Case Study: Cervical epidural anaesthesia for shoulder arthroscopy

Cervical epidural anaesthesia for shoulder arthroscopy and effective postoperative physiotherapy for a frozen shoulder: a case study

Marodkar K, MD Anaesthesiology, Assistant Professor; Deshmukh S, MD Anaesthesiology, Professor Department of Anaesthesiology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India Correspondence to: Ketaki Marodkar, e-mail: [email protected] Keywords: cervical epidural anaesthesia, shoulder arthroscopy, frozen shoulder, postoperative physiotherapy

Abstract
Shoulder arthroscopy is used to treat various diseases of the shoulder, including refractory adhesive capsulitis. Effective postoperative pain relief is critical for these patients, as the success of surgery largely depends on early and regular physiotherapy. Although traditionally, various methods of postoperative analgesia have been described, each has its own disadvantages. We report a case of adhesive capsulitis, for which arthroscopic capsular release was carried out under cervical epidural anaesthesia with general anaesthesia, resulting in excellent intraoperative and postoperative analgesia, with a better patient compliance for physiotherapy, and a significant improvement in the range of movement at the shoulder joint.
Peer reviewed. (Submitted: 2011-10-03. Accepted: 2012-02-10.) SASA South Afr J Anaesth Analg 2012;18(3):172-175

Introduction
Shoulder arthroscopy is commonly used to treat various diseases of the shoulder, including subacromial impingement, acromioclavicular osteoarthritis, rotator cuff tears, a frozen shoulder (adhesive capsulitis), chronic tendonitis, partial tears of the long biceps tendon, superior labrum anterior-posterior (SLAP) lesions, and shoulder instability. Even minor shoulder surgery, such as rotator cuff repair, may lead to severe postoperative pain within the first 48-72 hours.1 This not only causes discomfort for the patient, but also compromises the intensive postoperative physiotherapy that is essential to avoid recurrence of the problem.2 Many shoulder procedures can be carried out with regional anaesthesia alone, but a combination of regional and general anaesthesia may be more appropriate for prolonged major procedures, or where discomfort in other areas may limit comfortable positioning on the operating table.3 Currently, single-injection interscalene brachial plexus block,4 suprascapular nerve block,5 and intra-articular injection of ropivacaine,6 are some of the modalities used for analgesia in shoulder arthroscopies, but none of them is effective in providing sustained postoperative analgesia.

Continuous epidural infusion represents a viable alternative that has the advantage of the addition of local anaesthetics to narcotics, to provide better intraoperative and postoperative analgesia, and improve the range of movement. The risks and complications of this approach can be avoided by careful titration of the infused medications, careful haemodynamic monitoring, and adequate patient and family education.7 We hereby report successful anaesthetic management of a case of a 50-year-old woman with a frozen shoulder, posted for capsular release surgery using cervical epidural anaesthesia, together with general anaesthesia.

Case study
A 50-year-old woman attended an orthopaedic outpatient department with a history of pain and stiffness in the left shoulder for the period of a year. There was no history of trauma to the joint, and no significant past medical or surgical history. On general examination, she was thinly built (a weight of 40 kg), with a regular pulse rate of 70 beats per minute, and blood pressure of 128/72 mmHg in the right arm, in a supine position. Her systemic examination did not reveal any abnormality. Her spine was normal, and her Mallampatti grade was I.

South Afr J Anaesth Analg

172

2012;18(3)

Case Study: Cervical epidural anaesthesia for shoulder arthroscopy

Local examination of her left shoulder revealed a stiff shoulder, with a reduced range of movement. Table I shows how severely her range of movement was reduced, as compared to normal values.
Table I: Patients preoperative range of motion compared to normal range
Movement Forward flexion Abduction External rotation (side) Internal rotation (side) External rotation:internal rotation Normal range (degree) 160-180 160-180 70-80 Reach D8-D10 90:90 Patients range (degree) 20 20 10 Nil Not possible

was administered with 8 ml of 0.25% bupivacaine and 25 g fentanyl citrate. Vitals remained stable. Twenty to 30 minutes later, when the patient was asked to reassess her pain, she confirmed an improvement in her symptoms in the form of reduced pain and stiffness. On checking passive movements by the orthopaedician, a significant improvement in the range of movements was noticed, as depicted in Table II.
Table II: Comparison of range of motion before, and after, epidural analgesia
Movement Forward flexion Abduction External rotation (side) Internal rotation (side) External rotation:internal rotation Pre-epidural (degree) 20 20 10 Not possible Not possible Post-epidural (degree) 40 45 30 Can reach sacral region (30) 30:30

