Suprascapular Nerve Block

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Original Editors - Lise De Wael

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Search Strategy

Web of science and Pubmed where used to collect information about the suprascapular nerve block. Keywords for this research where suprascapular nerve block (SSNB) in combination with indication, physical therapy, procedures, comparisons, chronic shoulder pain, ultrasound, fluoroscopy, anatomy, course… If on Pubmed the search is refined to humans and articles that are published the last 5 years there are 39 hits. Reviews of randomised control trials, reviews of case control studies, randomised control trials, case studies and an opinion of a clinic where used to collect evidence based information and compose a text about the SSNB intervention.

Description

The suprascapular nerve is a mixed motor and sensory peripheral nerve arising from the superior trunk of the brachial plexus. The nerve supplies motor innervation to shoulder muscles and sends sensory branches to multiple places in the shoulder region.(17) Suprascapular nerve block (SSNB) is a safe and effective method to treat pain in chronic diseases that affect the shoulder. The technique consists of injecting anesthetic in supraspinatus fossa of affected shoulder, with the patient sitting down and upper limbs pending beside the body.(1)

Indication

Shoulder pain causes disability with people who are coping with musculoskeletal problems which causes limitations on their daily live activities and participations. Suprascapular nerve block (SSNB) has been found effective and safe to treat pain created by chronic diseases, trauma, surgery… that affect the shoulder which are described below (1). There have been studies showing that this method improves pain decrease and range of motion (ROM) with patients who suffered an irrecoverable injury of rotator cuff(2), rheumatoid arthritis, calcific tendinitis (2),(4),(5),(6), cancer(7), post-cerebrovascular accident(8),(9) and adhesive capsulitis(10). The prevalence of patients who complain of shoulder pain are elderly people(11),(16).
The use of SSNB for postoperative analgesia of surgeries in the shoulder region has also increased, since pain has a big influence on the rehabilitation. A study aimed to assess critically the evidence relating to the effectiveness of regional anaesthesia techniques commonly used for postoperative analgesia following shoulder surgery. They found that compared to placebo, suprascapular nerve block reduces postoperative pain, morphine consumption and nausea following arthroscopic shoulder surgery. Suprascapular nerve block also provides better postoperative analgesia compared with intra-articular infiltration, but inferior analgesia compared with SSISB. Suprascapular nerve block adds little clinical benefit when added to a general anaesthesia–interscalene block technique(12). (level of evidence IIA)
Another study concluded that the combination of patient-controlled anaesthesia (PCA), suprascapular nerve block (SSNB) and additional axillary nerve block (ANB) using a blind technique is a better pain control method than PCA + SSNB and only PCA during the initial(12) post-operative hours. PCA + SSNB + ANB is a cost-effective, time-saving, and easily performed method for post-operative pain control as an axis of multimodal pain control strategy(13). (level of evidence IIB)
The use of SSNB to reduce pain with patient who had a stroke or suffer from lung cancer is also effective. The pain in the hemiplegic shoulder is a frequent complaint after stroke, with incidence ranging from 16% to 84%, which increases hospitalization time and greatly impairs the rehabilitation process. The cause that leads to appearance of this pain is still inconclusive and controversial. Shoulder pain obstructs participation in rehabilitation and has been associated with poorer outcomes. Evidence-based treatments for hemiplegic shoulder pain are limited. Suprascapular nerve block (SSNB) is a safe and effective treatment of shoulder pain(1),(9). (level of evidence IIA, IIB) Acute postthoracotomy pain is as well a well-known potential problem, with pulmonary complications, ineffective respiratory rehabilitation, and delayed mobilization in the initial postoperative period, and it is followed by chronic pain. In this case preoperative ultrasound- guided SSNB with thoracic epidural analgesia could achieve effective shoulder pain relief for 72 hours postoperatively, both at rest and coughing(7). (level of evidence IIB)
The use of SSNB with patients who have an irrecoverable injury of rotator cuff improves pain relief and creates an reduction in disability. There is an improvement in quality of ADL and sleep during the night. Although no single treatment technique guarantees total pain relief. SSNB will provide an effective temporary pain control but this must be included in a total pain management program(2). (level of evidence IIB)
Degenerative diseases and /or arthritis in the shoulder are also treated with SSNB. It decreases pain, incompetence, and ROM at the shoulder compared with placebo. SSNB is a save and efficient treatment when integrated in a total therapy and is helpful for the practicing clinician to assist in the management of a difficult and common clinical problem(3). (level of evidence IB) Rheumatoid arthritis patients often suffer chronic shoulder pain and disabling symptom. Studies have already proven that the standard mixture of bupivacaine (medication that decreases feeling in a specific area, begins working within 15 minutes and lasts for 2-8 hours) and adrenaline plus methylprednisolone (a synthetic glucocorticoid or corticosteroid drug with anti-inflammatory effects), often used in pain clinics, provides a considerable improvement in pain and stiffness reduction and ROM compared to conventional intra-articular steroid injections in patients with rheumatoid artritis. A double blind study was carried out in 29 patients (58 shoulders) with RA. Results of improvement favoured bupivacaine and adrenaline alone. It is concluded that the addition of methylprednisolone to the SSNB mixture confers no extra benefit.(6) (level of evidence IIB) Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy(5). (level of evidence IIA) Calcific tendinitis of the shoulder is characterized by a reactive calcification that affects the rotator cuff tendons. Calcium hydroxyapatite crystal deposits cause inflammation on neighboring tissue and gives rise to pain. Calcific tendinitis of the rotator cuff conservatively is treated with oral nonsteroidal anti-inflammatory drugs, physical rehabilitation to prevent loss of joint mobility, subacromial steroid injections, and intra-articular steroid injections. Recently, other therapeutic methods are considered as possible alternative. A case report describes a patient suffering from right shoulder and arm pain for 3 years. The patient had pain management which was performed using medication and conservative management after she had been diagnosed with calcific tendinitis. However, substantial pain relief was not consistently achieved, and recurrence of pain was reported. Therefore, right axillary nerve and suprascapular nerve block were performed through pulsed radiofrequency. Two months after the procedure, the shoulder pain gradually subsided and she needed no more pain management(4). (level of evidence IIIB)
One of most frequent shoulder pathologies with SSNB indication is adhesive capsulitis. Frozen shoulder or adhesive capsulitis is a common problem in general practice presenting as pain that may be severe and as a progressive loss of movement resulting in a loss of function. Painful stiffness of the shoulder is an ill-defined clinical entity that is difficult to assess and delicate to treat(14). (level of evidence IV) Suprascapular nerve block is a safe and well-tolerated method(15). (level of evidence IA) In a recent study physical therapy was found to be effective in reducing pain severity and functional disability, and the addition of suprascapular nerve block to physical therapy improved functional status and pain levels in patients with adhesive capsulitis(10). (level of evidence IB) Another study also applying SSNB to frozen shoulder patients their simple pain scores, total pain scores as well as abduction, external rotation and internal rotation angles were improved significantly after suprascapular nerve block(14). We can conclude from several studies the effective results after suprascapular nerve blockage was obtained for the treatment of frozen shoulder cases.

Clinical Presentation

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Key Evidence

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Resources

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Case Studies

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References

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