Suprascapular Nerve Block

Original Editors - Lise De Wael, Laura Loquet, Eowyne Léonard, Carol Meesens

Top Contributors - Laura Loquet, Eowyne Léonard, Carol Meesens

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 Anatomy

The suprascapular nerve originates from the superior trunk of the brachial plexus (C5-C6).
This nerve gives off both motor and sensory fibers. The sensory branches will gain sensory information from 70% of the shoulder joint. This is sensory information obtained from(1),(18),(19):

* The acromioclavicular joint
* The glenohumeral joint (posterior and superior capsula)
* Bursa subacromiale
* The coracoclavicular ligament

The remaining sensory information will be obtained by the axillary nerve and the lateral pectoral nerve(18),(20).
The suprascapular nerve runs through the posterior triangle of the neck, anterior of the trapezius muscle and dorsal of the omohyoid muscle, in direction of the scapula.

Once the suprascapular nerve reaches the scapula, it will always go through the incisura scapulae, under the superior transversus ligament of the scapula but in 50% of the cases it will be accompanied by the suprascapular artery(18). At this moment the nerve is in the fossa supraspinatus where the nerve will provide two branches:

* the first one will innervate the M. Supraspinatus. This branche can split off from the suprascapular nerve proximal and distal from the superior transverse ligament of the scapula.

* The second one will go to the acromioclavicular articulation,the subacromial bursa and the coracoclavicular ligament. This is a direct branch that runs superiorly to the supraspinatus muscle toward the acromioclavicular joint. Nearing the AC joint, the sensory branch splits in two, one goes to the acromion and the other to the superior part of the subacromial bursae(18).

The suprascapular nerve now descends by passing the spinoglenoid notch (made by a transverse ligament of the scapula that is only present within 50% of the population (1) so it ends up in the fossa infraspinatus where it provides 2 – 3 motor braches that innervate the infraspinatus muscle. Just before innervating the infraspinatus muscle it gives off a sensory branche that will innervate the posterior capsule of the glenohumeral joint.

Clinical Procedure

Within the procedure of Suprascapular nerve block there are multiple options. At first you’ve got the the blind technique where anatomical landmarks have to be palpated and marked. These marks are always:

* The spine of the scapula
* The acromion
* The clavicula
* The acromioclavicular joint

Next the needle will be inserted at a specific location. This site of insertion depends on the technique that is used. These techniques differ from each other by the site of insertion, the position of the needle insertion (will it be directed in lateral/medial; superior/inferior; anterior/posterior position?) and is it a direct or indict block. If it is a direct block the needle will be placed near the nerve, thus the suprascapular notch has to be located.

If one chooses the indirect block, localisation of the suprascapular notch isn’t neccesary. Then they insert the needle at the floor of the supraspinatus fossa where the nerve has passed.
Secondly people perform a suprascapular nerve block with help of visualization methods. Originally a fluoroscopy guidence was used to identify the suprascapular nerve. Altough the efficacy was good it had some health care disadvantages. It exposed both patient and medical staff to radiation(21),(22). In present pain management, a ultrasound guided SSBN is applied. This new visualization technique uses strong sound waves to indentify several kinds of soft tissue.
This method(21),(22):

* Does not expose patient and medical staff to radiation.
* It is less expensive then fluoroscopy guidance
* It is more available for patients
* The use of apparature is simple

In ultrasound – guided suprascapular nerve block one will traditionally look for the suprascapular nerve in the suprascapular notch. This nerve is found by placing the ultrasound transducer in a transverse plane(19), medial at the base of the spine of the scapula. Then the transducer will be moved cranio- laterally. Some structures will be recognized:
* supraspinatus muscle
* The spine of the scapula
* The trapezius muscle
* The superior transverse ligament of the scapula.

