Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 44-47  

Role of suprascapular nerve block in chronic shoulder pain: A comparative study of 60 cases


Departmnet of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hosptial and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication10-Dec-2013

Correspondence Address:
Anil Salgia
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.122771

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  Abstract 

Background: Suprascapular nerve block using anatomical landmark has been shown to be a safe and effective treatment for chronic shoulder pain from rheumatoid and degenerative arthritis. This can be performed as an outpatient procedure that reduces pain and disability. Aims and Objectives: To access efficacy of suprascapular nerve block in chronic shoulder pain. To compare results between placebo and use of methyl prednisolone with bupivacaine for nerve block . Materials and Methods: 60 patients with chronic shoulder pain were taken up for the trial. In the study group, all patients received the block through the anatomical landmark approach, with a single sitting suprascapular nerve block. On randomized basis, 30 patients were given 10 ml of 0.5% bupivacaine and 40 mg of methyl prednisolone acetate (depo medrol) to block the suprascapular nerve. Another 30 patients were injected with 11 ml of 0.9% saline. Patients were followed up on 2 nd day, 7 th day, and 21 st day and 3 months for the status of relief of pain and improvement of movement of joint. Results: Evaluation of the efficacy of the block was achieved by comparing verbal pain scores and improvement in range of movements at 2, 7, 21 days and 3 months after the injection. Significant pain relief is defined as improvement of more than 70% on verbal and visual analog pain scale scores. Results were consistent with VAS score of pain. Maximum improvement was noted in the bupivacaine+methyl prednisolone mixed group. Conclusion: The result of this study shows a clear benefit of methyl prednisolone + bupivacaine for suprascapular nerve block in cases of chronic shoulder pain. There was statistically and clinically significant reduction in pain and improvement in range of movements.

Keywords: Bupivacaine, chronic shoulder pain, methylprednisolone acetate, placebo (normal saline), suprascapular nerve block


How to cite this article:
Salgia A, Agarwal T, Puri SR, Sanghi S, Mohapatra A. Role of suprascapular nerve block in chronic shoulder pain: A comparative study of 60 cases. Med J DY Patil Univ 2014;7:44-7

How to cite this URL:
Salgia A, Agarwal T, Puri SR, Sanghi S, Mohapatra A. Role of suprascapular nerve block in chronic shoulder pain: A comparative study of 60 cases. Med J DY Patil Univ [serial online] 2014 [cited 2019 Dec 14];7:44-7. Available from: http://www.mjdrdypu.org/text.asp?2014/7/1/44/122771


  Introduction Top


Shoulder pain is a common condition affecting around 15-30% of adults at any time. [1] In our institution, we get large number of patients complaining of shoulder pain. Shoulder pain from inflammatory arthritis, rheumatoid arthritis, and/or degenerative disease is a common cause of morbidity in the community. Chronic shoulder pain is a pain that lingers more than 3 months continuously or intermittently associated with restricted range of movement. Chronic pain can range from mild, to severe, to disabling, and can last from a few weeks or months to many years. Evidence of the efficacy of various treatments of shoulder pain is limited. [2] From a clinician's perspective, therapeutic options for management of this problem are also limited. Simple analgesia, non-steroidal anti-inflammatory drugs (NSAID's), intra-articular steroid injection, physiotherapy, and surgery all have their limitations, particularly in older populations with co-morbidities.

Chronic shoulder pain can be due to many conditions like supraspinatus tendinitis, acromioclavicular arthritis, glenohumeral arthritis, rheumatoid arthritis, rotator cuff tear, adhesive capsulitis, labral tear and calcified tendinitis.

Suprascapular nerve block has shown promise in limited trials in reducing shoulder pain. [3] Suprascapular nerve block is a simple outpatient procedure that has been observed to give considerable pain relief for more than 3 months, without any significant complications or side effects. It is cost-effective, patient and surgeon-friendly procedure.


