|Year : 2015 | Volume
| Issue : 2 | Page : 91-95
A preliminary study of a novel technique of suprascapular nerve block in treating chronic shoulder pain
Mayank Chansoria1, Gautam Das2, Neelesh Mathankar3, Dilip Chandar1, Neha Vyas4, Sachin Upadhyay5
1 Department of Anaesthesiology, Jabalpur Medical College, Jabalpur, Madhya Pradesh, India
2 Daradia Pain Clinic, Kolkata, West Bengal, India
3 Department of Anaesthesiology, Meditrina Hospital, Nagpur, Maharashtra, India
4 Department of Dentistry, Jabalpur Hospital, Jabalpur, Madhya Pradesh, India
5 Department of Orthopaedics, Jabalpur Medical College, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||15-Apr-2015|
Dr. Mayank Chansoria
Department of Anaesthesiology, Jabalpur Medical College, Jabalpur, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The objective was to evaluate efficacy of a novel landmark-based technique of suprascapular nerve block (SSNB) in the treatment of shoulder pain and disability. Study Design: Prospective, observational study. Materials and Methods: Forty patients with chronic shoulder pain were treated with a new technique of SSNB. Visual analog scale for pain (VAS) and shoulder pain disability index (SPADI) were assessed before giving the block and at both the follow-up visits at the end of 1 st and 4 th week. Pain relief was also assessed on Likert scale in both the follow-up visits. Results: The baseline VAS of 8.45 ± 0.87 was significantly improved to 2.80 ± 0.70 and 5.02 ± 1.02 after 1 st and 4 th week of SSNB, respectively (P = 0.000). Similarly, the baseline total SPADI was of 71.15 ± 4.96, was significantly improved to 55.22 ± 1.32 and 57.61 ± 3.50 after 1 st and 4 th week of follow-up, respectively (P = 0.000). The mean Likert scale score after 1 week was 3.68 ± 0.656 and after 4 weeks was 4.00 ± 0.679. Conclusion: This new technique of SSNB is safe, effective, and well-tolerated in treating chronic shoulder pain and disability.
Keywords: Landmark-based technique, new technique, pneumothorax, shoulder pain, suprascapular nerve block
|How to cite this article:|
Chansoria M, Das G, Mathankar N, Chandar D, Vyas N, Upadhyay S. A preliminary study of a novel technique of suprascapular nerve block in treating chronic shoulder pain. Indian J Pain 2015;29:91-5
|How to cite this URL:|
Chansoria M, Das G, Mathankar N, Chandar D, Vyas N, Upadhyay S. A preliminary study of a novel technique of suprascapular nerve block in treating chronic shoulder pain. Indian J Pain [serial online] 2015 [cited 2020 May 29];29:91-5. Available from: http://www.indianjpain.org/text.asp?2015/29/2/91/155177
| Introduction|| |
Shoulder joint is pivotal for day to day activities, and shoulder pain leads to functional disability and decrease in quality-of-life.  Chronic shoulder pain, defined as shoulder pain lasting for a period of more than 6 months, is one of the common complaints encountered by pain physicians. Since most of the shoulder pain prevalence data is derived from population-based research, with different definitions used for defining shoulder pain, the prevalence of shoulder pain varies widely (from 1% to 67%) across different population. The incidence of chronic shoulder pain is approximately 15-30% with variations among different population and age groups. ,,
The most common etiologies of chronic shoulder disorders include rotator cuff syndrome, glenohumeral joint osteoarthritis, adhesive capsulitis, posttraumatic pain, and persistent pain following surgery.  Other causes can be rheumatologic disorders like osteoarthritis, fibromyalgia, rheumatoid arthritis or secondary to the damage of nerves supplying shoulder joint due to trauma or neurodegenerative diseases like diabetes, chronic alcoholism, etc.
The treatment modalities available for alleviating chronic shoulder pain varies from simple anti-inflammatory drugs to interventional procedures like intra-articular steroid injections, suprascapular nerve block (SSNB), etc.  A substantial number of patients may not be appropriate surgical candidates, or they may have significant medical comorbidities. SSNB has a long history of reducing pain and improving range of motion in patients with shoulder pain.  The suprascapular nerve (SSN) innervates nearly 70% of the shoulder joint, and therefore, its blockade is a commonly accepted mode of pain therapy in acute and chronic settings.  SSNB being simple, inexpensive, and associated with minimal complications, pain physicians around the globe prefer it in the management of shoulder pain. 
