Article published online: 2021-08-16
THIEME
22
Costoclavicular
Original Article Block and Interscalene Block for Pain Relief
Pradhan et al.
A Comparison of Costoclavicular Block and
Interscalene Block for Pain Relief after Arthroscopic
Shoulder Surgery
Kamalakanta Pradhan1
Sarat Chandra Jayasingh2
1 Department of Anesthesiology and Critical Care, SCB Medical
College Cuttack, Odisha, India
2 Department of Surgical Gastroenterology, SCB Medical College,
Cuttack, Odisha, India
3 Department of Community Medicine, SCB Medical College
Cuttack, Odisha, India
Sikata Nanda3
Sidharth Sraban Routray1
Address for correspondence Sidharth Sraban Routray, MD,
Department of Anesthesiology and Critical Care, SCB Medical
College, Cuttack 753007, Odisha, India (e-mail: drsidharth74@
gmail.com).
Int J Recent Surg Med Sci 2022;8:22–26.
Abstract
Keywords
► interscalene block
► costoclavicular block
► postoperative pain
► shoulder surgery
► arthroscopy
Introduction Interscalene block (ISB) is commonly used for efficient pain relief after
arthroscopic shoulder surgery. But, it is linked with a greater occurrence of unilateral
diaphragmatic paralysis (UDP). This may add to patient dissatisfaction and also may
not be tolerated well by patients having respiratory diseases. We have compared the
efficacy of costoclavicular block (CCB) with ISB for postoperative analgesia in patients
undergoing arthroscopic shoulder surgery.
Materials and Methods Fifty patients were divided into two groups of 25 each (ISB
or CCB group). In total, 20 mL of 0.5% levobupivacaine along with 4 mg of dexamethasone as adjuvant was used during both ultrasound-guided ISB and CCB. Numerical
rating scale (NRS) scores for pain were assessed at 0, 0.5, 1, 2, 3, 6, 12, and 24 hours
in postoperative period. The mean onset time of block, time of first painkiller demand,
total painkiller demand for 24 hours postoperatively, patient wellbeing, incidence of
UDP, and any other complications were recorded.
Results NRS pain scores in both groups at 0, 0.5, 1, 2, 3, 6, 12, and 24 hours were
comparable. (p > 0.05) Mean onset time of block was earlier in ISB group contrary to
CCB group (p < 0.05). There was higher occurrence of UDP in ISB group contrary to CCB
group (p < 0.05). There was no notable variation regarding the time of first painkiller
demand and total painkiller demand in the first 24 hours. Patients were more satisfied
in CCB group contrary to ISB group.
Conclusion As CCB provided equivalent analgesia in postoperative period like ISB
without any risk of UDP, it can be a better substitute to ISB for pain relief in arthroscopic
shoulder surgery.
DOI https://doi.org/
10.1055/s-0041-1734210
ISSN 2455-7420
© 2021. Medical and Surgical Update Society.
This is an open access article published by Thieme under the terms of the Creative
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Costoclavicular Block and Interscalene Block for Pain Relief
Introduction
Arthroscopic shoulder surgeries are minimally invasive
procedures, which are usually associated with moderate to
severe postoperative pain. This can produce serious aches
and pains to the patients, leading to delayed recovery, rehabilitation, and discharge.1 Patients with pre-existing respiratory diseases pose a challenge for postoperative analgesia
after shoulder surgery as interscalene block (ISB), commonly
used block for shoulder surgery, can produce unilateral diaphragmatic paralysis (UDP). ISB was also associated with
complications like arm weakness, Horner’s syndrome, and
hoarseness of voice. Whereas so many nerve blocks sparing
diaphragm have been studied, no block has come close to provide equipotent analgesia to ISB without producing UDP.2 In a
study by Wiegel et al,3 they concluded that analgesic efficacy
of isolated suprascapular blocks was not so potent. Lee et
al4studied combined suprascapular and axillary nerve block
which produced poor analgesia after arthroscopic surgery.
Karmakar et al5described the costoclavicular block (CCB)
in which they earmarked the costoclavicular space (CCS) to
block the brachial plexus. They opined that, three cords are
densely packed and tightly clustered in CCS. So lower local
anesthetic volume is needed for the block and also avoid the
chance of pneumothorax and UDP. Garcia-Vitoria et al6 in
their study opined that the CCS can act as a backward route
to block supraclavicular brachial plexus which can avoid UDP.
