Proksimal Humerus Cerrahisi Sonrası Postoperatif Analjezi için Ultrason Eşliğinde Superior Trunk Bloğunun Etkinliği: Randomize Kontrollü Çalışma

Öz

Amaç: Proksimal humerus cerrahisi sonrası orta ve şiddetli düzeyde ağrı sık görülmekte ve çoğu zaman opioid temelli analjezi gerektirmektedir. Selektif bir brakiyal pleksus bloğu olan superior trunk blok (STB), postoperatif ağrı kontrolü için alternatif bir yöntem olarak önerilmektedir. Bu çalışmanın amacı, proksimal humerus cerrahisi sonrası STB’nin intravenöz hasta kontrollü analjezi (PCA) ile karşılaştırıldığında analjezik etkinliğini değerlendirmektir. Yöntem: Çalışma randomize kontrollü bir çalışma olarak tasarlandı. Proksimal humerus cerrahisi uygulanan toplam 60 hasta çalışmaya dahil edildi ve rastgele iki gruba ayrıldı. STB grubunda (n=30), hastalara intravenöz PCA ile birlikte ultrason eşliğinde 10 mL %0,25 bupivakain ile superior trunk bloğu uygulandı. Kontrol grubunda (n=30) yalnızca intravenöz PCA kullanıldı. Primer sonlanım noktası, cerrahi sonrası 1., 2., 6., 12. ve 24. saatlerde istirahatte ölçülen görsel analog skala (VAS) ile değerlendirilen ağrı düzeyiydi. Sekonder sonlanım noktaları arasında 12. ve 24. saatteki toplam tramadol tüketimi, subjektif solunum şikayetleri, advers etkiler ve ek analjezi gereksinimi yer aldı. Bulgular: STB grubunda tüm zaman noktalarında VAS skorları anlamlı olarak daha düşüktü (p < 0,001). 12. ve 24. saatte tramadol tüketimi de STB grubunda anlamlı derecede daha düşüktü (p < 0,001). Parasetamol gereksinimi kontrol grubunda %12 oranında görülürken STB grubunda hiç görülmedi (p = 0,007). Advers etkiler her iki grupta benzerdi; STB grubunda iki hastada Horner sendromu gelişti. Solunumsal komplikasyon gözlenmedi. Sonuç: Ultrason eşliğinde uygulanan STB, proksimal humerus cerrahisi sonrası omuz ve üst kolda etkili postoperatif analjezi sağlamış, opioid tüketimini azaltmış ve minimal solunumsal yan etki ile güvenli bulunmuştur. Anahtar Kelimeler: Proksimal humerus kırığı, sinir bloğu, superior trunk bloğu, analjezi, brakiyal pleksus

Anahtar Kelimeler

• Proksimal humerus kırığı
• sinir bloğu
• superior trunk bloğu
• analjezi
• brakiyal pleksus

Destekleyen Kurum

Beyan edilecek herhangi bir finansman kaynağı bulunmamaktadır.

Etik Beyan

Çalışma, kurumsal (Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi) inceleme kurulu tarafından onaylanmıştır (Onay numarası: 2022/06-12, onay tarihi 20/10/2021). Çalışma, kurumun etik standartları ve Helsinki Bildirgesi ilkeleri doğrultusunda yürütülmüştür.

Efficacy of Ultrasound-Guided Superior Trunk Block for Postoperative Analgesia After Proximal Humerus Surgery: A Randomised Controlled Trial

Öz

Abstract Aim: Moderate to severe pain is common after proximal humerus surgery, often requiring opioid-based analgesia. Superior trunk block (STB), a selective brachial plexus block, has been proposed as an alternative for postoperative pain control. This study aimed to evaluate the analgesic efficacy of STB compared with intravenous patient-controlled analgesia (PCA) following proximal humerus surgery. Methods: This prospective randomized controlled trial included 60 patients undergoing proximal humerus surgery who were randomly assigned to two groups. In the STB group (n = 30), patients received an ultrasound-guided superior trunk block with 10 mL of 0.25% bupivacaine in combination with intravenous PCA. The control group (n = 30) received intravenous PCA alone. The primary endpoint was pain level, as measured using a visual analogue scale (VAS), at rest at 1, 2, 6, 12 and 24 hours postoperatively. Secondary endpoints included total tramadol consumption at 12 and 24 hours, subjective respiratory complaints, adverse effects, and the requirement for rescue analgesia. Results: The STB group had significantly lower VAS scores at all time points (p < 0.001). Tramadol consumption at 12 and 24 hours was also significantly lower in the STB group (p < 0.001). Paracetamol was required by 12% of control patients but by none in the STB group (p = 0.007). Adverse effects were similar; two STB patients developed Horner’s syndrome, and no respiratory complications were observed. Conclusion: Ultrasound-guided STB provided effective postoperative analgesia for the shoulder and upper arm after proximal humerus surgery, reducing opioid consumption with minimal respiratory side effects. Keywords: Proximal humerus fracture, nerve block, superior trunk block, analgesia, brachial plexus

Anahtar Kelimeler

• Proximal humerus fracture
• nerve block
• superior trunk block
• analgesia
• brachial plexus

Destekleyen Kurum

There are no sources of funding to declare.