A diagnosis of left adhesive capsulitis was made, and the patient was advised to undergo physiotherapy. The severe pain did not allow her to participate in regular exercise, and the stiffness was progressive. Therefore, she was posted for elective arthroscopic capsular release surgery. Her haematological investigations and electrocardiograph (ECG) were unremarkable, and so she was classified as an American Society of Anesthesiologists (ASA) I patient, and posted for surgery. A decision was taken to administer cervical epidural anaesthesia with general anaesthesia, and the procedure was explained to the patient. After written informed consent had been obtained, and overnight fasting status had been confirmed, the patient was taken into the operating room and routine non-invasive monitors, including a five-lead ECG, a non-invasive blood pressure monitor, a capnograph, a pulse oximetry probe, and a temperature probe, were attached. Peripheral wide-bore intravenous access was achieved on the right forearm, and lactated Ringer infusion was started. Premedication given to the patient included intravenous glycopyrrolate (0.2 mg), intravenous ranitidine hydrochloride (50 mg), and intravenous ondansetron (4 mg). The position given to the patient was that of sitting on a stool with a flexed neck, with her head resting on the operation table. The C7-T1 intervertebral space was infiltrated with 2 ml of 2% lignocaine. The epidural space was identified using an 18 G Tuohy needle by loss of resistance to air, and reconfirmed by the ability to inject saline without resistance. The distance of the epidural space from the skin was found to be 3.5 cm. An epidural catheter (18 G) was inserted and flushed, and after confirming negative aspiration of blood or cerebrospinal fluid (CSF), it was fixed at the 8 cm mark. The patient was made supine, and an epidural test dose was given with 3 ml of 1% lignocaine with adrenaline. After confirming stable vitals, an epidural top-up dose

Next, we sedated the patient with intravenous midazolam (1 mg) and intravenous fentanyl citrate (50 g). After preoxygenation with 100% oxygen via a mask for three minutes, general anaesthesia was induced with intravenous propofol (100 mg), and endotracheal intubation facilitated with intravenous suxamethonium (100 mg). A polyvinylchloride cuffed number seven (07) endotracheal tube was used to intubate the trachea, and anaesthesia was maintained with 50% nitrous oxide and 0.8-1% isoflurane in oxygen. Intravenous vecuronium bromide (3 mg) was used for muscle relaxation. Surgery was performed in the right lateral position and was uneventful. The patients haemodynamics remained stable throughout the procedure. Intraoperative narcotic top-up doses were not required. Surgery was completed in one hour and 45 minutes, after which the patient was reversed, and her trachea extubated. An epidural top-up dose was administered containing 8 ml of 0.125% bupivacaine, and the patient was moved to the post-anaesthesia care unit. Postoperatively, epidural top-up doses of 8 ml of 0.125% bupivacaine, with 25 mcg fentanyl citrate, were given eight hourly to keep the patient pain-free. Postoperatively, the patients vitals were monitored using a multipara monitor (Phillips Suresign VM6) in the postanaesthesia care unit. Vitals remained stable throughout the postoperative period. The visual analogue scale (VAS) scores were noted hourly in the postoperative period. The dynamic VAS score remained around 3-4, and the static VAS score remained around 2 in the postoperative period. The patient did not require any rescue analgesia in the postoperative period. Physiotherapy was started after 12 hours, and was conducted thrice a

South Afr J Anaesth Analg

173

2012;18(3)

Case Study: Cervical epidural anaesthesia for shoulder arthroscopy

day. The epidural catheter was removed after 72 hours, and the patient was discharged on the sixth day. At the time of discharge, her shoulder stiffness had decreased significantly, and the range of motion in her operated shoulder was as depicted in Table III.
Table III: Comparison of range of motion before and after surgery
Movement Forward flexion Abduction External rotation (side) Internal rotation (side) External rotation:internal rotation Preoperative (degree) 20 20 10 Not possible Not possible Postoperative (degree) 100 110 40 Can reach L5 (60) 60:60

A decision was taken to conduct the surgery under general anaesthesia with cervical epidural anaesthesia. Brown9 has quoted the innumerable advantages of regional anaesthesia for shoulder surgery, including better postoperative analgesia, less intraoperative blood loss, localised muscle relaxation, reduced recovery room stay, and cost effectiveness. Although some of these advantages may be lost by using the combined technique, the overall comfort of the patient in the lateral decubitus position for almost two hours, may be best served by the use of a combinedanaesthesia technique.9 Brown has mentioned that interscalene brachial plexus block is better, and technically easier, than cervical epidural anaesthesia. Continuous interscalene brachial plexus block, using a catheter, can be an effective mode of analgesia, but catheter insertion and threading can be really difficult in interscalene block.13 Single-injection interscalene brachial plexus block and suprascapular nerve block are both effective anaesthetic modalities for intraoperative analgesia, but are limited by the duration of action of the local anaesthetic, and readmission for pain control is common in the postoperative period.4,5 Intra-articular injection of ropivacaine can also be used for postoperative analgesia after arthroscopic surgeries, but its use after shoulder arthroscopy is still under investigation.6 We used a cervical epidural catheter for intraoperative and prolonged postoperative analgesia, by using a combination of bupivacaine and fentanyl citrate. Cervical epidural anaesthesia, although a safe technique if performed by an experienced anaesthesiologist, has several known complications, including inadvertent dural puncture, inadvertent subdural puncture, inadvertent intravenous needle and catheter placement, haematoma and ecchymosis, infection, neurological complications, respiratory compromise, bilateral phrenic nerve palsy, and urinary retention. These complications should always be kept in mind while performing a cervical epidural anaesthetic technique. Narouze et al7 studied 25 patients with frozen shoulders, posted for shoulder arthroscopy. They used a tunnelled cervical epidural catheter for postoperative analgesia, and noted a statistically significant increase in range of motion. They concluded that this method was an effective alternative to oral pain medications for analgesia in the rehabilitative phase of a refractory frozen shoulder. Zablocki et al14 have reported the successful use of cervical epidural anaesthesia in controlling postoperative pain following shoulder surgery, but they have warned that it may be risky in inexperienced hands.

