To the Editor:—

I read with interest and am in full agreement with the findings of Hadzic et al.  1regarding the benefits of regional over general anesthesia for outpatient rotator cuff surgery. Patients undergoing shoulder surgery during interscalene block (ISB) anesthesia and intraoperative sedation were able to bypass phase I postanesthesia care unit in greater numbers that patients receiving general anesthesia (GA). In addition, regional anesthesia resulted in fewer unplanned hospital admissions, a faster time to discharge, fewer adverse events (including nausea, vomiting, sore throat), and greater patient satisfaction. None of the patients in the ISB group required treatment for pain before discharge home, whereas 80% of patients in the GA group required pain management despite wound infiltration and intraarticular instillation of local anesthetic by the surgeon.

However, the authors seem to have overlooked a study published by us out of Columbia University Medical Center (formerly Columbia-Presbyterian Medical Center) in which we reviewed 103 consecutive patients who underwent shoulder arthroscopic surgery during either GA or ISB anesthesia with sedation between August 1988 and March 1990.2Before the primary author’s arrival at Columbia-Presbyterian Medical Center in July 1989, most shoulder surgery was performed during GA. The use of ISB anesthesia was subsequently encouraged, and the benefits were so obvious that within a short time, the suggestion that GA be used for shoulder surgery was met with a great degree of resistance from the surgeons. As with the study of Hadzic et al. , we found that the benefits of ISB over GA for shoulder surgery included a shorter hospital stay, fewer unplanned admissions, fewer adverse events, and greater patient satisfaction.2 

The comments by Hadzic et al.  1regarding the study by Weber and Jain3are certainly valid and are supported by similar comments in our study regarding perceived disadvantages of regional anesthesia. With respect to the time factor, regional anesthesia is performed at Columbia University Medical Center in a “block room” before the patient’s entry into the operating room. After completion of the operative procedure, the patient is wide awake, pain free, without GA-associated side effects, and ready to be discharged to the postanesthesia care unit immediately after placement of the surgical dressing, i.e. , time is saved  when the practice of regional anesthesia is optimized. Weber and Jain3reported a 13% incidence of failed ISB, and 92% of patients required additional opioid analgesics after ISB. This high percentage of patients requiring postoperative opioid analgesics raises the question as to how successful the ISBs were, because it is most unusual for a patient to require any form of analgesia in the postoperative period after an ISB for shoulder surgery until the effect of the local anesthetic has worn off. Adequate training and experience certainly play a major role in the success as well as the complication rate associated with regional anesthesia.

At Columbia University Medical Center, we would have a great deal of difficulty attempting to perform a study similar to that performed by Hadzic et al.  1because approval by the surgeons to perform shoulder surgery during GA as part of a study would be all but impossible. Hence, the study by Hadzic et al.  1is an extremely welcome reminder of the benefits of regional over general anesthesia for shoulder surgery.

Columbia University, New York, New York. arb6@columbia.edu

References

1.
Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005; 102:1001–7
2.
Brown A, Weiss R, Greenberg C, Flatow E, Bigliani L: Interscalene block for shoulder arthroscopy: Comparison with general anesthesia. Arthroscopy 1993; 9:295–300
3.
Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002; 84-A: 775–9