Etik Beyan

The study was approved by the institutional (Bursa Yuksek Ihtisas Training and Research Hospital) review board (Approval number: 2022/06-12, approval date 20/10/2021). The study was conducted in accordance with the ethical standards of the institution and the principles of the Declaration of Helsinki.

Kaynakça

1. Iliaens J, Metsemakers WJ, Coppens S, et al. Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal. Arch Orthop Trauma Surg. 2019;139:1731-1741. doi:10.1007/s00402-019-03253-0.
2. Falyar CR, Grossman EC. Ultrasound-guided interscalene-supraclavicular block for an intramedullary nailing of a pathologic humeral fracture: practical application of ultrasound-guided regional anesthesia. AANA J. 2014;82:219-222.
3. Beaudet V, Williams SR, Tetreault P, Perrault MA. Perioperative interscalene block versus intra-articular injection of local anesthetics for postoperative analgesia in shoulder surgery. Reg Anesth Pain Med. 2008;33:134-138. doi:10.1136/rapm-00115550-200803000-00008.
4. Burckett-St Laurent D, Chan V, Chin KJ. Refining the ultrasound-guided interscalene brachial plexus block: the superior trunk approach. Can J Anaesth. 2014;61:1098-1102. doi:10.1007/s12630-014-0237-3.
5. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472:1576-1585. doi:10.1007/s11999-013-3415-7.
6. Kang R, Jeong JS, Chin KJ, et al. Superior trunk block provides noninferior analgesia compared with interscalene brachial plexus block in arthroscopic shoulder surgery. Anesthesiology. 2019;131:1316-1326. doi:10.1097/ALN.0000000000002919.
7. Kessler J, Schafhalter-Zoppoth I, Gray AT. An ultrasound study of the phrenic nerve in the posterior cervical triangle: implications for the interscalene brachial plexus block. Reg Anesth Pain Med. 2008;33:545-550. doi:10.1136/rapm-00115550-200811000-00006.
8. Lee JH, Cho SH, Kim SH, et al. Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. Can J Anaesth. 2011;58:1001-1006. doi:10.1007/s12630-011-9568-5.

9. Kim DH, Lin Y, Beathe JC, et al. Superior trunk block: a phrenic-sparing alternative to the interscalene block: a randomized controlled trial. Anesthesiology. 2019;131:521-533. doi:10.1097/ALN.0000000000002841.
10. Amaral S, Arsky Lombardi R, Medeiros H, Nogueira A, Gadsden J. Superior trunk block is an effective phrenic-sparing alternative to interscalene block for shoulder arthroscopy: a systematic review and meta-analysis. Cureus. 2023;15(11):e48217. doi:10.7759/cureus.48217.
11. Mistry T, Dey S, Kalbande JV. Superior trunk block for humerus surgery: application beyond shoulder analgesia. Saudi J Anaesth. 2020;14:547-548. doi:10.4103/sja.SJA_198_20.
12. Wardhan R, Nimma SR. Ultrasound-guided upper trunk perineural catheter for shoulder surgery: a description of catheter technique. Cureus. 2020;12:e11095. doi:10.7759/cureus.11095.
13. Sinha C, Kumari P, Kumar A, et al. Superior trunk versus interscalene brachial plexus block in humerus surgery: a randomized controlled trial. Anaesthesiol Intensive Ther. 2024;56:194-198. doi:10.5114/ait.2024.142772.
14. Zhang H, Miao Y, Qu Z. Upper trunk block for shoulder analgesia with potential phrenic nerve sparing: a preliminary anatomical report—one fascia, two blocks, and a concern on diaphragm-sparing. Reg Anesth Pain Med. 2019;44:rapm-2019-100746. doi:10.1136/rapm-2019-100746.
15. Cros Campoy J, Domingo Bosch O, Sala-Blanch X. Upper trunk block: “primum non nocere”. Reg Anesth Pain Med. 2019;44:rapm-2019-101162. doi:10.1136/rapm-2019-101162.
16. Wang H, Bao Q, Cao D, Zhu L, Chen L, Yu Y. Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy: a randomized controlled trial. J Orthop Surg Res. 2024;19:604. doi:10.1186/s13018-024-05083-2.
17. Tessler O, Gilardino MS, Bartow MJ, et al. Transverse cervical artery: consistent anatomical landmarks and clinical experience with its use as a recipient artery in complex head and neck reconstruction. Plast Reconstr Surg. 2017;139:745e-751e. doi:10.1097/PRS.0000000000003085.
18. Sutcliffe P, Lasrado S. Anatomy, Head and Neck, Deep Cervical Neck Fascia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.