  Materials and Methods Top


A total of 60 patients with chronic shoulder pain were initially evaluated clinically and radiologically after carrying out relevant investigations like X-ray and laboratory investigations. Inclusion criteria: - Patients of all ages and either sex with history of chronic shoulder pain with decrease range of motion of shoulder. Exclusion criteria: - Local infection, diabetes mellitus, anatomic anomalies, children, septic and tubercular arthritis, cases with radiculopathy and avulsion fractures of cervical spine. Procedure: - After coming to a provisional clinical and radiological diagnosis, they were subjected to therapeutic evaluation for the proposed treatment. On randomized basis, the intervention group of 30 cases was given 10 ml of 0.5% bupivacaine and 40 mg of methylprednisolone acetate (depo medrol) to block the suprascapular nerve, and the control group of 30 cases was given 0.9% normal saline as placebo. The method of the injection has been described by Dangoisse et al. [2] Although a previous study has demonstrated the efficacy of suprascapular nerve block using bupivacaine only, [4] we used a mixture of steroid and anesthetic as this is the more commonly used combination. Anatomical landmarks were used to identify the injection sites [Figure 1]. Procedure was performed in the sitting position of patient and a line was drawn along the length of spine of the scapula. This was bisected with a vertical line drawn from the angle of scapula, dividing the scapula into the quadrants. After skin preparation 21 gauge spinal needle was introduced through the skin 2.5 cm away from intersecting point along the line of spine in the upper quadrant. The needle was directed over the spine in the plane of the scapula and advanced until contact was made with the floor of suprascapular fossa. After attempting the aspiration the agent was slowly injected to fill the fascial contents of the fossa to produce indirect suprascapular nerve block [Figure 2]. Suprascapular nerve block was performed in outpatient department and patients were advised to continue both static and dynamic physiotherapy as an outpatient.
Figure 1: Method of suprascapular nerve injection by identification of surface anatomy. A perpendicular line is drawn from the angle of the scapula upward to bisect the spine of the scapula. 2 cm lateral to the intersecting point, in upper outer quadrant, needle is inserted to the hub of the needle or until the floor of the fossa is reached

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Figure 2: Clinical demonstration of suprascapular nerve injection

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Mechanism of Action

  1. Decrease in sensitization of dorsal horn neurons by bupivacaine. [5]
  2. Depletion of substance 'P' in synovium and afferent nerve supplying the shoulder joint. [6]
  3. Bulk of injection 11 ml itself baths the location of suprascapular nerve, as it exits from suprascapular fossa, resulting in blockade of suprascapular nerve fibers by bupivacaine.
  4. Methyl prednisolone acetate (depo medrol) exhibits anti-inflammatory reaction.


Assessment of Outcome

ROM: Range of Movement, ABD: Abduction

VAS: Visual analog pain scale

All patients were evaluated for improvement in pain and ROM. Pain according to VAS score 0 to 10 was noted. VAS 0 being least pain and 10 being maximum. Significant pain relief was defined by improvement in pain relief by 70% or more.

ROM was recorded according to patients response and categorized as A, B, or C.

0-30% Improvement in ROM Category C

31-60% Improvement in ROM Category B

61-90 % Improvement in ROM Category A

Statistical Analysis

For testing significant differences in the outcomes in the two groups, two sample t-test for continuous data and chi-square tests for categorical data were used.

Ethical Clearance: The study was approved by the Institutional Ethical Committee. Besides, informed consent was obtained from the study participants.


  Results Top


  1. Age- and sex-wise distribution of cases in study groups: - In our study, most of the patients were in age group of 41-50 years, comprising of 60% (n = 36) and least were from 61 to 70 years, comprising of 13.33% (n = 8), rest between 51 and 60 years. Mean age in the intervention group was 51 years and in the control group was 50 years. Both sexes have equal predilection, right side was more commonly involved than left [Table 1].
  2. Side of shoulder distribution of cases in study groups: - In our study, chronic shoulder pain was more common in right shoulder, comprising 58.33% (n = 35) and left 41.67% (n = 25) cases [Table 1].
  3. Diagnosis wise distribution of cases in study groups: - In our study supraspinatus tendinitis was the most common pathology observed in 36% cases (n = 22) followed by adhesive capsulitis 30% (n = 18) [Table 2].
  4. Pain relief 70% and above in control and intervention group: - Evaluation of efficacy of block was achieved by calculating verbal pain scores at 2, 7, 21 and 90 days after injection. Significant pain relief as defined by improvement in pain by 70% and above on verbal and visual pain scores at different time intervals was achieved in majority of cases where bupi+methyl was used, in cases where only (saline) placebo was used had hardly any improvement on follow up at 2 , 7 , 21 , 90 days [Table 3].
  5. Comparison of vas0 pain score 70% and above (significant pain relief in both groups): - Study group and control group were compared, it was found that study group was better providing short term as well as long term pain relief [Table 4].
  6. Improvement in rom0 on follow up in intervention and control groups: - ROM was evaluated by simple shoulder test score.
Table 1: Demographic data


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Table 2: No demographic distribution of diagnosis


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Table 3: Pain relief in intervention and control groups


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Table 4: Comparison VAS pain score 70 % and above in 2 groups


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ROM was expressed as percentage of normal ROM (N:Normal ROM)

A: 61 - 90%

B: 31 - 60%

C: 0 - 30%

In the intervention group, results show maximum response in ROM (group A) in 21 patients on 21 st follow up day and persisted to be the same even on 90 th day.

