|LETTERS TO EDITOR
|Year : 2020 | Volume
| Issue : 12 | Page : 1083-1084
Scapular surgery under combined thoracic paravertebral and interscalene blocks
Prasanna Vadhanan1, Nikhilesh Bokka2
1 Department of Anaesthesiology, Vinayaka Missions Medical College, Karaikal, Puducherry, & Consultant Anaesthesiologist, Vairam Multispeciality Hospitals, Mayiladuthurai, India
2 Department of Anaesthesiology, Vinayaka Missions Medical College, Karaikal, Puducherry, India
|Date of Submission||24-Jun-2020|
|Date of Decision||25-Aug-2020|
|Date of Acceptance||27-Sep-2020|
|Date of Web Publication||12-Dec-2020|
Prof. Prasanna Vadhanan
Department of Anaesthesiology, Vinayaka Missions Medical College, Karaikal, Puducherry
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vadhanan P, Bokka N. Scapular surgery under combined thoracic paravertebral and interscalene blocks. Indian J Anaesth 2020;64:1083-4
Scapular fractures are relatively rare (0.5-1%) and many of them are managed conservatively. Nowadays surgical fixation is preferred for better functional outcomes. Usually general anaesthesia is required as the procedure involves extensive tissue dissection and prolonged uncomfortable positioning. We report a combined thoracic para-vertebral (TPVB) and interscalene blocks (ISB) for scapular fixation. To the best of our knowledge this technique has not been reported in literature.
A 22-year-old man weighing 78 kg was posted for plate and screw fixation of a comminuted and displaced scapular body fracture. He had a run-over injury of his left chest 20 days back resulting in scapular and multiple rib fractures with left haemo-pneumothorax. An intercostal drain was placed which was subsequently removed. The patient was in considerable pain preoperatively. In the operation theatre intravenous access was secured and monitoring (Electrocardiogram, pulse oximetry, noninvasive blood pressure) was initiated. Ultrasound (Sonoray DS50 plus, Ultraserve systems, Chennai, India) guided TPVB was performed at T7-T8 level using a 16 G Tuohy needle (Romsons, India) on the left side in sitting position. After confirming pleural drop sign on ultrasound, a mixture of 6 ml 2% lignocaine with adrenaline, 8 ml 0.5% bupivacaine and 6 ml normal saline was injected. Subsequently a 16 G epidural catheter was introduced and fixed away from the surgical field. The patient was then turned supine and ultrasound guided interscalene block (ISB) was performed with 15 ml of 0.25% bupivacaine. After confirming absence of pain on deep palpation and skin hypoaesthesia over scapular region, the patient was positioned in right lateral with a slight anterior tilt aided by appropriate supports [Figure 1]a. The incision site was infiltrated with 10 ml of 1% lignocaine with adrenaline. Intraoperative sedation was administered with 50 μg of dexmedetomidine over 15 minutes followed by an infusion of 15 μg/hour. A bolus of 50 μg of fentanyl was administered as the patient complained of shivering. Open reduction and internal fixation of the scapula was done by the modified Judet posterior approach. Total blood loss was around 350 ml. The patient was arousable and comfortable throughout the surgery which lasted for 90 minutes. Position of the paravertebral catheter was confirmed postoperatively by injection of 2 ml of iohexol [Figure 1]b. A bolus of 8 ml of 0.125% bupivacaine through the catheter provided adequate post-operative analgesia for 4 hours. Further boluses were continued for 48 hours.
|Figure 1: (a) Patient positioning and extent of surgical incision (b) Post-operative radiographic image (ipsilateral oblique view) after radioopaque dye injection through the paravertebral catheter, multiple rib fractures and crowding visible. Thoracic spines labelled.|
Click here to view
Regional techniques are preferable in the coronavirus disease (COVID) era as general anaesthesia is aerosol generating. The scapula is innervated by the dorsal scapular (C5), upper and lower subscapular (C5, C6) and suprascapular nerves (C5, C6). The muscles (18 in number) attached to scapula receive nerve supply from cranial to thoracic nerve roots. Recently a combination of erector spinae block (ESB) and ISB was used for fixation of a glenoid rim fracture. However, this method involved a single injection of a rather large volume of local anaesthetic and required repeated boluses of propofol and fentanyl throughout the intraoperative period making the degree of surgical anaesthesia obtained questionable. The surgical site was lateral, near the neck of the scapula and did not involve medial scapula like in our case.
Compared to ESB, TPVB, an interfascial block acts on a well confined space, blocking both the dorsal and ventral nerve roots producing denser blocks. The catheter helps in titrated dosing. A potential complication of this ISB-TPVB approach is respiratory insufficiency due to combined paralysis of diaphragm and intercostal muscles. Careful avoidance of C4 nerve root during the ISB can prevent this problem. Total local anaesthetic dosing recommendations should be adhered to avoid toxicity, as thoracic blocks result in high systemic levels.
In conclusion, we used a combination of thoracic paravertebral and interscalene blocks to provide surgical anaesthesia for scapular fixation. Further studies evaluating this approach are warranted to evaluate its feasibility in routine anaesthesia practice.
The authors wish to acknowledge Dr. Dhanpal Singh MS (Ortho), Professor, Department of Orthopaedics, Raja Muthiah Medical College, Chidambaram and Dr. Rajasekaran D. Ortho, Consultant orthopaedician, Vairam Multispeciality Hospitals, Mayiladuthurai for their contributions.
Declaration of patient consent
An informed written consent was obtained from the patient for publication of photographs and clinical details.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Noguchi T, Mautner JF, Duncan SFM. Dorsal plate fixation of scapular fracture. J Hand Surg Am 2017;42:843.e1-5.
Malhotra N, Joshi M, Datta R, Bajwa SJ, Mehdiratta L. Indian society of anaesthesiologists (ISA national) advisory and position statement regarding COVID-19. Indian J Anaesth 2020;64:259-63. [Full text]
Kilicaslan A, Hacibeyoglu G, Goger E, Uzun ST, Ozer M. Combined erector spinae plane and interscalene brachial plexus block for surgical anesthesia of scapula fracture. J Clin Anesth 2019;54:166-7.
Jain K, Jaiswal V, Puri A. Erector spinae plane block: Relatively new block on horizon with a wide spectrum of application – A case series. Indian J Anaesth 2018;62:809-13.
] [Full text]