Under this ligament we can visualize a hyperechoic structure : the suprascapular nerve will reflect the soundwaves very strong. We can add some colour doppler to identify the suprascapular artery that runs near to this nerve(19). When the nerve is located, the needle has to insert the skin in such angle so that the performer of the block can see it in-plane view. These needles are specially made so they can be seen clearly on the screen.

During this process the patient will be putting his hand from the affected shoulder on screen. The hand of the affected schoulder is put on the contra lateral schoulder so that the scapula is moved and there is no sight of any long tissue. It is important to locate the long tissue before locating the suprascapular notch in sagittal plane. This is to avoid a pneumothorax which is one of the most common complications during a suprascapular nerve block (with an incidence of <1%(22).

In research they are looking for a better place to visualize and locate the suprascapular nerve because the traditional localization may be harder than we thought. At a supraclavicular region the suprascapular nerve lies more superficial than in the suprascapular notch, deep under the omohyoid muscle (which is easily identified). They researched at which region the SSN was best identified in 120 healthy subjects. The localization had to be done in an exact matter of time, if not the nerve was identified as “not found” at the site. The result was that 91% of the SSN were identified at a supraclavicular region and only 36% of the SSN’s were identified at suprascapular notch. In a next step they inserted needles in 20 shoulders of 10 cadavers after an ultra sound search for the SSN. At all 20 shoulders The needle was placed right. (8)
Although this seems a better technique then the traditional technique, some things must be considered. Locating the suprascapular nerve at supraclavicular region is easier, but this place is located nearby the brachial plexus and we don’ know what effect a nerve block will have. Further investigation is necessary.

In the next video there will be a short explication about the course of the suprascapular nerve and the procedure of suprascapular nerve block.

https://www.youtube.com/watch?v=dgAedXjhxHw

Physical Therapy

Suprascapular nerve block can be applied to a patient who had conservative management of shoulder pain such as oral nonsteroidal anti-inflammatory drugs, physical rehabilitation to prevent loss of joint mobility, subacromial steroid injections and intra-articular steroid injections that didn’t had an effect on the pain relief and shoulder mobility. Normally after the failure of these interventions an open surgical or arthroscopic removal of the deposits can be done. For patients who are unwilling to consider or unfit for surgical intervention the SSNB is a perfect alternative or additional approach(4),(3). (level of evidence IIIB, IB)

The effect of SSNB on shoulder function is a decrease in pain experience and an increase in the range of motion. It can be expected that subsequent physiotherapy, besides being less painful, also is more effective in terms of restoring shoulder mobility. As shoulder function is increased and pain is alleviated, we hypothesize that this could be a more effective treatment than physiotherapy alone or with conventional analgesics(23). (level of evidence IV)

There has been a study comparing the effectiveness of continuous suprascapular nerve block under ultrasound guidance versus intra-articular corticosteroid injection of the shoulder and/or physiotherapy in management of chronic shoulder pain. And they assess the effectiveness of these methods for relieving pain, improve range of movement of the shoulder and to demonstrate the most suitable method for treatment of such patients. It seemed that SSNB improves pain, disability, and range of movement of the shoulders more compared to intra-articular corticosteroid injection of the shoulder and/or physiotherapy alone. SSNB is a useful adjunct treatment for management of chronic shoulder pain(24). (level of evidence IB)

In another study they compare the efficacy of SSNB plus physical therapy with physical therapy alone for the treatment of adhesive capsulitis of the shoulder. The current study supports that suprascapular nerve block is a safe and well-tolerated method. Physical therapy was found to be effective in reducing pain severity and functional disability in patients with adhesive capsulitis, and the application of SSNB before physical therapy further increased tis efficacy. The physical therapy in this study was composed of ultrasound, TENS, hot packs, ROM, stretching and isometric strengthening exercices.(10) (level of evidence IB)

The addition of SSNB to physical therapy has been shown easy to repeat, safe, cost-efficient and effective for several shoulder pathologies including adhesive capsulitis, rotator cuff lesion and hemiplegic shoulder. For these pathologies physical therapy alone can be improved by applying SSNB prior to physical therapy. Pain relief is the main achievement of SSNB, which helps to maintain pain-free physical-therapy. (10) (level of evidence IB)

Conclusion

Suprascapular Nerve Block is a safe and very efficient technique for relieving pain in patients with shoulder pathologies, which helps for a pain-free therapy.