However, the control group showed maximum response in ROM (Group A) in only 2 patients by 90 th day [Table 5].
Table 5: Improvement in ROM on follow up in 2 groups


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So our study shows that supra scapular nerve block with methyl prednisolone + bupivacaine showed considerable good results in terms of relief of pain and Rom as compared to placebo (saline) injection which hardly showed any improvement.


  Discussion Top


In our study, 60 cases presenting with chronic shoulder pain lasting for a minimum period of 3 months were studied. All the patients were evaluated for pain and ROM. Pain according to VAS score on the scale of 0 to 10 was noted. An intervention group of 30 patients based on randomized selection basis were given 10 ml of 0.5% bupivacaine and 40 mg of methyl prednisolone acetate. Control group of 30 patients were injected with 10 ml of 0.9% normal saline placebo.

[Table 1] shows demographic distributions as per diagnosis of chronic shoulder pain.

We did not find any significant relief of pain and improvement of ROM in placebo group as shown in [Table 3], [Table 4], [Table 5].

There was no significant side effects from injections and was well tolerated by all patients.

The pain relief from the block extends beyond the pharmacological effect of the drug, possible explanations for this are:

  1. Decrease in sensitization of dorsal horn neurons by bupivacaine has been suggested. [5]
  2. A depletion of substance P in synovium and nerve growth factor in synovium and diffuse C fibers of glenohumeral joint after blockade may also contribute to the long term relief. [6]


Our findings were similar to a study carried out in 108 cases by Shananhan et al. [7] Taskaynatan et al. [8] published a paper of suprascapular nerve block with steroid injection for non specific shoulder pain. Patients with mean age of 57.2 years were included in this study. The average duration of presenting symptoms was more than 6 months in 53.3% patients. In our study most of the patients were in age group 41-50 years with mean age 45 years. Average duration of symptoms was between 3 and 6 months.


  Conclusion Top


In conclusion, this study provides evidence that suprascapular nerve block with methyl pred+bupi is safe, effective, and well-tolerated treatment for patient with chronic shoulder pain from supraspinatus tendinitis, adhesive capsulitis, rotator cuff tear, glenohumeral arthritis, rheumatoid arthritis, and acromioclavicular arthritis. This has been proved by comparing effects with placebo of with 0.9% normal saline. Suprascapular nerve block is a safe and extremely effective procedure in shoulder pain therapy. It also has an easy reproducibility and has been used by professionals of many medical specialities. [9] there were no side effects of this therapy.

The benefits are long term even on 90th day from block. Pain relief extending for more period as compared to other study group is because of addition of steroid. Steroid has anti-inflammatory action which prolongs the action. This is also because of a depletion of substance P and nerve growth factor in synovium and afferent C fibers of glenohumeral joint after the blockade by bupivacaine. [6]

 
  References Top

1.Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder pain in the community: The influence of case definition. Ann Rheum Dis 1997;56:308-12.  Back to cited text no. 1
    
2.Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: Selection criteria, outcome assessment, and efficacy. BMJ 1998;316:354-60.  Back to cited text no. 2
    
3.Brown DE, James DC, Roy S. Pain relief by suprascapular nerve block in glenohumeral arthritis. Scand J Rheumatol 1988;17:411-5.  Back to cited text no. 3
    
4.Gado K, Emery P. Modified suprascapular nerve block with bupivacaine alone effectively controls chronic shoulder pain in patients with rheumatoid arthritis. Ann Rheum Dis 1993;52:215-8.  Back to cited text no. 4
    
5.Woolf CJ. Somatic pain-pathogenesis and prevention. Br J Anaesth 1995;75:169-76.  Back to cited text no. 5
    
6.Lewis RN. The use of combined suprascapular and circumflex nerve blocks in management of chronic arthritis of shoulder joint. Eur Acad Anaesth 1999;16;37-41.  Back to cited text no. 6
    
7.Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan B, FitzGerald O. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis. 2003;62:400-6.  Back to cited text no. 7
    
8.Taskaynatan MA, Yilmaz B, Ozgul A, Yazicioglu K, Kalyon TA. Suprascapular nerve block versus steroid injection for non-specific shoulder pain Tohoku J Exp Med 2005;205:19-25.  Back to cited text no. 8
    
9.Fernandes MR, Barbosa MA, Sousa AL, Ramos GC. Suprascapular nerve block: Important procedure in clinical practice. Rev Bras Anestesiol 2012;62:96-104.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
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