The patient was discharged, fully satisfied with the treatment, with instructions to do shoulder exercises at home, and to return for a review and follow-up after four weeks.

Discussion
Arthroscopic surgery, being a minimally invasive surgery, reduces recovery time, and may increase the rate of surgical success due to less trauma to the connective tissue. In their study of patients with frozen shoulders, Warner et al8 concluded that in patients experiencing loss of mobility, refractory to closed manipulation arthroscopic capsular release improves motion reliably, with little operative morbidity. Frozen shoulder surgery may be associated with severe postoperative pain that needs to be effectively controlled to encourage early physiotherapy, which is critical for the success of the surgery.9 Although idiopathic adhesive capsulitis is usually selflimiting, 10% of patients who receive non-operative therapy never fully recover normal shoulder activity.10 Our patient had a significantly reduced range of motion in her left shoulder that was progressive, and accordingly, she was posted for arthroscopic capsular release surgery. Evelin et al11 have reported venous air embolism during shoulder arthroscopy, and concluded that although rare, it should always be kept in mind. Therefore, proper monitoring is essential. Ichai et al12 have reported death due to cerebral oedema, caused by intravascular absorption of glycine in shoulder arthroscopy. With these complications in mind, we attached the necessary monitors to our patient, including an ECG, a non-invasive blood pressure monitor, a pulse oximetry probe, a capnograph, and a temperature probe.

South Afr J Anaesth Analg

174

2012;18(3)

Case Study: Cervical epidural anaesthesia for shoulder arthroscopy

Conclusion
We conclude that cervical epidural anaesthesia, together with general anaesthesia, can be a safe and effective method of conducting shoulder arthroscopic surgery, and providing analgesia for postoperative physiotherapy. However, it should be performed by an experienced anaesthesiologist, and careful monitoring of the patient should continue in the intraoperative and postoperative period, bearing in mind the abovementioned complications.

5. Barber FA. Suprascapular nerve block for shoulder arthroscopy. ShoulderDoc.co.uk [homepage on the Internet]. c2011. Available from: www.shoulderdoc.co.uk /article.asp?article=560 6. Rodola F, Vagnoni S, Avolio SD, et al. Intra-articular analgesia following arthroscopic surgery of the shoulder. Eur Rev Med Pharmacol Sci. 2001;5(4):143-146. 7. Narouze SN, Govil H, Guirguis M, Mekhail NA. Continuous cervical epidural analgesia for rehabilitation after shoulder surgery: a retrospective evaluation. Pain Physician. 2009;12(1):189-194. 8. Warner JP, Allen A, Marks PH, Wong P. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am. 1996;78:1808-1816. 9. Brown AR. Anaesthesia for shoulder surgery. In: Iannotti JP, Williams GR Jr, editors. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams and Wilkins, 2006; p.1075-1098. 10. Pearsall AW. Adhesive capsulitis treatment and management. Medscape [homepage on the Internet]. c2011. Available from: http://emedicine.medscape.com/article/1261598-treatment 11. Eveline AM, Cook RI, Miles D. Air embolism during anaesthesia for shoulder arthroscopy. Anasthesiology. 1998;89(3):805-806. 12. Ichai C, Ciais J, Roussel L. Intravascular absorption of glycine irrigating solution during shoulder arthroscopy: a case report and follow-up study. Anesthesiology. 1996;85:1481-1485. 13. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth. 2010;105(1):97-107. 14. Zablocki A, Baysinger C, Epps J, Bucknell A. Cervical epidural anaesthesia for surgery of the shoulder. Orthop Rev. 1987;16(2):65-70.

References
1. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg. 2000;91(6):1473-1438. 2. Singelyn FJ. Peripheral nerve blocks for postoperative analgesia after major orthopaedic upper limb surgery. CSEN Anesthesia Mailing List [homepage on the Internet]. c2011. Available from: http:// health.dir.groups.yahoo.com/group/csen-anesthesia-mailing-list/ message/5589?var=1 3. Beecroft CL, Coventry DM. Anaesthesia for shoulder surgery. BJA. 2008;8(6):193-198. 4. Phillips P, Cagle H, Herrera H. The use of interscalene block prior to shoulder arthroscopy: implications for postoperative pain management. The Internet Journal of Anaesthesiology [homepage on the Internet]. c2011. Available from: http://www.ispub.com/ journals/IJA/Vol1N1/articles/isblock.htm

South Afr J Anaesth Analg

175

2012;18(3)