Möglichkeiten und Grenzen der interskalenären Blockade

 

 Buy Article Permissions and Reprints

Zusammenfassung

Regionalverfahren haben in den letzten Jahren zunehmend an Bedeutung gewonnen. Voraussetzung für eine erfolgreiche Regionalanästhesie der Schulterregion ist die exakte Kenntnis der anatomisch relevanten Strukturen. Die gebräuchlichsten Techniken der interskalenären Blockade sind das Verfahren nach Winnie, seine Modifikationen nach Meier und Borgeat sowie der posteriore Zugang nach Pippa. Insbesondere die Techniken nach Meier und Borgeat zeichnen sich durch geringe Komplikationsraten aus. Sie sind für fast alle Eingriffe an der Schulter geeignet und bieten – vor allem als Kathetertechniken –sowohl eine wichtige Ergänzung bzw. Alternative zur Allgemeinanästhesie als auch eine unentbehrliche Option für die postoperative Schmerztherapie.

Abstract

Regional anaesthesia has gained increasing importance during the last decades. Successful regional anaesthesia for shoulder surgery requires a detailed knowledge of the relevant anatomy. Interscalene nerve blocks are most frequently used to anaesthetize the shoulder and among them the techniques according to Winnie, Meier, Pippa and Borgeat are the most popular. The techniques described by Meier and Borgeat are characterized by low complication rates. They are efficient for the majority of surgical procedures and therefore offer an interesting supplementation or an alternative to general anaesthesia. When carried out as a catheter–technique they provide a high quality postoperative pain therapy.

Kernaussagen

• Operative Eingriffe am Schultergelenk sind sehr schmerzhaft. Oft besteht eine große Diskrepanz zwischen mäßigen Ruheschmerzen und erheblichen bewegungsabhängigen Schmerzen.

• Regionalverfahren bieten eine gegenüber anderen Verfahren überlegene Analgesiequalität.

• Genaue Kenntnisse der Anatomie des Plexus brachialis sind für eine erfolgreiche Blockadetechnik notwendig.

• Auch bei „lege artis” durchgeführten Blockaden können Teilbereiche des Operationsgebietes von der Blockade ausgespart bleiben.

• Hohe Erfolgsraten bieten die interskalenären Blockaden, z. B. die Techniken nach Meier oder Borgeat.

• Die Komplikationsraten dieser Techniken sind gering; bleibende neurologische Defizite sind nur in Einzelfällen beschrieben.

• Wird die Blockade als singuläres Verfahren eingesetzt, können neben den blockadetechnischen Komplikationen auch die Auslösung des Bezhold–Jarisch–Reflexes und Atemwegsverlegungen durch periartikuläre Flüssigkeitseinschwemmung bei Arthroskopien Probleme bereiten.

• Eine Single–Shot–Blockade sollte nur bei kurzen Eingriffen ohne Eröffnung der Gelenkkapsel durchgeführt werden. In allen anderen Fällen bietet sich der interskalenäre Katheter als sichere und längerfristig wirksame Alternative an.

• Ob Regionalverfahren zu verbesserten Rehabilitationsergebnissen nach Schulterchirurgie führen, ist derzeit unklar.

