Comparison of the Combination of Interscalene Block and Superficial Cervical Block Anaesthesia with Interscalene Block Anaesthesia in Shoulder Surgery Operations

By Abdulhakim Sengel¹, Selcuk Secilmis², Evren Buyukfirat³, Nuray Altay³, Veysi Yazar⁴, Mehmet Baki Bilsel⁴

Affiliations

1. Department of Anaesthesiology and Reanimation, Siverek State Hospital, Siverek, Turkiye
2. Department of Anaesthesiology and Reanimation, Kahta State Hospital, Kahta, Turkiye
3. Department of Anaesthesiology and Reanimation, Faculty of Medicine Harran University, Haliliye, Turkiye
4. Department of Anaesthesiology and Reanimation, Mehmet Akif Inan Education and Research Hospital, Haliliye, Turkiye

doi: 10.29271/jcpsp.2025.06.769

ABSTRACT
Objective: To compare shoulder surgery patients who received interscalene nerve block (INB) and superficial cervical block (SCB) anaesthesia with those who received only INB anaesthesia.
Study Design: Observational study.
Place and Duration of the Study: Department of Anaesthesiology and Reanimation, Faculty of Medicine Harran University, Haliliye, Turkiye, from October 2020 to April 2023.
Methodology: A total of 60 participants aged between 18 and 75 years, belonging to the ASA I-II physical class and scheduled for arthroplastic and arthroscopic shoulder surgery, were divided into two groups. Group I received INB + SCB; Group II received only INB. Variables were compared as per the objective.
Results: There was no significant difference between the groups in terms of demographic variables. There was no significant difference between Group I and Group II in VAS scores at the 1^st hour; however, a significant difference was observed at the 3^rd, 6^th, and 12^th hours, with lower VAS scores in Group I.
Conclusion: Combined block method resulted in lower postoperative pain scores, longer pain-free periods, less opioid requirement, and higher patient satisfaction. Therefore, the INB + SCB combination will be a safe, less time-consuming, and highly effective alternative to other anaesthetic methods in arthroscopic and arthroplastic shoulder surgeries.

Key Words: Anaesthesia, Brachial plexus block, Cervical plexus block, Regional anaesthesia, Shoulder, Surgery.

INTRODUCTION

Ultrasound (US)-guided interscalene nerve block (INB) presently stands as the established gold standard regional anaesthesia (RA) approach for delivering analgesia following shoulder arthroplasty, shoulder arthroscopy, and other upper extremity procedures.^1-3 However, the pursuit of an optimal method for conducting shoulder surgery persists. The suprascapular nerve and the axillary nerve play a predominant role in providing motor and sensory innervation to the shoulder.
 

The supraclavicular nerves facilitate cutaneous supply to the shoulder, nose, and upper thoracic region, as well as sensory input to the acromioclavicular and sternoclavicular joints. Consequently, the cervical and brachial plexus coordinate the motor and sensory innervation of the shoulder.

The combined use of INB and superficial cervical block (SCB) is a novel approach that has been documented in a limited number of cases. Vandepitte et al. demonstrated successful application of this technique as the primary mode of anaesthesia in a pregnant patient with a clavicular fracture, attesting to its efficacy in achieving surgical anaesthesia.⁴

Based on this information, the aim of this study was to retrospectively compare a group of patients who underwent arthroscopic and arthroplasty shoulder surgery with the combination of INB and SCB as anaesthesia method with another group of patients who underwent only INB in order to facilitate the surgeon's work and increase the patient's intraoperative comfort and postoperative satisfaction.

METHODOLOGY

The study was approved by the Ethics Committee of Harran University, Turkiye (Approval ID: 23.09.25, Dated: 22 May 2023). G*Power 3.1.9.7 programme was used for power analysis. Sample size was calculated using the VAS score as the primary effect variable. Power analysis was calculated by determining 0.89 effect value and 0.95 power ratio for the VAS score. The calculated sample size was 58 patients, with 29 patients in each group. In order to increase the power of the study, the sample size of the study was rounded up to 60 patients.

From October 2020 to April 2023, a total of 60 participants aged between 18 and 75 years, belonging to the ASA I-II group based on the American’s Society of Anesthesiologists’ (ASA) physical classification, and scheduled for arthroplastic and arthroscopic shoulder surgery, were enrolled in the study. All participants in the study were adult individuals, and written informed consent was acquired from each of them.

