Clinical Orthopaedics and Related Research®

, Volume 472, Issue 5, pp 1482–1488 | Cite as

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

  • Ottokar Stundner
  • Rehana Rasul
  • Ya-Lin Chiu
  • Xuming Sun
  • Madhu Mazumdar
  • Chad M. Brummett
  • Reinhold Ortmaier
  • Stavros G. Memtsoudis
Symposium: Perioperative Pain Management in Orthopaedic Surgery



Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.


Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups?


We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay.


We identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2–68.9 years] versus 69.1 years [95% CI: 68.9–69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97–1.02; p = 0.467)


Addition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.


Carpal Tunnel Syndrome Nerve Block Regional Anesthesia Negative Binomial Regression Shoulder Arthroplasty 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

11999_2013_3356_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 14 kb)


  1. 1.
    Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:560879.PubMedCentralPubMedGoogle Scholar
  2. 2.
    Austin P, Rothwell DM, Tu JV. A comparison of statistical modeling strategies for analyzing length of stay after CABG surgery. Health Services & Outcomes Research Methodology. 2002;3:107–133.CrossRefGoogle Scholar
  3. 3.
    Bhatia A, Lai J, Chan VW, Brull R. Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block. Anesth Analg. 2010;111:817–819.PubMedCrossRefGoogle Scholar
  4. 4.
    Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001;95:875–880.PubMedCrossRefGoogle Scholar
  5. 5.
    Brandl F, Taeger K. [The combination of general anesthesia and interscalene block in shoulder surgery] [in German]. Anaesthesist. 1991;40:537–542.PubMedGoogle Scholar
  6. 6.
    Claeys MJ, Sinnaeve PR, Convens C, Dubois P, Boland J, Vranckx P, Gevaert S, Coussement P, Beauloye C, Renard M, Vrints C, Evrard P. Inter-hospital variation in length of hospital stay after ST-elevation myocardial infarction: results from the Belgian STEMI registry. Acta Cardiol. 2013;68:235–239.PubMedGoogle Scholar
  7. 7.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619.PubMedCrossRefGoogle Scholar
  8. 8.
    Gaughan J, Kobel C, Linhart C, Mason A, Street A, Ward P. Why do patients having coronary artery bypass grafts have different costs or length of stay? An analysis across 10 European countries. Health Econ. 2012;21(suppl 2):77–88.PubMedCrossRefGoogle Scholar
  9. 9.
    Guay J. The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis. J Clin Anesth. 2006;18:124–128.PubMedCrossRefGoogle Scholar
  10. 10.
    Hortense A, Perez MV, Amaral JL, Oshiro AC, Rossetti HB. Interscalene brachial plexus block: effects on pulmonary function. Rev Bras Anestesiol. 2010;60:130–137, 74–78.Google Scholar
  11. 11.
    Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons Inc; 2000:162.CrossRefGoogle Scholar
  12. 12.
    Hosmer DW, Lemeshow SA. Goodness-of-fit test for the multiple logistic regression model. Commun Stat. 1980;A10:1043–1069.CrossRefGoogle Scholar
  13. 13.
    llfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–925.Google Scholar
  14. 14.
    Ilfeld BM, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW. 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.PubMedCrossRefGoogle Scholar
  15. 15.
    Ilfeld BM, Wright TW, Enneking FK, Morey TE. 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
  16. 16.
    Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 2013;33:383–391.PubMedCrossRefGoogle Scholar
  17. 17.
    Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, Malchow RJ. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13:828–834.PubMedCrossRefGoogle Scholar
  18. 18.
    Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol. 2013;26:467–474.PubMedGoogle Scholar
  19. 19.
    Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.PubMedCrossRefGoogle Scholar
  20. 20.
    Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, Yadeau JT. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg. 2010;111:617–623.PubMedCrossRefGoogle Scholar
  21. 21.
    Memtsoudis SG, Sun X, Chiu YL, Nurok M, Stundner O, Pastores SM, Mazumdar M. Utilization of critical care services among patients undergoing total hip and knee arthroplasty: epidemiology and risk factors. Anesthesiology. 2012;117:107–116.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 2013;118:1046–1058.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Merkow RP, Hall BL, Cohen ME, Dimick JB, Wang E, Chow WB, Ko CY, Bilimoria KY. Relevance of the c-statistic when evaluating risk-adjustment models in surgery. J Am Coll Surg. 2012;214:822–830.PubMedCrossRefGoogle Scholar
  24. 24.
    Pepe MS. The Statistical Evaluation of Medical Tests for Classification and Precision. Oxford, UK: Oxford University Press; 2003:66–94.Google Scholar
  25. 25.
    Premier Inc. Premier perspective database. Available at: Accessed September 7, 2013.
  26. 26.
    Rohrbaugh M, Kentor ML, Orebaugh SL, Williams B. Outcomes of shoulder surgery in the sitting position with interscalene nerve block: a single-center series. Reg Anesth Pain Med. 2013; 38:28–33.PubMedCrossRefGoogle Scholar
  27. 27.
    Shah A, Nielsen KC, Braga L, Pietrobon R, Klein SM, Steele SM. Interscalene brachial plexus block for outpatient shoulder arthroplasty: postoperative analgesia, patient satisfaction and complications. Indian J Orthop. 2007;41:230–236.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Sinha SK, Abrams JH, Barnett JT, Muller JG, Lahiri B, Bernstein BA, Weller RS. Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2011;36:17–20.PubMedCrossRefGoogle Scholar
  29. 29.
    Stundner O, Chiu YL, Sun X, Mazumdar M, Fleischut P, Poultsides L, Gerner P, Fritsch G, Memtsoudis SG. Comparative perioperative outcomes associated with neuraxial versus general anesthesia for simultaneous bilateral total knee arthroplasty. Reg Anesth Pain Med. 2012;37:638–644.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Sviggum HP, Jacob AK, Mantilla CB, Schroeder DR, Sperling JW, Hebl JR. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012;37:490–494.PubMedCrossRefGoogle Scholar
  31. 31.
    Tetzlaff JE, Yoon HJ, Brems J. Interscalene brachial plexus block for shoulder surgery. Reg Anesth. 1994;19:339–343.PubMedGoogle Scholar
  32. 32.
    United States Department of Health and Human Services. OCR Privacy Brief: Summary of the HIPAA Privacy Rule. Washington, DC: Office for Civil Rights, HIPAA Compliance Assistance; 2003.Google Scholar
  33. 33.
    Urmey WF, Gloeggler PJ. Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume. Reg Anesth. 1993;18:244–249.PubMedGoogle Scholar
  34. 34.
    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.PubMedCrossRefGoogle Scholar
  35. 35.
    Verelst P, Van Zundert A. Respiratory impact of analgesic strategies for shoulder surgery. Reg Anesth Pain Med. 2013;38:50–53.PubMedCrossRefGoogle Scholar
  36. 36.
    Wolfe JW, Butterworth JF. Local anesthetic systemic toxicity: update on mechanisms and treatment. Curr Opin Anaesthesiol. 2011;24:561–566.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Ottokar Stundner
    • 1
  • Rehana Rasul
    • 2
  • Ya-Lin Chiu
    • 2
  • Xuming Sun
    • 2
  • Madhu Mazumdar
    • 2
  • Chad M. Brummett
    • 3
  • Reinhold Ortmaier
    • 4
  • Stavros G. Memtsoudis
    • 5
  1. 1.Department of Anesthesiology, Perioperative Medicine and Intensive CareParacelsus Medical UniversitySalzburgAustria
  2. 2.Division of Biostatistics and Epidemiology, Department of Public HealthWeill Medical College of Cornell UniversityNew YorkUSA
  3. 3.Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborUSA
  4. 4.Department of Trauma SurgeryParacelsus Medical UniversitySalzburgAustria
  5. 5.Department of Anesthesiology, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA

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