Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain

Abstract

Background: Shoulder pain from inflammatory arthritis and/or degenerative disease is a common cause of morbidity in the community. It is difficult to treat and there are limited data on the efficacy of most interventions. Suprascapular nerve block has shown promise in limited trials in reducing shoulder pain. There have been no large randomised placebo controlled trials examining the efficacy of suprascapular nerve block for shoulder pain in arthritis and/or degenerative disease using pain and disability end points.

Objective: To perform a randomised, double blind, placebo controlled trial of the efficacy of suprascapular nerve block for shoulder pain in rheumatoid arthritis (RA) and/or degenerative disease of the shoulder.

Methods: 83 people with chronic shoulder pain from degenerative disease or RA took part in the trial. If a person had two painful shoulders, these were randomised separately. A total of 108 shoulders were randomised. Patients in the group receiving active treatment had a single suprascapular nerve block following the protocol described by Dangoisse et al, while those in the other group received a placebo injection of normal saline administered subcutaneously. The patients were followed up for 12 weeks by an observer who was unaware of the randomisation and reviewed at weeks 1, 4, and 12 after the injection. Pain, disability, and range of movement data were gathered.

Results: Clinically and statistically significant improvements in all pain scores, all disability scores, and some range of movement scores in the shoulders receiving suprascapular nerve block compared with those receiving placebo were seen at weeks 1, 4, and 12. There were no significant adverse effects in either group.

Conclusion: Suprascapular nerve block is a safe and efficacious treatment for the treatment of shoulder pain in degenerative disease and/or arthritis. It improves pain, disability, and range of movement at the shoulder compared with placebo. It is a useful adjunct treatment for the practising clinician to assist in the management of a difficult and common clinical problem.

Figures

Figure 1

Method of suprascapular nerve injection by identification of surface anatomy. With the patient seated, the spine of the scapula is identified. A perpendicular line is drawn from the angle of the scapula upward to bisect the spine of the scapula. About 2 cm lateral to the intersecting point, in the upper outer quadrant of the scapula, the needle is inserted to the hub of the needle or until the floor of the fossa is reached.

Figure 2

Fluoroscopic image of the suprascapular nerve block injection. The needle is directed over the spine of the scapular and downward into the suprascapular fossa. (A) Anteroposterior view; (B) Neers view. Bupivacaine 10 ml and 1 ml (40 mg) of methylprednisolone is injected into the suprascapular fossa. For the purpose of illustration the injection material is mixed with contrast media. Arrows indicate the injected material. This material suffuses through the suprascapular fossa—(C) anteroposterior view; (D) Neers view.

Figure 3

Computed tomographic scan of suprascapular fossa at the level of the suprascapular notch after a suprascapular nerve block mixed with contrast medium. The arrow illustrates the notch, through which runs the suprascapular nerve, bathed in contrast material.

Figure 4

SPADI scores in the group receiving active treatment and placebo group at baseline and weeks 1, 4, and 12. (A) SPADI total scores; (B) SPADI pain subscale; (C) SPADI disability subscale. Values are mean scores and error bars are 95% confidence intervals.