Participants for whom peripheral nerve block (PNB) was deemed contraindicated, those classified under ASA III-IV-V groups, and those with moderate-to-severe pulmonary diseases, contralateral haemidiaphragm dysfunctions, or phrenic nerve injuries were excluded from the study.

In the first group, consisting of 30 patients, INB + SCB was given. In the second group, consisting of 30 patients, only INB was given (Figure 1). Twenty minutes following the block procedure, the patients underwent evaluation using the Bromage scale, cold sensation loss test, and pinprick test on the extremity where the block was performed for control purposes. The effectiveness of the block was documented, indicating whether it was successful or not. Following this assessment, the patient was transferred to the operating room, and the surgical procedure was  commenced.

Statistical analyses were performed in SPSS for Windows version 11. The Shapiro-Wilk’s test was employed to assess the conformity of the numerical data to a normal distribution. The Mann-Whitney U test was used to analyse non-normally distributed variables when comparing successful and unsuccessful block groups. The independent t-test was used to test whether there was a statistically significant difference between two independent groups by looking at the means. The chi-square test was used to compare categorical variables. Additionally, the Wilcoxon signed-rank test was utilised to compare non-normally distributed variables between the block and control groups. The mean values with standard deviations were used to present numerical variables, while categorical variables were expressed as counts and percentages. The analyses were performed using SPSS Windows version 24. Results were evaluated at a 95% confidence interval, and a p-value less than 0.05 was considered statistically significant.

RESULTS

Table I presents patients’ demographic information. Table II presents a comparison of some parameters between Group I and Group II. Table III presents the comparison of visual analogue scale (VAS) scores between Group I and Group II.

Upon examination of patient satisfaction, the duration of postoperative analgesia needed POKSAGD, and the frequency of analgesia required within the first 24 hours (I24SKDAGD) between the groups; a significant difference was observed in terms of patient satisfaction (Table IV).

DISCUSSION

In this study, no significant difference was found between the two groups in terms of intraoperative vital parameters. Moreover, the duration of surgical procedures exhibited comparable outcomes in both cohorts. Specifically, the application of the block persisted for an average of 6.26 ± 0.81 minutes in patients subjected to the combined approach of INB + SCB, while patients who underwent solely INB experienced a block duration of 4.73 ± 0.52 minutes. In this sense, a significant difference was found between the groups (p <0.001).

Table I: Patients’ demographic data.
 

Variables			n	Mean	Min.	Max.	Median	Std. deviation	p-value
Age (years)	Group I		30	51.2	18	73	56	17.297	0.790*
	Group II		30	53.2	18	74	56.5	15.110
Height (cm)	Group I		30	169.3	155	178	171	6.910	0.859*
	Group II		30	170.5	158	176	168.5	5.843
Weight (kg)	Group I		30	77.5	61	85	72	6.299	0.138**
	Group II		30	77.7	62	84	74	6.067
Gender	Male	Group I	17		56.7 %				0.797***
		Group II	16		53.3 %
	Female	Group I	13		43.3 %
		Group II	14		46.7 %
ASA	1	Group I	5		16.7 %				0.720***
		Group II	4		13.3 %
	2	Group I	25		83.3 %
		Group II	26		86.7 %
Comorbidity	No	Group I	19		63.3 %				0.792***
		Group II	18		60 %
	Yes	Group I	11		36.7 %
		Group II	12		40 %
ASA: American Society of Anesthesiology, Min-max: Minimum and maximum values, p <0.05: Statistically significant, Std. Deviation: Standard deviation, ***Chi-square test, **Independent t-test, *Mann-Whitney U test.

Table II: Comparison of the monitored and evaluation parameters between Group I and Group II.