Since its initial description various authors have proposed different approaches in blocking the SSN to reduce its complications. The incidence of pneumothorax associated with suprascapular block is reported as <1%. Avoiding entering the suprascapular notch in the vertical plane has been postulated to decrease the risk of pneumothorax.  The present study describes a novel technique to block SSN for chronic shoulder pain.
Suprascapular nerve anatomy
Suprascapular nerve, a mixed nerve, originates in upper trunk of brachial plexus, C5 and C6 roots, receiving in over 50% contributions of C4 root and crosses the deep posterior triangle of neck, below omohyoid muscle and trapezium, entering the suprascapular incisures/notch below the superior transverse scapular ligament.
The nerve then enters into the suprascapular fossa, where two motor branches to the supraspinatus muscle originate. Just proximal to the suprascapular notch, the SSN gives off the sensitive branches, which travels with it through the notch before proceeding laterally to innervate the acromioclavicular joint and its associated bursa and the coracoclavicular and coracohumeral ligaments.
It continues its descending obliquous path bypassing the spinoglenoid (SGN) incisure, under the inferior transverse scapular ligament present in 50% of people. It follows then toward the infraspinatus fossa, in which it provides three to four motor branches for infraspinatus muscle.
Novel technique for suprascapular block
We propose a novel technique, based on anatomical landmarks, to block SSN and to virtually eliminate the chances of pneumothorax. In this technique, the superior surface of the spine of scapula is marked. Scapular spine is palpated from medial to lateral to a point where the spine becomes broad. The needle is inserted parallel to the skin hitting the superior surface of the spine of scapula as close as possible to the posterior surface of wing of scapula. Then the needle is walked of laterally remaining in close proximity to the bone, as soon the needle gives way it implies the needle is in SGN notch. With proper aspiration, a total volume of 10 ml local lignocaine 1% plus depomedrol 40 mg is injected to bath the SSN in suprascapular fossa. Throughout the procedure, care should be taken to maintain the direction of needle parallel to the surface of the skin.
| Materials and Methods|| |
After getting Internal Ethics Committee approval, the present study was conducted as a prospective observational study in Netaji Subash Chandra Bose Medical College from a time period of October 2013 to May 2014. The patients who satisfied inclusion criteria were recruited for the study after informed consent. The inclusion criteria were defined as following.
- Pain and stiffness in one or both the shoulders for at least 4 weeks
- Restricted and passive range of motion at the glenohumeral joint
- Pain at night causing sleep disturbance and inability to lie on the affected side
- No history of recent trauma
- No previous injection in the involved shoulder
- No history of allergy to local anesthetics
- No medical condition such as coagulation disorders.
Patients who refused the informed consent and patients with chronic shoulder pain due to other causes like nerve damage or neurologic disorders or disorders whose pain could not be alleviated by SSNB and patients with irregular follow-up were excluded from the study.
Under all aseptic precautions, all the patients were administered SSNB by the above-described technique. A total volume of 10 ml of drug (9 ml of 1% Lignocaine and 40 mg methylprednisolone [Depomedrol]) was injected into suprascapular fossa. The patients were followed-up in two visits after SSNB at the end of the 1 st week after injection and at the end of 4 th week after injection.
Visual analog scale for pain (VAS) and shoulder pain disability index (SPADI) were assessed before giving the block and at both the follow-up visits. The patients were asked to answer a questionnaire in their native language. Patients were also asked to rate their pain relief on a 5-point standard Likert scale as 0 = no pain relief, 1 = a little pain relief, 2 = moderate pain relief, 3 = a lot of pain relief, and 4 = complete pain relief. The results were analyzed using repeated measures analysis of variance using a Statistical Package for the Social Sciences 16 software.
| Results|| |
A total of 40 patients who received suprascapular block by our novel technique were analyzed 30 of them were male (75%), and the remaining 10 were female (25%). The mean age of the patients was of 47.93 years with a maximum age of 79 years and a minimum age of 37 years. 25 (62.5%) of the patients had right shoulder involvement while the rest 15 (37.5%) of the patients had left shoulder involvement.
