upper limb and this also simplifies our practice in that we do not have to rely on the disappointing results that we obtained from infraclavicular blocks for elbow and wrist surgery and we certainly do not have to fear telephone calls from surgeons following capsulotomy for adhesive capsulitis.
I trust that this explanation answers your questions. Should you have any further questions, please do not hesitate to contact me personally or to post your question via the website.
Yours sincerely,
André Boezaart.
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I read in one of your articles that an interscalene block is contraindicated in a frozen shoulder, and that you recommend a cont. cervical PVB?
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I don't think ISB is contra-indicated, I think it is relatively contra-indicated for me personally. I am of that opinion, since of a personal series of 4700 Continuous ISB I had 14 patients who ended up with neuropathic pain (transient) and 10 of these 14 were patients who had arthroscopic capsulotomy for frozen shoulder. But, as you know, not all frozen shoulders are equal and there is MUCH more to it than that. The reason for the problem (I think) is that the ISB is placed where the plexus crosses the first rib. This is a narrow space and, also, the plexus in the case of frozen shoulder is already under traction and stressed where it crosses the first rib because of rotation of the scapula. Since we have been doing cervical paravertebral block, this problem has not been seen - well over 2000 now. CPVB is also a better block for frozen shoulder, since it is very much motor sparing.
Please visit the RA Education website at http://www.RAEducation.com and download these movies. There are three movies on the CCPVB. One is a 3-minute movie, a 10-minute workshop and a full demonstration of the block. You will also find a full narrative on the block. Please also see Reg Anesth Pain Med 2003: 28: 241 - 244 and Reg Anesth Pain Med 2003; 28: 406 - 413 for the original description and our experience with the first 256 CCPVB/s.
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What are your thoughts on blocks in frozen shoulders?
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The primary concern in frozen shoulder surgeries lies in the fact that these surgeries are essentially capsulotomy of the gleno-humeral joint. As a result of this, the brachial plexus is at great risk for traction injury. The surgeon cuts the capsule of the shoulder joint and the block reduces the muscle tone. The brachial plexus may also be under stress from traction because the scapula is rotated with frozen shoulder. The area of maximum stress of the plexus is where it crosses the first rib. In fact, these surgeries have a very high rate of peripheral neuropathies post-operatively. It is wise then, to try to not include oneself in any unfortunate sequelae that may result, if possible. Cervical paravertebral block may be the ideal block to do for this condition, since it provides a more sensory than motor block, and the block is done more proximal and away from the area where the brachial plexus crosses the first rib. Be careful of the patient who presents for shoulder surgery, but presents with pain or paresthesia distal to the elbow. Bona fide shoulder pathology does not cause pain distal to the elbow. It is most likely caused by existing brachial plexitis. This condition is often associated with frozen shoulder and it is hugely under-recognized.
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