Variables		n	p-value	95% CI			Median
				Mean	Min.	Max.
Processing time	Group I	30	<0.001	6.26	5	7	6
	Group II	30		4.73	4	6	5
Pinprick test	Group I	30	0.305	1.966	1	2	2
	Group II	30		1.870	1	2	2
Cold sense test	Group I	30	0.305	1.966	1	2	2
	Group II	30		1.870	1	2	2
C3C4DAA	Group I	30	0.88	0.033	0	1	0
	Group II	30		0.166	0	1	0
IODSR	Group I	30	0.88	0.033	0	1	0
	Group II	30		0.166	0	1	0
C3C4DAA: Pain in the C3-C4 dermatome area, IODSG: Intraoperative deep sedation requirement, Min-max: Minimum and maximum values, p <0.05: Statistically significant, Mann-Whitney U test.

Table III: Comparison of VAS scores between the groups.

Variables		n	Mean	Median	p-value	95% CI
						Mean	Min.	Max.
VAS1	Group I	30	1.20	1	0.614	1.23	1	3
	Group II	30	1.30	1
VAS3	Group I	30	1.3	1	0.008	1.6	1	3
	Group II	30	1.9	2
VAS6	Group I	30	1.26	3	0.002	3.2	2	7
	Group II	30	1.90	3
VAS12	Group I	30	3.70	3.5	0.001	4.75	2	8
	Group II	30	5.46	5
VAS: Visual analogue scale, Wilcoxon signed-rank test, Min-max: Minimum and maximum values, p <0.05: Statistically significant.

Table IV: Comparison between Group I and Group II in terms of satisfaction and analgesia.

Variables		n	Mean	Median	p-value	95% CI
						Mean	Min.	Max.
Satisfaction	Group I	30	4.57	5	<0.001	4.16	2	5
	Group II	30	3.75	4
POKSAGD	Group I	30	11.06	11.5	<0.001	9.18	4	14
	Group II	30	7.30	7
I24SKDAGD	Group I	30	1.36	1	<0.001	1.88	1	4
	Group II	30	2.40	2.5
POKSAGD: Number of hours postoperative analgesia needed, I24SKDAGD: How many times analgesia was needed in the first 24 hours, Min-max: Minimum and maximum values, p <0.05: Statistically significant, Mann-Whitney U test.

Figure 1: Block procedure and ultrasound image of the brachial plexus.
AS: Anterior scalene muscle; MS: Medial scalene muscle; VA: Vertebral artery; C: Cervical nerve root; T: Thoracic nerve root.

There was no significant difference in the postoperative first-hour VAS scores between the groups (p = 0.614); however, statistically significant differences were observed at the 3^rd (p = 0.008), 6^th (p = 0.002), and 12^th (p = 0.001) hours, with the INB + SCB group demonstrating lower pain scores. This early reduction in postoperative pain in the INB + SCB group may be attributed to the broader dermatomal coverage and additional analgesic effect provided by the superficial cervical plexus block.

In this study, it was determined that the postoperative analgesia effect of the blocks reduced postoperative opioid consumption in both groups. In this sense, Salviz et al. supported each other with the study on outpatient rotator-cuff repair surgery, in which, a decrease in postoperative opioid consumption was found in patients who underwent continuous INB.⁵

Alterations in the INB technique, including reducing the volume of local anaesthetic (LA),⁶ decreasing its concen-tration,⁷ and utilising low-pressure injection,⁸ have notably decreased the incidence of phrenic nerve palsy.⁹ To mitigate these complications, a total of 20 mL of LA mixture (14 mL for INB and 6 mL for SCB) was administered to patients in Group I. Patients in Group II received only 14 mL of LA solution for INB. Therefore, complications such as respiratory depression, Horner syndrome, and hoarseness due to phrenic nerve involvement resulting from the block were not detected in any patient.

Again, serious side effects, including pneumothorax, arterial puncture, LA intoxication, arrhythmia, seizures, and neurologic disorders, have been described concerning RA of the upper extremity.¹⁰ In this study, no complication similar to these studies in the literature was encountered.

Upon further review of the literature, numerous studies have consistently reported that INB and SCB performed by experienced anaesthesiologists yield high success rates and lead to high levels of patient satisfaction.^11-14 In this study, under US guidance, the success rate was 100% on the first attempt in both groups. These findings align closely with those of previous studies and likely contributed significantly to the overall high level of patient satisfaction.