Literaturverzeichnis

• 1 Dauber A, Ure BM, Neugebauer E. et al. . The incidence of postoperative pain on general surgical wards. Results of different evaluation procedures.  Anaesthesist. 1993;  42 448-54
  PubMedGoogle Scholar
• 2 Chung F, Ritchie E, Su J.. Postoperative pain in ambulatory surgery.  Anesth Analg. 1997;  85 808-16
  CrossrefPubMedGoogle Scholar
• 3 Urmey WF, Talts KH, Sharrock NE.. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography.  Anesth Analg. 1991;  72 498-503
  PubMedGoogle Scholar
• 4 Waldeyer A, Mayet Arm. A. Der. Systemische Anatomie des Armes. Anatomie des Menschen 2. Berlin: de Gruyter 1986: 490-494
  Google Scholar
• 5 Craß D, Gerheuser F.. Regionalanästhesie. In: Rossaint R, Werner C, Zwißler B (Hrsg.). Die Anästhesiologie. Berlin: Springer 2004: 621-726
  Google Scholar
• 6 Meier G, Bauereis C, Maurer H. et al. . Interscalene plexus block. Anatomic requirements – anesthesiologic and operative aspects.  Anaesthesist. 2001;  50 333-341
  CrossrefPubMedGoogle Scholar
• 7 Aszmann OC, Dellon AL, Birely BT. et al. .Innervation of the human shoulder joint and its implications for surgery. Clin Orthop Relat Res 1996: 202-207
  Google Scholar
• 8 Aszmann OC, Dellon AL.. The internal topography of the axillary nerve: an anatomic and histologic study as it relates to microsurgery.  J Reconstr Microsurg. 1996;  12 359-63
  Article in Thieme ConnectPubMedGoogle Scholar
• 9 Borgeat A, Ekatodramis G.. Anaesthesia for shoulder surgery.  Best Pract Res Clin Anaesthesiol. 2002;  16 211-225
  CrossrefPubMedGoogle Scholar
• 10 Pippa P, Aito S, Cominelli E. et al. . Brachial plexus block using the transcoracobrachial approach.  Eur J Anaesthesiol. 1992;  9 235-239
  PubMedGoogle Scholar
• 11 Rucci FS, Pippa P, Barbagli R. et al. . How many interscalenic blocks are there? A comparison between the lateral and posterior approach.  Eur J Anaesthesiol. 1993;  10 303-307
  PubMedGoogle Scholar
• 12 Pippa P.. Brachial plexus block using a new subclavian perivascular technique: the proximal cranial needle approach.  Eur J Anaesthesiol. 2000;  17 120-125
  PubMedGoogle Scholar
• 13 Pippa P, Cominelli E, Marinelli C. et al. . Brachial plexus block using the posterior approach.  Eur J Anesth. 1990;  7 411-420
  PubMedGoogle Scholar
• 14 Dagli G, Guzeldemir ME, Volkan AH.. The effects and side effects of interscalene brachial plexus block by posterior approach.  Reg Anesth Pain Med. 1998;  23 87-91
  PubMedGoogle Scholar
• 15 Winnie AP.. Interscalene brachial plexus block.  Anesth Analg. 1970;  49 455-466
  PubMedGoogle Scholar
• 16 Dutton RP, Eckhardt 3rd WF, Sunder N.. Total spinal anesthesia after interscalene blockade of the brachial plexus.  Anesthesiology. 1994;  80 939-941
  CrossrefPubMedGoogle Scholar
• 17 Ross S, Scarborough CD.. Total spinal anesthesia following brachial–plexus block.  Anesthesiology. 1973;  39 458
  CrossrefPubMedGoogle Scholar
• 18 Scammell SJ.. Case report: inadvertent epidural anaesthesia as a complication of interscalene brachial plexus block.  Anaesth Intensive Care. 1979;  7 56-57
  PubMedGoogle Scholar
• 19 Benumof JL.. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia.  Anesthesiology. 2000;  93 1541-1544
  CrossrefPubMedGoogle Scholar
• 20 Meier G, Bauereis C, Heinrich C.. Interscalene brachial plexus catheter for anesthesia and postoperative pain therapy. Experience with a modified technique.  Anaesthesist. 1997;  46 715-719
  CrossrefPubMedGoogle Scholar
• 21 Walter M, Rogalla P, Spies C. et al. . Intrathecal misplacement of an interscalene plexus catheter.  Anaesthesist. 2005;  54 215-219
  CrossrefPubMedGoogle Scholar
• 22 Borgeat A, Dullenkopf A, Ekatodramis G. et al. . Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery.  Anesthesiology. 2003;  99 436-442
  CrossrefPubMedGoogle Scholar
• 23 Borgeat A, Ekatodramis G, Kalberer F. et al. . Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study.  Anesthesiology. 2001;  95 875-880
  CrossrefPubMedGoogle Scholar
