Armpit Pain After Shoulder Surgery

[StillAwake]

We do a significant number of shoulder scopes (mostly beach chair, but some lateral) and shoulder replacements. I've noticed many patients experience armpit pain after shoulder surgery. The blocks are solid. Anyone else running into this? Any suggestions as to the reason for the pain or how to manage it?

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[GassYous]

Interscalene misses the intercostobrachial nerve. T2 innervation. Either you or the surgeon can put some local in the subq near armpit. You can use ultrasound if you wish but I just use my block needle and put 10 cc of 0.5% bupivacaine right under the skin.

 

[dhb]

Never had that complain, your surgeon must be doing something unusual.

 

[kmurp]

I see this fairly often as well with multiple different surgeons. Usually responds to a little fentanyl but ICB block as above also has worked for me in more severe cases.

 

[deleted126335]

Also very common in our practice. Intercostobrachial nerve lies outside the plexus.

 

[GaseousClay]

Also could be simple as tons of sticky drapes and ioban and then a nice wax job when taking it off can sting for a while after. I’ve seen some red raw areas from ortho techs just savagely tearing those off. I agree most likely intercostobrachial tho

 

[coffeebythelake]

Yep it is the T2 block

 

[GassYous]

Never had that complain, your surgeon must be doing something unusual.

Depends on where they are putting their ports and if they use local with epi to decrease bleeding.

 

[BLADEMDA]

I have performed a rescue Pecs2 block in the PACU for armpit pain. I also use this block for certain orthopedic procedures as well.


Pecs blocks have also been proposed in letters to the editor as alternative techniques to anesthetize operative regions such as the axilla, proximal medial upper arm, and posterior shoulder, which are not innervated by the brachial plexus (Figure 1).

 

[BLADEMDA]

http://www.anesthscape.com/Content/docs/%E9%B1%BC%E9%B1%BC%E9%B1%BC%E9%B1%BC%E6%91%86%E6%91%86/20191206/676d6180-c00e-4e33-8fa9-66697763c5b2.pdf

 

[ethilo]

Our surgeon does open biceps tenodesis often, I always do a intercostobrachial block for these.

Spread 10 mL 0.25% marcaine sybcutaneously along a line across the axilla from the insertion of the long head of the triceps to the anterior deltoid. ICBN is a cutaneous nerve, doesn't need anything more than this to cover the T2 region.

I'll do it too for fistulas that have a chance of going proximal

 

[Hoya11]

We do a significant number of shoulder scopes (mostly beach chair, but some lateral) and shoulder replacements. I've noticed many patients experience armpit pain after shoulder surgery. The blocks are solid. Anyone else running into this? Any suggestions as to the reason for the pain or how to manage it?

The blocks are solid but are they too high?

I have seen this mostly with the "true" interscalenes up in the neck as opposed to a "low interscalene" or high supraclav block.

Maybe scan down a little lower near the base of the neck and try depositing some local lateral to the artery down low near the lower roots.

I do a lot of these and have found the most success with various surgeons from the "low interscalene" and not forgetting to deposit (in addition to the C567 roots above the artery) down low near the lateral/inferior border of the artery, a block kind of like a supraclav/interscalene hybrid.

 

[nimbus]

Our surgeon does open biceps tenodesis often, I always do a intercostobrachial block for these.

Spread 10 mL 0.25% marcaine sybcutaneously along a line across the axilla from the insertion of the long head of the triceps to the anterior deltoid. ICBN is a cutaneous nerve, doesn't need anything more than this to cover the T2 region.

I'll do it too for fistulas that have a chance of going proximal

Same. I do supraclav+subq infiltration for ICBN for AV fistulas.

 

[okayplayer]

I generally explain to folks that the block helps with pain over the shoulder itself but other adjacent areas (arm pit, over pec major) may hurt depending on the surgical approach and may need supplementation with opiates. People seem to get it and I’ve never heard complaints postop with this schpiel.

 

[BLADEMDA]

I generally explain to folks that the block helps with pain over the shoulder itself but other adjacent areas (arm pit, over pec major) may hurt depending on the surgical approach and may need supplementation with opiates. People seem to get it and I’ve never heard complaints postop with this schpiel.

That's my approach as well. But, if they complain a lot I have done the Pecs 2 block in pacu with excellent results. This block doesn't disturb the dressing much either.

 

[StillAwake]

Thanks for the input. Most patients do well with a little bit of fentanyl or one oxycodone. However, I have occasional patients, despite telling me they have a very high pain tolerance, who are extremely uncomfortable from the armpit pain. I will try the Pecs II as a rescue.

 

[Drfirextinguisher]

Thanks for the input. Most patients do well with a little bit of fentanyl or one oxycodone. However, I have occasional patients, despite telling me they have a very high pain tolerance, who are extremely uncomfortable from the armpit pain. I will try the Pecs II as a rescue.

That's my approach as well. But, if they complain a lot I have done the Pecs 2 block in pacu with excellent results. This block doesn't disturb the dressing much either.

I’ve had to do a couple suprascapular blocks in the PACU for posterior capsular pain s/p rotator cuff repair. I usually treat isolated Armpit pain with a little fentanyl/po opioids before they go home, but anecdotally noticed the suprascapular block treated the arm pit pain really well. Just curious if others have seen this as well?

 

[Southpaw]

Some of my patients definitely have armpit pain. I’m forced to treat with narcotic, but don’t like it because you know, I’ve already done the spinal of the upper extremity. I’ll start augmenting w ICB for a few months and see how it goes. If that doesn’t work I’ll try @BLADEMDA’s suggestion.

 

[BLADEMDA]

From the study I provided a link to previously:


Interestingly, while the majority of patients in the ISB group reported axillary pain at 6 hours (71%), it was not present in every patient. There could be several possible explanations for this finding. First, it is conceivable that in some patients, the ISB was performed more caudal than intended and therefore blockade of the lower trunk of the brachial plexus was achieved. This could explain the lack of axillary pain given that the medial brachial cutaneous nerve and the medial pectoral nerve both originate from the lower trunk of the brachial plexus. Interestingly, a prior study investigating whether an ISB performed at the lowest bra- chial plexus nerve roots could adequately block the hand and forearm revealed a success rate of 6%–33%.11 Second, it is possible that because of anatomic variability, the location of the incision for the open biceps tenodesis was actually in an area of the arm innervated by the axillary nerve, which would theoretically be covered by an ISB.

 

[GA8314]

That's my approach as well. But, if they complain a lot I have done the Pecs 2 block in pacu with excellent results. This block doesn't disturb the dressing much either.

We routinely do PECS2 blocks for shoulder surgeries when they do a biceps tenodesis, and since adding this block, axillary pain has been greatly reduced.

 

[nimbus]

How much volume are people injecting in their ISB? I inject a larger volume and have not had patients complaining of axillary pain.

 

[Arch Guillotti]

How much volume are people injecting in their ISB? I inject a larger volume and have not had patients complaining of axillary pain.

Same here.

 

[dhb]

Lowish ISB, 10cc never had a complain of axillary pain.

 

[anbuitachi]

How much volume are people injecting in their ISB? I inject a larger volume and have not had patients complaining of axillary pain.

what is a larger volume?

 

[nimbus]

what is a larger volume?

25-30ml

 

[BLADEMDA]

I am typically using 22-25 mls and my estimate is less than 10% of patients complain of axillary pain. This is at a high volume center with a lot of shoulder scopes. Therefore, I don't bother with a sub Q injection but prefer a "rescue" Pecs 2 which is only needed about once per month.