Shoulder surgery was performed in the chaise lounge position. In literature, studies comparing GA and RA in cases of shoulder surgery performed in the chaise lounge position, it was reported that RA had a much lower risk of cerebral desatu-ration events (CDE) compared to GA groups (0-2.2 vs. 56.7-71.1%).^15,16 In light of this information, it is known that RA contributes to preventing many life-threatening complications, probably by facilitating the maintenance of blood perfusion and is safer than GA in this respect.¹⁷ In this study, no finding or symptom related to CDE was observed in any of the sixty patients in the two separate groups.

In this study, one of the most common problems and even the most important problem identified in Group I and Group II patients was the increase in intraoperative blood pressure immediately after the start of surgery. It was thought that this could be due to many reasons. First, this state of haemody-namic instability may result from surgical manipulations performed during anaesthesia. Secondly, conscious patients' doubts, fears, and excitement about whether they will feel pain at the beginning of the operation may trigger this situation. To prevent this, sedation was applied to each patient before the block procedure. A third potential factor may be the increased risk of intraoperative urinary urgency resulting from benign prostatic hyperplasia, a condition more common in older age groups. After inserting a urinary catheter into all patients included in the study, operations were started in order to accurately monitor their haemodynamics and prevent the tension from increasing during the surgery. The fourth reason was that the area where the block was applied was rich in vascular and nerve structures; these vital structures were exposed to pressure due to the applied volume, which may have caused an increase in blood pressure as a reaction. For this, larger and more detailed studies are needed.

Takayama et al. reported a satisfaction rate of approximately 98.3% among participants who received INB. The primary reason for dissatisfaction was urinary urgency and the need to urinate during surgery.¹⁷ Another study in the literature reported that opioid consumption decreased in patients who underwent INB, the discharge time of patients from the hospital was shortened, and patient satisfaction increased.¹⁸ In this study, a 5-point Likert scale was used to evaluate patient satisfaction between Group I and Group II patients. In this sense, a significant difference was detected between the groups (p = 0.000). The lower values ​​of VAS3, VAS6 and VAS12 in Group I suggested that patients in this group expe-rienced less pain in the postoperative period than Group II, and therefore, patients in this group received less analgesics in the postoperative period and use fewer opioids in the first 24 hours after surgery. This was thought to affect patient satisfaction.

This study has some limitations. The first limitation is that not all anaesthesiologists are experienced in regional anaesthesia techniques, so the study results may not be valid for institutions without an expert team. A second limitation of the study is that not all institutions have access to the US technology for applying regional anaesthesia. Again, the sample size limits the study, and a larger study on this subject would be appropriate.

CONCLUSION

This study suggests combining INB + SCB under US guidance may be more effective than the INB alone in arthroscopic and arthroplastic shoulder surgeries. Although no significant difference was found between the groups in terms of pain in the C3-C4 dermatome region, it was thought that more studies were needed in this regard. The combined block method resulted in lower postoperative pain scores, longer pain-free periods, less opioid requirement, and higher patient satisfaction. Therefore, the INB + SCB combination will be a safe, less time-consuming, and highly effective alternative to other anaesthetic methods in arthroscopic and arthroplastic shoulder surgeries.

ETHICAL  APPROVAL:
This study was approved by the Ethics Committee of Harran University, Turkiye (Approval ID: 23.09.25, Dated: 22 May 2023).