• 24 Borgeat A, Ekatodramis G, Dumont C.. An evaluation of the infraclavicular block via a modified approach of the Raj technique.  Anesth Analg. 2001;  93
  PubMedGoogle Scholar
• 25 Rosenblatt MA, Fishkind D.. Proficiency in interscalene anesthesia–how many blocks are necessary?.  J Clin Anesth. 2003;  15 285-288
  CrossrefPubMedGoogle Scholar
• 26 Kapral S, Greher M, Huber G. et al. . Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade.  Reg Anesth Pain Med. 2008;  33 253-258
  PubMedGoogle Scholar
• 27 Bishop JY, Sprague M, Gelber J. et al. . Interscalene regional anesthesia for shoulder surgery.  J Bone Joint Surg Am. 2005;  87 974-979
  CrossrefPubMedGoogle Scholar
• 28 Dullenkopf A, Zingg P, Curt A. et al. . Persistent neurological deficit of the upper extremity after a shoulder operation under general anesthesia combined with a preoperatively placed interscalene catheter.  Anaesthesist. 2002;  51 547-551
  CrossrefPubMedGoogle Scholar
• 29 Deruddre S, Vidal D, Benhamou D.. A case of persistent hemidiaphragmatic paralysis following interscalene brachial plexus block.  J Clin Anesth. 2006;  18 238-239
  CrossrefPubMedGoogle Scholar
• 30 Bashein G, Robertson HT, Kennedy Jr. WF. Persistent phrenic nerve paresis following interscalene brachial plexus block.  Anesthesiology. 1985;  63 102-104
  CrossrefPubMedGoogle Scholar
• 31 Robaux S, Bouaziz H, Boisseau N. et al. . Persistent phrenic nerve paralysis following interscalene brachial plexus block.  Anesthesiology. 2001;  95 1519-1521
  CrossrefPubMedGoogle Scholar
• 32 Ediale KR, Myung CR, Neuman GG.. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block.  J Clin Anesth. 2004;  16 573-575
  CrossrefPubMedGoogle Scholar
• 33 Cheney FW, Domino KB, Caplan RA. et al. . Nerve injury associated with anesthesia: a closed claims analysis.  Anesthesiology. 1999;  90 1062-1069
  CrossrefPubMedGoogle Scholar
• 34 Liguori GA, Kahn RL, Gordon MA. et al. . Mechanisms of hypotension and bradycardia during regional anesthesia in the sitting position.  Anesthesiology. 2004;  100 191-192
  CrossrefPubMedGoogle Scholar
• 35 D'Alessio JG, Weller RS, Rosenblum M.. Activation of the Bezold–Jarisch reflex in the sitting position for shoulder arthroscopy using interscalene block.  Anesth Analg. 1995;  80 1158-1162
  CrossrefPubMedGoogle Scholar
• 36 Turker G, Demirag B, Ozturk C. et al. . Cardiac arrest after interscalene brachial plexus block in the sitting position for shoulder arthroscopy: a case report.  Acta Orthop Belg. 2004;  70 84-86
  PubMedGoogle Scholar
• 37 Liguori GA, Kahn RL, Gordon J. et al. . The use of metoprolol and glycopyrrolate to prevent hypotensive/bradycardic events during shoulder arthroscopy in the sitting position under interscalene block.  Anesth Analg. 1998;  87 1320-1325
  CrossrefPubMedGoogle Scholar
• 38 Blumenthal S, Nadig M, Gerber C. et al. . Severe airway obstruction during arthroscopic shoulder surgery.  Anesthesiology. 2003;  99 1455-1456
  CrossrefPubMedGoogle Scholar
• 39 Orebaugh SL.. Life–threatening airway edema resulting from prolonged shoulder arthroscopy.  Anesthesiology. 2003;  99 1456-1458
  CrossrefPubMedGoogle Scholar
• 40 Antonucci S, Orlandi P, Mattei PA. et al. . Airway obstruction during arthroscopic shoulder surgery: anesthesia for the patient or for the surgeon?.  Minerva Anestesiol. 2006;  72 995-1000
  PubMedGoogle Scholar
• 41 Yoshimura E, Yano T, Ichinose K. et al. . Airway obstruction involving a laryngeal mask airway during arthroscopic shoulder surgery.  J Anesth. 2005;  19 325-327
  CrossrefPubMedGoogle Scholar
• 42 Ilfeld BM, Vandenborne K, Duncan PW. et al. . Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple–masked, placebo–controlled study.  Anesthesiology. 2006;  105 999-1007
  CrossrefPubMedGoogle Scholar
• 43 Ilfeld BM, Morey TE, Enneking FK.. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double–blinded, placebo–controlled study.  Anesthesiology. 2002;  96 1297-1304
  CrossrefPubMedGoogle Scholar
• 44 Bernard JM, Macaire P.. Dose–range effects of clonidine added to lidocaine for brachial plexus block.  Anesthesiology. 1997;  87 277-284
