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General Anesthesia No Longer a Must for Shoulder Surgery

COLUMBUS, Ohio – There is no getting around one fact about shoulder surgery – it hurts. A lot.

But an orthopedic surgeon at Ohio State University Medical Center has led two studies indicating that the pain of waking up from general anesthesia after an operation can be eliminated by using a regional numbing block for almost all shoulder surgeries. The numbing medicine can provide up to 20 hours of pain relief, reducing or eliminating the use of strong narcotics that treat pain but leave many patients with nausea or vomiting after surgery.

The two studies looked at the use of the regional blocks on both open and arthroscopic surgeries. In both cases, researchers reported overwhelming success using what is called an interscalene block for a variety of surgeries, including fracture repairs and joint replacements. Moreover, this anesthesia technique was considered safe, with an average short-term complication rate of only about 2 percent, typically involving tingling in the fingers that eventually subsided.

When the block wears off, patients still feel the pain associated with the surgery, but they don’t wake up from general anesthesia suffering from horrible pain, said Dr. Julie Bishop, an orthopedic surgeon and sports medicine specialist at Ohio State’s Medical Center and lead author on the studies.

“With the regional block, they wake up and feel comfortable. Sometimes even patients who have undergone big procedures feel too good and want to go home. I have a hard time convincing them they should stay in the hospital overnight,” Bishop said. Even with a precautionary overnight stay, the use of the block also tends to lower costs by reducing the amount of recovery time and shortening hospital stays, she said.

In the first study, Bishop and colleagues reviewed the cases of 547 patients: 295 who underwent an arthroscopic procedure and 252 who underwent open surgery. Of the 478 patients for whom the interscalene block was planned, 462 patients, or 97 percent, had a successful regional block, and 16 required general anesthesia because the block was inadequate. These results were published in the Journal of Bone and Joint Surgery.

In another study examining the arthroscopic cases only, the researchers reported a 96 percent rate of successful blocks (277) among the 295 cases reviewed. These results were published in the Journal of Shoulder and Elbow Surgery.

Both studies show the regional block “can provide effective anesthesia for most types of shoulder surgery,” Bishop said.

Some doctors continue to resist a shift to the regional block because of a concern about complications. Bishop said collaboration between anesthesiologists and surgeons is key to successful use of the numbing technique, as well as discussion with patients about anesthesia options before the day of surgery.

With an interscalene block, numbing medication is injected via the neck to surround nerves throughout the arm. Depending on hospital, physician and patient preferences, the patient may also be sedated and intubated during the procedure. The numbing effect can last up to 20 hours, offering patients lasting pain relief after a typical two- to three-hour operation without the assault on the stomach associated with narcotic painkillers.

Though researchers did not ask patients about their level of satisfaction with the regional block experience, they reported a 100 percent acceptance rate of the numbing technique for patients who returned for repeat surgery or a procedure on a second shoulder.

“Most people don’t have an opposite experience to compare to, but if they do, they really notice the fact that they feel much better after a surgery with a regional block. They notice they leave the recovery room and hospital sooner, as well,” Bishop said.

Bishop described arthroscopy as the future of shoulder surgery because most conditions, especially athletic injuries, can be repaired with the minimally invasive procedure. In open shoulder surgeries, a three- to four-inch incision is required to split muscles and gain access to the location for repair.

Bishop said that in general, the most common injuries in high school and college athletes are shoulder dislocations experienced during a contact sport. Surgery is often recommended for these injuries because in people age 20 or younger, chances of repeat dislocation increase to 90 percent after the first injury. In middle age and older patients, the most common issues involve rotator cuff repairs.

Bishop collaborated with colleagues in the departments of orthopedics and anesthesiology at Mount Sinai Hospital in New York to conduct the research.

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