Key Evidence

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Resources

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Case Studies

The patient was suffering from chronic pain and limited mobility of the shoulder due to adhesive shoulder capsulitis. The multiple operations, physical therapy sessions and the glenohumeral intra-articular steroid injection didn’t improve the shoulder pain and mobility much. The group implemented a multimodality treatment strategy, including a trial of a suprascapular nerve block. After the suprascapular nerve block, her shoulder pain decreased and there was some improvement of range of motion. A suprascapular nerve stimulation was then executed, resulting in significant pain reduction and improved ROM and therefore better participation during physical therapy. On her 3 months’ follow-up she no longer had pain at rest and the ROM improved dramatically(25).

Stroke patients with hemiplegic shoulder pain were allocated to the suprascapular nerve block or ultrasound group. Both groups were given the same standard program of ROM exercise, and visual analogue scale scores and Croft Disability Questionnaire. Compared with therapeutic ultrasound, suprascapular nerve block was significantly better for reducing pain, increasing range of motion and decreasing shoulder disability score. We can conclude that suprascapular nerve block is a simple, safe and inexpensive technique to relief pain originating from the hemiplegic shoulder and is more effective tan therapeutic ultrasound(26).

50 patients with chronic, nonspecific perishoulder pain were included in the study and were randomly assigned to either the study or the control group. The study group underwent nerve block using ultrasonography guidance and the control group underwent nerve block without ultrasonography guidance and using the technique described by Moore. The mean VAS score of the study group immediately after the procedure was lower than the VAS score of the control group immediately after the procedure. SSNB is effective in relieving shoulder pain. However, patients in the study group who underwent ultrasound-guided nerve block had more significant pain relief and the effect was longer lasting than that achieved for patients in the control group. The significantly better short-term outcomes can be attributed to the ability of ultrasonography to guide the clinician in injecting the anesthetic agent in close proximity to the suprascapular nerve. The improved long-term outcomes can be attributed to fact that the hypertonic dextrose used as an adjuvant to the local anesthetic was responsible for breaking the pain inflammation cascade when injected close to the nerve with the help of ultrasound. However, the pharmacologic action of the injective material is still debatable. We can conclude that Ultrasound-guided suprascapular nerve block is a safe, effective, and accurate method in achieving immediate and long-term pain relief in patients with chronic, nonspecific perishoulder pain, with normal range of motion, normal imaging studies, and no identified shoulder pathology(27).

64 patients with frozen shoulder were selected in the study. Baseline data, including shoulder pain and disability index (SPADI), and visual analogue scale for pain intensity at rest, at night and pain on movement, were gathered before the injection and follow up data were gathered after 4 weeks of suprascapular nerve block. The results of this study show a clear benefit from the use of suprascapular nerve block using bupivacaine and methylprednisolone in patients with frozen shoulder. There was statistically and clinically significant reduction in pain and disability. This benefit was prolonged, with benefit still present at 4th week. This study provides evidence that suprascapular nerve block is a safe, effective, and well tolerated treatment for patients with frozen shoulder(28).