  CrossrefPubMedGoogle Scholar
• 45 Singelyn FJ, Gouverneur JM, Robert A.. A minimum dose of clonidine added to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block.  Anesth Analg. 1996;  83 1046-1050
  CrossrefPubMedGoogle Scholar
• 46 Picard PR, Tramer MR, McQuay HJ. et al. . Analgesic efficacy of peripheral opioids (all except intra–articular): a qualitative systematic review of randomised controlled trials.  Pain. 1997;  72 309-318
  CrossrefPubMedGoogle Scholar
• 47 Bouaziz H, Kinirons BP, Macalou D. et al. . Sufentanil does not prolong the duration of analgesia in a mepivacaine brachial plexus block: a dose response study.  Anesth Analg. 2000;  90 383-387
  CrossrefPubMedGoogle Scholar
• 48 Borgeat A, Schappi B, Biasca N. et al. . Patient–controlled analgesia after major shoulder surgery: patient–controlled interscalene analgesia versus patient–controlled analgesia.  Anesthesiology. 1997;  87 1343-1347
  PubMedGoogle Scholar
• 49 Borgeat A, Tewes E, Biasca N. et al. . Patient–controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA.  Br J Anaesth. 1998;  81 603-605
  PubMedGoogle Scholar
• 50 Capdevila X, Barthelet Y, Biboulet P. et al. . Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.  Anesthesiology. 1999;  91 8-15
  CrossrefPubMedGoogle Scholar
• 51 Capdevila X, Dadure C, Bringuier S. et al. . Effect of Patient–controlled Perineural Analgesia on Rehabilitation and Pain after Ambulatory Orthopedic Surgery: A Multicenter Randomized Trial.  Anesthesiology. 2006;  105 566-573
  CrossrefPubMedGoogle Scholar
• 52 Ilfeld BM, Wright TW, Enneking FK. et al. . Joint range of motion after total shoulder arthroplasty with and without a continuous interscalene nerve block: a retrospective, case–control study.  Reg Anesth Pain Med. 2005;  30 429-433
  PubMedGoogle Scholar
• 53 Hofmann–Kiefer K, Eiser T, Chappell D. et al. . Does patient–controlled continuous interscalene block improve early functional rehabilitation after open shoulder surgery?.  Anesth Analg. 2008;  106
  PubMedGoogle Scholar
• 54 Constant CR, Murley AH.. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987: 160-164
  Google Scholar
• 55 Brown AR, Weiss R, Greenberg C. et al. . Interscalene block for shoulder arthroscopy: comparison with general anesthesia.  Arthroscopy. 1993;  9 295-300
  PubMedGoogle Scholar
• 56 Wu CL, Rouse LM, Chen JM. et al. . Comparison of postoperative pain in patients receiving interscalene block or general anesthesia for shoulder surgery.  Orthopedics. 2002;  25 45-48
  PubMedGoogle Scholar
• 57 Tetzlaff JE, Yoon HJ, Brems J.. Patient acceptance of interscalene block for shoulder surgery.  Reg Anesth. 1993;  18 30-33
  PubMedGoogle Scholar
• 58 D'Alessio JG, Rosenblum M, Shea KP. et al. . A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy.  Reg Anesth. 1995;  20 62-68
  PubMedGoogle Scholar
• 59 Beaudet V, Williams SR, Tetreault P. et al. . Perioperative interscalene block versus intra–articular injection of local anesthetics for postoperative analgesia in shoulder surgery.  Reg Anesth Pain Med. 2008;  33 134-138
  PubMedGoogle Scholar
• 60 Nisar A, Morris MW, Freeman JV. et al. . Subacromial bursa block is an effective alternative to interscalene block for postoperative pain control after arthroscopic subacromial decompression: a randomized trial.  J Shoulder Elbow Surg. 2008;  17 78-84
  CrossrefPubMedGoogle Scholar
• 61 Delaunay L, Souron V, Lafosse L. et al. . Analgesia after arthroscopic rotator cuff repair: subacromial versus interscalene continuous infusion of ropivacaine.  Reg Anesth Pain Med. 2005;  30 117-122
  PubMedGoogle Scholar
• 62 Singelyn FJ, Lhotel L, Fabre B.. Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block.  Anesth Analg. 2004;  99
  PubMedGoogle Scholar

Dr. med. Klaus Hofmann–Kiefer
PD Dr. med. Matthias Jacob
PD Dr. med. Markus Rehm
Dr. med. Philip Lang

Email: Klaus.Hofmann-Kiefer@med.uni-muenchen.de

Email: matthias.jacob@med.uni-muenchen.de

Email: markus.rehm@med.uni-muenchen.de

Email: philip.lang@med.uni-muenchen.de

• Supplementary Material