The baseline VAS was of 8.45 ± 0.87 which improved to 2.80 ± 0.70 after 1 week and 5.02 ± 1.02 after 4 weeks of SSNB. Similarly, the baseline total SPADI was of 71.15 ± 4.96 which improved to 55.22 ± 1.32 after 1 week and 57.61 ± 3.50 after 4 weeks of SSNB. When compared statistically a highly significant P = 0.000 was obtained. [Table 1] summarizes the data. [Figure 1], [Figure 2], [Figure 3] show the improvements in patients shoulder pain using box plots.
|Figure 1: Improvement of visual analog scale for pain after suprascapular nerve block|
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|Figure 2: Improvement of shoulder pain disability index-pain after suprascapular nerve block|
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|Figure 3: Improvement of shoulder pain disability index-disability after suprascapular nerve block|
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The mean Likert scale score after 1 week was 3.68 ± 0.656 and after 4 weeks was 4.00 ± 0.679 showing that the majority of patients were satisfied with the outcomes of our technique of administering SSNB. No incidence of pneumothorax or intravascular injection of the drugs was recorded.
| Discussion|| |
Chronic shoulder pain originating intrinsically in the joint structures is a common cause of functional disability. Frequently, it is difficult to treat and responds poorly to pharmacological and physical therapies. Hence, it is important to consider interventional options, including SSNB, when conservative therapy fails. 
Suprascapular nerve block is an effective treatment for chronic shoulder pain, providing a simple, safe, and noninvasive alternative to manipulation under anesthesia, arthroscopy, or open surgery. SSNB carries less risk of complications than the aforementioned invasive treatments and can be administered in a clinic setting by a pain physician rather than in an operating room by a surgeon; so there is a reduction in patient discomfort and possibly some reduction in treatment cost. 
The technique of SSNB was initially described by Wertheim and Rovenstine (classic technique) in 1941.  In the classical technique, the needle is introduced into the supraspinous fossa perpendicular to the blade of the scapula and then is moved to enter the scapular notch, with the risk of pneumothorax or damage to the SSN or vessels. However, it is not necessary to locate the scapular notch in order to perform this block. Introducing the needle parallel to the blade, that is away from the direction of the lung and the SSN and vessels, and injecting the solution into the floor of the supraspinous fossa is an easy and safe technique. Numerous modifications of the classical technique were practiced thereafter by Parris,  Wassef,  Risdall and Sharwood-Smith,  Dangoisse et al.,  Meier et al.  and Fernandes et al. 
Our technique described above is closely in correlation to the technique described by Dangoisse et al.  However, the major difference is in the direction of needle introduction. In Dangoisse's technique needle is inserted 1 cm above the middle of scapular spine parallel to the lamina until the floor is reached, and drug is deposited in the floor of the fossa. In our technique, needle is introduced almost parallel to the skin and hits the superior surface of the spine of scapula, and we just slide laterally to enter the SGN notch, where drug is deposited after proper aspiration. In our technique, drug is deposited in close proximity to the nerve, and use of 10 ml volume makes sure that the drug seeps along the nerve proximally and distally and also fills the floor of the fossa. This helps to block most of the articular branches of the shoulder joint which can have high anatomic variability. Although Dangoisse's technique decreases the chances of pneumothorax, our technique virtually eliminates any pneumothorax because the direction of needle introduction is exactly opposite to that of the apex of the lungs.
Techniques that target the nerve more selectively are potentially advantageous. Use of ultrasound, fluoroscopy, and nerve stimulation plus computed tomography (CT) guidance have been described for SSNBs. Shanan et al. found that CT-guided control and landmark approaches to performing SSNBs result in similar significant and prolonged pain and disability reductions with equal safety.  Moreover, these techniques cannot be routinely practiced by pain physicians in the in-clinic settings and of limited use in the developing countries due to their higher cost and scarcity.
Although there is no consensus in the literature about the ideal anesthetic drug volume to be used in SSNB, the volume most frequently used is 10 mL. Jerosch et al. documented the fluid volume required to infiltrate supraspinatus fossa by image intensifier. They concluded that 10 mL would be more than enough to block SSN.  We have also used 10 ml of volume in our study. Small sample size and lack of the control group are potential limitations of our study.
| Conclusion|| |
This novel method of SSNB is safe, effective, and well-tolerated in treating chronic shoulder pain. It not only reduces pain but also decreases disability. In addition, it can be safely practiced in the in-clinic settings without the fear of potentially dangerous complications like pneumothorax.
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[Figure 1], [Figure 2], [Figure 3]