PATIENTS’  CONSENT:
Written informed consent was acquired from each patient involved in the study.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
AS: Conception and design of the work.
SS: Data interpretation.
EB: Drafting and data acquisition.
NA: Final approval of the manuscript.
VY: Drafting of the work.
MBB: Data analysis.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Panchamia JK, Amundson AW, Jacob AK, Sviggum HP, Nguyen NTV, Sotelo JS, et al. A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty. J Shoulder Elb Surg 2019; 28(10):e325-e38. doi: 10.1016/j. jse.2019.05.013.
2. Yan S, Zhao Y, Zhang H. Efficacy and safety of interscalene block combined with general anesthesia for arthroscopic shoulder surgery: A meta-analysis. J Clin Anesth. 2018; 47: 74-9. doi: 10.1016/j.jclinane.2018.03.008.
3. Gundogdu O, Avci O. Evaluation of the Effect of interscalene brachial plexus block on intracranial pressure using optic nerve sheath diameter and internal jugular vein collapsibility index. J Coll Physicians Surg Pak 2022; 32(10):1249-54. doi: 10.29271/jcpsp.2022.10.1249.
4. Vandepitte C, Latmore M, O'Murchu E, Hadzic A, de Velde MV, Nijs S. Combined interscalene-superficial cervical plexus blocks for surgical repair of a clavicular fracture in a 15-week pregnant woman. Int J Obstet Anesth 2014; 23(2): 194-5. doi: 10.1016/j.ijoa.2013.10.004.
5. Salviz EA, Xu D, Frulla A, Kwofie K, Shastri U, Chen J, et al. Continuous interscalene block in patients having outpatient rotator cuff repair surgery: A prospective randomized trial. Anesth Analg 2013; 117(6):1485-92. doi: 10.1213/01.ane. 0000436607.40643.0a.
6. Chibata I, Tosa T. Transformations of organic compounds by immobilized microbial cells. Adv Appl Microbiol 1977; 22:1-27. doi: 10.1016/S0065-2164(08)70158-8.
7. Wong AK, Keeney LG, Chen L, Williams R, Liu J, Elkassabany NM. Effect of local anesthetic concentration (0.2% versus 0.1% ropivacaine) on pulmonary function, and analgesia after ultrasound-guided interscalene brachial plexus block: A randomized controlled study. Pain Med 2016; 17(12):2397- 403. doi: 10.1093/pm/pnw057.
8. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic nerve palsy and regional anesthesia for shoulder surgery: Anatomical, physiologic, and clinical considerations. Anaesthesiology 2017; 127(1):173-91. doi: 10.1097/ALN.0000000000001668.
9. Vijayakumar V, Ganesamoorthi A, Subramaniyan N, Kasirajan P. Ultrasound‑guided superior and middle trunk brachial plexus block with superficial cervical plexus block for shoulder surgeries in high‑risk patients: Case series. J Med Ultrasound 2020; 28(3):185-7. doi: 10.4103/JMU.JMU_73_19.
10. Lenters TR, Davies J, Matsen FA. 3^rd the types and severity of complications associated with interscalene brachial plexus block anesthesia: Local and national evidence. J Shoulder Elbow Surg 2007; 16(4):379-87. doi: 10.1016/j.jse.2006. 10.007.
11. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: A prospective study. Anesthesiol 2001; 95(4):875-80. doi: 10.1097/00000542-200110000- 00015.
12. Bishop JY, Sprague M, Gelber J, Krol M, Rosenblatt MA, Gladstone JN, et al. Interscalene regional anesthesia for arthroscopic shoulder surgery: A safe and effective technique. J Shoulder Elbow Surg 2006; 15(5):567-70. doi: 10.1016/j.jse.2006.01.009.
13. Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: A systematic review. J Bone Joint Surg Am 2013; 95(14):1318-24. doi: 10.2106/JBJS.L.01116.
14. Singh A, Kelly C, O'Brien T, Wilson J, Warner JJP. Ultrasound-guided interscalene block anesthesia for shoulder arthroscopy: A prospective study of 1319 patients. J Bone Joint Surg Am 2012; 94(22):2040-6. doi: 10.2106/JBJS.K. 01418.
15. Aguirre J, Borgeat A, Trachsel T, Del Prado IC, De Andres J, Buhler P. Cerebral oxygenation in patients undergoing shoulder surgery in beach chair position: comparing general to regional anesthesia and the impact on neurobehavioral outcome. Rev Esp Anestesiol Reanim 2014; 61(2):64-72. doi: 10.1016/j.redar.2013.08.002.
16. Koh JL, Levin SD, Chehab EL, Murphy GS. Neer award 2012: Cerebral oxygenation in the beach chair position: A prospective study on the effect of general anesthesia compared with regional anesthesia and sedation. J Shoulder Elbow Surg 2013; 22(10):1325-31. doi: 10.1016/j.jse.2013. 01.035.
17. Takayama K, Shiode H, Ito H. Ultrasound-guided inter-scalene block anesthesia performed by an orthopedic surgeon: A study of 1322 cases of shoulder surgery. JSES Int 2022; 6(1):149-54. doi: 10.1016/j.jseint.2021.08.008.
18. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, et al. A preemptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008; 33(6):510-7.