There were very few studies in literature comparing ISB with
CCB for postoperative analgesia after arthroscopic shoulder
surgeries. So in this study, we have compared CCB with ISB
for pain relief after arthroscopic shoulder surgery.
Materials and Methods
We have conducted this randomized, prospective trial in a
tertiary care hospital from January 2020 to January 2021 after
obtaining Institutional Ethical Committee approval and written informed consent. Fifty patients of ASA I/II and aged
18 to 70years, posted for arthroscopic shoulder surgery were
enrolled in our trial. Patients with pre-existing respiratory disease, coagulation abnormalities, infection at the site of block,
liver or renal problems, pregnancy, hypersensitivity to local
anesthetics, and prior surgery in the block site were excluded
from the study. On arrival in operation theater, an 18-gauge
intravenous (IV) cannula was put. Premedicant like IV
midazolam 0.04 mg/kg and fentanyl 1 µg/kg were injected to
all patients. Oxygen was supplemented at the rate of 5 L/min
and SpO2, pulse rate, noninvasive blood pressure, and ECG
were monitored. For both blocks, GE Logiq F ultrasound with
a high frequency (6–15 MHz) of 38 mm L6–12 linear probe
was used. Using a computer-initiated sequence of random
numbers all patients were randomly distributed into two
groups, ISB (n = 25) and CCB (n = 25). The allocation outcomes
were kept consecutively in a nontransparent and sealed
cover, which was opened by the investigator before executing
the blocks. ISB was given as narrated by Spence et al.7 The
transducer was put at the level of the cricoid cartilage on
the lateral side of neck. Three hypoechoic structural images,
Pradhan et al.
representing the roots and trunks of the brachial plexus were
visualized. Using in-plane approach, the needle was guided
from lateral-to-medial direction. When tip reaches below
the prevertebral fascia and lies between the two superficial
hypoechoic images, 20 mL of levobupivacaine 0.5% with 4 mg
dexamethasone was injected. CCB was given as described
by Karmakar et al.5 The transducer was initially put over
the middle one-third of the clavicle. Then it was gradually
shifted below the lower margin and placed in medial infraclavicular fossa. Axillary artery was recognized below the
subclavius muscle and lateral to the axillary artery, three
brachial plexus cords were identified. In-plane approach was
used, and the needle was guided till the tip reaches the middle of three cords where 20 mL of levobupivacaine 0.5% with
4 mg dexamethasone was injected. All the blocks were given
by experienced anesthesiologist. After the performance of
the blocks, blocks were evaluated at every 5 minutes until
30 minutes. Sensation was assessed over the clavicle area for
supraclavicular nerve and the lateral part of the deltoid for
axillary nerve. For sensory block, every area was classified as
per a three-point scale utilizing a cold test8: failed block—0,
analgesia—1, anesthesia—2. Motor block was assessed by
various movements of shoulder like external rotation for
suprascapular nerve and abduction for axillary nerve using
a three-point scale: failed block—0, paresis—1, paralysis—2.
Block was perfect, if the combined sensory-motor score was
≥6 out of maximum score 8, 30 minutes after block.8
UDP was assessed by the anesthesiologist blinded to the
study group at 30 minutes after the blocks. Onset time of
block was interpreted as the time needed for combined
score of 6 to be achieved. After assessment of all the blocks,
patients were administered general anesthesia using IV
fentanyl (1 µg/kg), propofol (2 mg/kg), and vecuronium
(0.1 mg/kg). After surgery is over, patients were shifted to
post anesthesia care unit (PACU) after extubation. In PACU,
another anesthesiologist assessed pain on rest at 0.5, 1, 2, 3,
6, 12, and 24 hours. Numerical rating scale (NRS) was used
to assess pain. (no pain—0, worst imaginable pain—10).9 If
NRS score was >4, paracetamol 15 mg/kg was given IV. Same
anesthesiologist evaluated UDP at 30 minutes after arrival
in the PACU using ultrasound. Mean performance time,
complete blocks at 30 minutes, mean onset time, time of
first painkiller demand, and total painkiller demand were
recorded. The incidence of other complications like hoarseness and Horner syndrome was recorded. Patient wellbeing
was assessed on questionnaire method with a four-point
measurement (excellent, good, fair, poor). NRS score variation between ISB and CCB group of less than 1.3 points
studied at different time interval was taken as significant.
Established on an earlier trial,10 the difference in NRS score
was presumed to be 1.5 between the two groups within first
24 hours. So, taking the α as 0.05 and power as 0.90, the least
needed sample size was calculated to be 22 for each group.
