Case Study: Cervical epidural anaesthesia for shoulder arthroscopy

Shoulder arthroscopy is used to treat various diseases of the shoulder, including refractory adhesive capsulitis. Effective postoperative pain relief is critical for these patients, as the success of surgery largely depends on early and regular physiotherapy. Although traditionally, various methods of postoperative analgesia have been described, each has its own disadvantages. We report a case of adhesive capsulitis, for which arthroscopic capsular release was carried out under cervical epidural anaesthesia with general anaesthesia, resulting in excellent intraoperative and postoperative analgesia, with a better patient compliance for physiotherapy, and a significant improvement in the range of movement at the shoulder joint. Peer reviewed. (Submitted: 2011-10-03. Accepted: 2012-02-10.) © SASA South Afr J Anaesth Analg 2012;18(3):172-175 Case Study: Cervical epidural anaesthesia for shoulder arthroscopy 173 2012;18(3) South Afr J Anaesth Analg Case Study: Cervical epidural anaesthesia for shoulder arthroscopy Local examination of her left shoulder revealed a stiff shoulder, with a reduced range of movement. Table I shows how severely her range of movement was reduced, as compared to normal values. Table I: Patient’s preoperative range of motion compared to normal range Movement Normal range (degree) Patient’s range (degree) Forward flexion 160-180 20 Abduction 160-180 20 External rotation (side) 70-80 10 Internal rotation (side) Reach D8-D10 Nil External rotation:internal rotation 90:90 Not possible A diagnosis of left adhesive capsulitis was made, and the patient was advised to undergo physiotherapy. The severe pain did not allow her to participate in regular exercise, and the stiffness was progressive. Therefore, she was posted for elective arthroscopic capsular release surgery. Her haematological investigations and electrocardiograph (ECG) were unremarkable, and so she was classified as an American Society of Anesthesiologists (ASA) I patient, and posted for surgery. A decision was taken to administer cervical epidural anaesthesia with general anaesthesia, and the procedure was explained to the patient. After written informed consent had been obtained, and overnight fasting status had been confirmed, the patient was taken into the operating room and routine non-invasive monitors, including a five-lead ECG, a non-invasive blood pressure monitor, a capnograph, a pulse oximetry probe, and a temperature probe, were attached. Peripheral wide-bore intravenous access was achieved on the right forearm, and lactated Ringer infusion was started. Premedication given to the patient included intravenous glycopyrrolate (0.2 mg), intravenous ranitidine hydrochloride (50 mg), and intravenous ondansetron (4 mg). The position given to the patient was that of sitting on a stool with a flexed neck, with her head resting on the operation table. The C7-T1 intervertebral space was infiltrated with 2 ml of 2% lignocaine. The epidural space was identified using an 18 G Tuohy needle by loss of resistance to air, and reconfirmed by the ability to inject saline without resistance. The distance of the epidural space from the skin was found to be 3.5 cm. An epidural catheter (18 G) was inserted and flushed, and after confirming negative aspiration of blood or cerebrospinal fluid (CSF), it was fixed at the 8 cm mark. The patient was made supine, and an epidural test dose was given with 3 ml of 1% lignocaine with adrenaline. After confirming stable vitals, an epidural top-up dose was administered with 8 ml of 0.25% bupivacaine and 25 μg fentanyl citrate. Vitals remained stable. Twenty to 30 minutes later, when the patient was asked to reassess her pain, she confirmed an improvement in her symptoms in the form of reduced pain and stiffness. On checking passive movements by the orthopaedician, a significant improvement in the range of movements was noticed, as depicted in Table II. Table II: Comparison of range of motion before, and after, epidural analgesia Movement Pre-epidural (degree) Post-epidural (degree) Forward flexion 20 40