title: A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.
abstract: BACKGROUND
  Visualization with ultrasound during regional anesthesia may reduce the risk of intraneural injection and subsequent neurological symptoms but has not been formally assessed. Thus, we performed this randomized clinical trial comparing ultrasound versus nerve stimulator-guided interscalene blocks for shoulder arthroscopy to determine whether ultrasound could reduce the incidence of postoperative neurological symptoms.
  
  
  METHODS
  Two hundred thirty patients were randomized to a standardized interscalene block with either ultrasound or nerve stimulator with a 5 cm, 22 g Stimuplex insulated needle with 1.5% mepivacaine with 1:300,000 epinephrine and NaCO3 (1 meq/10 mL). A standardized neurological assessment tool (questionnaire and physical examination) designed by a neurologist was administered before surgery (both components), at approximately 1 wk after surgery (questionnaire), and at approximately 4-6 weeks after surgery (both components). Diagnosis of postoperative neurological symptoms was determined by a neurologist blinded to block technique.
  
  
  RESULTS
  Two hundred nineteen patients were evaluated. Use of ultrasound decreased the number of needle passes for block performance (1 vs 3, median, P < 0.001), enhanced motor block at the 5-min assessment (P = 0.04) but did not decrease block performance time (5 min for both). No patient required conversion to general anesthesia for failed block, and patient satisfaction was similar in both groups (96% nerve stimulator and 92% ultrasound). The incidence of postoperative neurological symptoms was similar at 1 wk follow-up with 11% (95% CI of 5%-17%) for nerve stimulator and 8% (95% CI of 3%-13%) for ultrasound and was similar at late follow-up with 7% (95% CI of 3%-12%) for nerve stimulator and 6% (95% CI of 2%-11%) for ultrasound. The severity of postoperative neurological symptoms was similar between groups with a median patient rating of moderate. Symptoms were primarily sensory and consisted of pain, tingling, or paresthesias.
  
  
  CONCLUSIONS
  Ultrasound reduced the number of needle passes needed to perform interscalene block and enhanced motor block at the 5 min assessment; however, we did not observe significant differences in block failures, patient satisfaction or incidence, and severity of postoperative neurological symptoms.
authors.affiliation: Department of Anesthesiology, Hospital for Special Surgery, Weill College of Medicine of Cornell University, 535 East 70th St., New York City, NY 10021, USA. liusp@hss.edu
authors.forename: Spencer S
authors.initials: SS
authors.lastname: Liu
authors.forename: Victor M
authors.initials: VM
authors.lastname: Zayas
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gordon
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Beathe
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Maalouf
authors.forename: Leonardo
authors.initials: L
authors.lastname: Paroli
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Liguori
authors.forename: Jaime
authors.initials: J
authors.lastname: Ortiz
authors.forename: Valeria
authors.initials: V
authors.lastname: Buschiazzo
authors.forename: Justin
authors.initials: J
authors.lastname: Ngeow
authors.forename: Teena
authors.initials: T
authors.lastname: Shetty
authors.forename: Jacques T
authors.initials: JT
authors.lastname: Ya Deau
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D004599:Electric Stimulation Therapy / Q000295:instrumentation / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D009407:Nerve Block / Q000295:instrumentation / Q000379:methods*; D009422:Nervous System Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery*; D011446:Prospective Studies; D012782:Shoulder / Q000000981:diagnostic imaging / Q000601:surgery*; D018084:Ultrasonography, Interventional / Q000295:instrumentation / Q000379:methods*