Sample size was increased to 25 patients per group, anticipating loss of 10% patients to follow-up. Chi-square test was
used for categorical data. For the numerical data, Student
t-test or ANOVA was used. p-Values <0.05 was taken as
statistically significant.
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Costoclavicular Block and Interscalene Block for Pain Relief
Pradhan et al.
Fig. 1 CONSORT diagram showing patient flow.
Table 1 Patient demographic profile, type, and duration of
surgery
Table 2 Numeric rating scale scores at rest at various time
interval
Variables
Group ISB
(n – 25)
Group CCB
(n – 25)
p-Value
Time
interval
Group ISB
(n – 25)
Group CCB
(n – 25)
p-Value
Age in years
51.42 ±
11.74
52.85 ±
11.94
0.231
0 min
1.75 ± 2.14
1.6 ± 2.12
0.146
30th min
1.42 ± 1.66
1.32 ± 1.74
0.172
Male /Female,(n)
20/5
19/6
0.354
1st h
1.58 ± 1.43
1.92 ± 1.78
0.184
BMI in (kg/m2)
25.12 ± 2.55
15.86 ± 3.12
0.251
2nd h
1.75 ± 1.73
1.25 ± 1.14
0.158
ASA status-I/II (n)
16/9
18/7
0.364
3rd h
1.8 ± 1.25
2.24 ± 1.48
0.193
Pre op NRS score
at rest
3.31 ± 1.05
3.54 ± 1.32
0.540
6th h
1.6 ± 1.48
2.83 ± 0.93
0.256
12th h
2.8 ± 1.4
2.23 ± 1.81
0.167
24th h
2.95 ± 0.93
2.89 ± 0.83
0.178
Type of surgery (n)
Rotator cuff repair
12
10
0.156
Acromioplasty (n)
8
11
0.195
Bankart repair (n)
5
4
0.207
Duration of surgery
(min)
110.55 ±
24.14
114.34 ±
21.68
0.412
Abbreviations: CCB, costoclavicular block; ISB, interscalene block.
Abbreviations: CCB, costoclavicular block; ISB, interscalene block.
Results
Sixty participants were evaluated for eligibility and ten of
them were ruled out as they did not meet the inclusion criteria. So, 50 patients were enrolled for this study (►Fig. 1).
There were no statistically remarkable variation in both
groups (A and B) regarding demographic parameters, ASA
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status, preoperative NRS score, type of surgery, and duration
of surgery (►Table 1).
NRS scores were comparable in both groups at 0, 0.5, 1, 2,
3, 6, 12, and 24 hours postoperatively (p >0.05) (►Table 2).
Mean onset time of block was earlier and patient wellbeing
was better in CCB group compared with ISB block (p <0.05).
Both groups were comparable with regard to mean performance time, perfect blocks at 30 minutes, time of first
painkiller demand, and total painkiller demand (p >0.05)
(►Table 3). Incidence of UDP 30 minutes after the block and
in the PACU was greater in ISB group contrary to CCB group (p
<0.05). Regarding other complications like Horner syndrome
and hoarseness, both groups were comparable (►Table 4).
©2021. Medical and Surgical Update Society.
Costoclavicular Block and Interscalene Block for Pain Relief
Pradhan et al.
Table 3 Block parameters and pain killer requirement
Parameters
Group ISB (n – 25)
Group CCB (n – 25)
p-Value
Performance time of block (min)
8.5 ± 2.9
8.1 ± 3.9
>0.05
Onset time of block (min)
15.78 4.50
20.42 3.74
<0.05
Perfect block at 30 min (n [%])
25 (100%)
25 (100%)
>0.05
Time of first painkiller demand (h)
6.8 ± 1.5
6.4 ± 1.8
>0.05
Total painkiller demand (g)
2.4 ± 0.7
2.6 ± 0.6
>0.05
Patient wellbeing at 24 h (n) (Excellent: good: fair: poor)
8:15:2:0
20:4:1:0
<0.05
Abbreviations: CCB, costoclavicular block; ISB, interscalene block.
Table 4 Complications of ISB and CCB
Parameters
Group ISB (n – 25)
Group CCB (n – 25)
p-Value
Unilateral diaphragmatic paralysis after 30 min of
block (n [%])
20 (80%)
0
<0.05
Unilateral diaphragmatic paralysis in PACU) (n [%])
20 (80%)
0
<0.05
Horner syndrome (n [%])
1 (4%)
0
>0.05
Hoarseness (n [%])
2 (8%)
2 (8%)
>0.05
Abbreviations: CCB, costoclavicular block; ISB, interscalene block; PACU, post anesthesia care unit.
