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Department of Anesthesia and Pain Management, Royal Melbourne Hospital Melbourne Orthopaedic Group, Melbourne, Australia
To the Editor:
We agree with Klein et al. (1) that a small dose local anesthetic infusion can be a valuable adjunct to interscalene brachial plexus anesthesia for shoulder arthroscopy. However, these authors failed to address a key aspect of management in such patients. Firstly, it was not specified whether arthroscopy was indicated for either a diagnostic, decompressive, release or reconstructive procedure. Secondly there was no assessment or mention of the duration of postoperative motor paresis following brachial plexus anesthesia.
In our practice, many patients undergo shoulder arthroscopic release procedures such as capsulectomy. Immediate post-operative mobilization is extremely important for maximizing the final range of motion of this joint (2). As such, any regional technique used must avoid prolonged motor blockade, as well as provide effective analgesia for active physiotherapy to occur. The Gold standard of continuous interscalene brachial plexus anesthesia using ropivacaine can provide analgesia, as well as maintain hand strength (3), but may still impair motor function, preventing active shoulder movement. Alternatively, intraarticular infusion of local anesthetic preceded by a short acting single-injection interscalene brachial plexus block is one approach that enables aggressive early physiotherapy and mobilization.
References
Department of Anesthesiology, Duke University Medical Center, Durham, NC
In Response:
We thank Dr. Soeding for his interest and support of our recent manuscript (1). The majority of the cases in our report consisted of diagnostic arthroscopies and therefore immediate shoulder mobilization as part of physiotherapy was not indicated. Because patients were partially immobilized during the course of the study (surgical preference) and motor paresis via the intraarticular route does not occur this assessment was not made. Extensive information already exists in the literature as to the duration of motor blockade after mepivacaine and ropivacaine (2).
We agree that in certain circumstances immediate postoperative mobilization is essential and there are several strategies to deal with analgesia including continuous outpatient interscalene brachial plexus blockade (3). While analgesia in our study was provided after a simple arthroscopy it would be interesting to investigate more painful procedures using these modalities with either active or passive range of motion.
References
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