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References

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1. Marcos Rassi Fernandes, Maria Alves Barbosa, Ana Luiza Lima Sousa, Gilson Cassem Ramos - Suprascapular Nerve Block: Important Procedure in Clinical Practice. Rev Bras Anestesiol 2012; 62: 1: 96-104 LEVEL OF EVIDENCE: IA
2. L. Di Lorenzo, M. Pappagallo, R. Gimigliano, E. Palmieri, E Saviano, A. Bello, A. Forte, E. Deblasio, C. Trombetti – Pain relief in early rehabilitation of rotator cuff tendinitis: any rol for indirect suprascapular nerve block? Eura Medicophys 2006;42:195-204 LEVEL OF EVIDENCE: IIB
3. E M Shanahan, M Ahern, M Smith, M Wetherall, B Bresnihan, O FitzGerald - Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis 2003;62:400–406 LEVEL OF EVIDENCE: IB
4. Jun Sik Kim, MD, Francis Sahngun Nahm, MD, Eun Joo Choi, MD, Pyung Bok Lee, MD, and Guen Young Lee, MD - Pulsed Radiofrequency Lesioning of the Axillary and Suprascapular Nerve in Calcific Tendinitis. Korean J Pain 2012; 25: 60-64 LEVEL OF EVIDENCE: IIIB
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17. Cummins, Craig., Messer, Terry., Nuber, Gordon., Current Concepts Review Suprascapular Nerve Entrapment; The Journal of Bone and Joint Surgery Vol. 82-A No. 3, March 2000 415–424                                                                                                                                          

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19. Carmelo Messina, Giuseppe Banfi, Davide Orlandi, Francesca Lacelli, Giovanni Serafini, Giovanni Mauri, Francesco Secchi, Enzo Silvestri and Luca Maria Sconfienza. “Ultrasound-guided interventional procedures around the shoulder.” International journal of radiology, radiation oncology and all related sciences. Volume 89, Issue 1057 LEVEL OF EVIDENCE: IIA
20. Hesham A. Elsharkawy, Alaa A. Abd-Elsayed, Kenneth C. Cummings, Loran Mounir Soliman. “Analgesic Efficacy and Technique of Ultrasound-Guided Suprascapular Nerve Catheters after Shoulder Arthroscopy.” The Ochsner Journal 14:259–263, 2014. LEVEL OF EVIDENCE: IIIB

21. Jae Hang Shim. “Is Fluoroscopy-guided Suprascapular Nerve Block Better Than Other Techniques?” Korean J Pain 2013 January; Vol. 26, No. 1: 102-103. LEVEL OF EVIDENCE: 5

22. Dominic Harmon and Conor Hearty. “Ultrasound-guided Suprascapular nerve block technique.” Pain Physician 2007; 10:743-746 • ISSN 1533-3159 LEVEL OF EVIDENCE: 4
23. Christian Dorn, Gudrun Rumpold-Seitlinger, Sylvia Farzi, Johann Auer, and Helmar Bornemann-Cimenti, The Effect of the Modified Lateral Suprascapular Block on Shoulder Function in Patients With Chronic Shoulder Pain. Anesth Pain Med. 2015 December; 5(6): e31640. LEVEL OF EVIDENCE: IV
24. Abdelshafi ME1, Yosry M, Elmulla AF, Al-Shahawy EA, Adou Aly M, Eliewa EA. - Relief of chronic shoulder pain: a comparative study of three approaches. Middle East J Anaesthesiol. 2011 Feb;21(1):83-92. LEVEL OF EVIDENCE: IB
25. Foad Elahi, MD, and Chandan G. Reddy, MD. “Neuromodulation of the Suprascapular Nerve.” Pain Physician Journal, (2014)
LEVEL OF EVIDENCE: IIIB
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LEVEL OF EVIDENCE: IB

27. Venkat Gorthi, MD, Young Lae Moon, MD, Jeong-Hoon Kang, MD. “The Effectiveness of Ultrasonography-guided Suprascapular Nerve Block for Perishoulder Pain.” Healio orthopedics journal vol. 33 (2010)
LEVEL OF EVIDENCE: IB

28. Malik Javed Iqbal, Wasim Anwar, Noor Rahman, Salik Kashif, Asghar Khan. “Suprascapular Nerve Block in the Treatment of Frozen Shoulder.” Journal of surgery Pakistan vol.17 (2012)
LEVEL OF EVIDENCE: IIB

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