Discussion
ISB is the benchmark block commonly used for postoperative
pain management after any shoulder surgery. ISB decreases
the pain scores for minimum 6 to 8 hours and reduces opioid requirement in postoperative 24 hours.11 Efficacy of
ISB in shoulder surgery has been well studied by Dhir et
al,12 Pitombo et al,13 and Neuts et al.14 But there were concerns regarding phrenic nerve paralysis and UDP in ISB which
can produce transient and long-term respiratory complications.5 Many different nerve blocks for shoulder analgesia
which spare the phrenic nerve have been studied by Tran
et al.15 They opined that, no block provided surgical anesthesia without phrenic nerve paralysis. Few cadaveric and
therapeutic trials have opined that, CCB may be utilized as a
substitute to ISB for postoperative pain relief after shoulder
surgery. Mistry et al16 has given15 mL of local anesthetics in
bilateral CCB and found good analgesia without phrenic nerve
paralysis. Also, Koyyalamudi et al17in a human cadaveric trial
approved this. In his study, 20 mL of 0.1% methylene blue was
injected to CCS and the dye was found spreading toward craniad part of brachial plexus. Whole of the trunks and cords
of the brachial plexus was stained, but phrenic nerve was not
stained. So, they opined that, local anesthetics injected to
CCS may spare phrenic nerve. But incidence of phrenic nerve
paralysis in CCB in different studies varied as different volume of drug was used in those studies. Sivashanmugam et
al18 in their study concluded that, the incidence of unilateral
phrenic nerve paralysis was nil with 20 mL of drug and was
maximum 8.9% when 35 mL of drug used in CCB in different
studies. In our study, we found that NRS scores were comparable in both ISB and CCB groups at 0, 0.5, 1, 2, 3, 6, 12, and
24 hours postoperatively. Mean onset time of block was earlier and patient well-being was better in CCB group contrary
to ISB group. Incidence of UDP, 30 minutes after the block and
in the PACU was greater in ISB group contrary to CCB group.
(p <0.05). This was in agreement with a study by Aliste et al.10
They have compared the efficacy of CCB with ISB for pain
relief and any complications after arthroscopic shoulder surgery. They concluded that, both ISB and CCB produced equivalent analgesia without any occurrence of phrenic nerve
paralysis. They hypothesized that, from CCS local anesthetics spread cephalad, toward the brachial plexus roots while
blocking the trunks and cords, thereby block the shoulder
innervations sparing phrenic nerve. They have advocated for
larger trial taking more number of patients to validate their
findings. Spread of local anesthetics in interscalene groove in
the direction of phrenic nerve or toward C3–C5 nerve roots
is a possible mechanism of UDP after ISB. Leurcharusmee et
al19in their study opined that, on moving from ISB toward
supraclavicular brachial plexus blocks, occurrence of UDP
gradually decreases from 100% to as low as 67%. On moving
further below toward the CCS in the infraclavicular region,
incidence of UDP further decreased. Aliste et al10hypothesized
that the CCB reliably anesthetize the lateral cord, posterior
cord, supraclavicular brachial plexus, and the suprascapular
nerve and termed it as a sweet spot. One of the dilemmas in
CCB was that the ideal volume of local anesthetic was still not
known. Sotthisopha et al20 in his study of CCB concluded that
in 90% of CCB, the minimum required volume of local anesthetic (1.5% lidocaine) is 34 mL for effective block. But in our
study, we have used low volume (20 mL) of local anesthetic
as suggested by Karmakar et al.5 With our aim to homogenize
the local anesthesia volume in the two groups and to reduce
incidence of UDP, we have used 20 mL of local anesthesia in
our study. We have added dexamethasone (4 mg) as adjuvant
to levobupivacaine to prolong the duration of action. Lastly
CCB may be used an alternative to ISB as it was equally potent
and spare the phrenic nerve but one of the limitations of our
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Costoclavicular Block and Interscalene Block for Pain Relief
study was that the number of participants was low. So large
scale studies are required to authenticate our findings.
Conclusion
Our study concludes that newer regional block like CCB prolongs the duration of analgesia and produces identical postoperative pain relief like ISB but unlike interscalene block it
does not produce UDP. So CCB can be used as a substitute for
interscalene block for effective postoperative pain relief after
arthroscopic shoulder surgery specifically in patients having
respiratory diseases.
Conflict of Interest
None declared.
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©2021. Medical and Surgical Update Society.