Brachial plexus anesthesia in shoulder stiffness surgery due to fibromyalgia Delta

The article was professionally consulted by Specialist Doctor II Dinh Van Loc - Department of General Surgery - Vinmec Danang International General Hospital.

For shoulder stiffness caused by Delta fibromyalgia, medical treatments and physical therapy can only treat symptoms, currently, surgical treatment of Delta fibromyalgia is the method to help solve these problems. stiffened muscle cord.

Mobilizing the shoulder joint within the range of joint motion requires the coordination of many muscle groups, in which the Delta muscle works with a number of other muscles to help the shoulder joint move to raise the arm. Osteoarthritis of the shoulder is a loss of deltoid muscle movement, thereby limiting shoulder joint mobility. Causes symptoms such as:
The patient is unable to use a comb to comb his hair, cannot use his hands to scratch the opposite side's back, has difficulty changing clothes, and has difficulty inserting his hands into the sleeves. in rest state. Occasional pain around the shoulder joint or frequent pain. Shoulder joints sag, hands are always bent, shoulder blades are raised, affecting aesthetics. The fissures are palpable along the fibrous band, or palpable fibrous patches on the deltoid muscle axis. In severe cases, shoulder dislocation can be seen, shoulder sloping, chest deformity

Causes of shoulder fibrosis: It can be caused by repeated injections into the deltoid muscle, usually by some drugs such as penicillin, lincomycin... However, there are many unknown causes.
Of the surgical treatment methods is considered the most effective, resolving the fibrous condition. During surgery, there are many methods of anesthesia such as anesthesia, anesthesia depending on each specific case. If there are no special problems, the brachial plexus anesthetic is always the preferred choice in the analgesia method of shoulder surgery.

Brachial plexus anesthesia is a regional anesthetic technique performed by a specialist, by inserting an anesthetic or a mixture of anesthetics into the patient's brachial plexus sheath.
2.1 Indications Anesthesia for upper limb surgery, clavicle Anesthesia for upper limb misalignment. Pain relief after upper extremity surgery. 2.2 Contraindications Patient refuses, has a history of allergy to local anesthetics Inflammation, open wounds in the area of ​​anesthetic needle puncture Severe coagulopathy. Inadequate resuscitation facilities Not proficient in plexus anesthesia techniques. 2.3 Preparation *Performer: Medical staff specializing in anesthesiology and resuscitation.
*Means:
Resuscitation facilities: Oxygen source, Ambu ball, mask, backup means for intubation, anesthesia machine with breathing, electric shock machine, suction machine...Resuscitation medicine circulation includes fluid, drugs such as ephedrine, adrenaline... Anticonvulsants, muscle relaxants. Monitor: Electrocardiogram, arterial blood pressure, oxygen saturation Sp02, breathing rate... *Supplies Medical: Syringe needles of all sizes, gloves, sterile gauze, pliers, antiseptic alcohol, sterile tissue... Peripheral nerve stimulator, specialized anesthetic needle, catheter in case of traction anesthesia long, ultrasound machine.
* Anesthetics: Local anesthetics such as lidocaine, bupivacaine, levobupivacaine, ropivacaine... mixed in 0.9% sodium chloride solution; can be combined with drugs of the family morphine and or adrenaline at the rate of 1: 200,000.
*Preparing the patient:
Pre-operative examination, explaining to the patient to cooperate when conducting anesthetic and disinfecting the anesthetic area. Give the patient sedation the night before surgery (if necessary).

The patient lies on his back, head turned to the opposite side, put a small pillow under the shoulder blades, hands along the body.
*Place of injection of nerve plexus anesthetic: Is the intersection point between the line
passing through the cricoid cartilage and the gap between the trapezius muscles.
Needle direction: From top to bottom, outside to inside and front to back, avoid
external jugular vein. Push the needle slowly until you feel paresthesia or motor response of the arm, forearm or hand muscle groups; Withdraw the needle 1-2mm, before injecting, must aspirate to see if there is blood and gas, avoid injecting into the blood vessel, if not, the drug will be injected.
Aspirate once after injecting every 3-5ml of anesthetic
*In case of neuromuscular stimulator: Position and direction of needle puncture as above, start neuromuscular stimulator with intensity 1-2 mA , frequency 1Hz; gradually reduce the intensity to achieve signs of muscle contraction in the muscle groups corresponding to the nerve plexus at 0.3 - 0.5 mA. Perform the injection technique as above.
*Using an ultrasound machine to locate the nerve plexus: Conduct needle puncture under the guidance of ultrasound and perform injection as above. The application of ultrasound-guided neurosurgery at Vinmec International Hospitals has brought many benefits to patients and medical staff. The reduction of side effects of anesthetics and complications of anesthesia, patients quickly recover after surgery, improve quality of life.
2.5 Post-anesthesia follow-up Ultrasound-guided neurosurgery is a method of injecting anesthetic drugs into the nerve sheaths under ultrasound guidance to help reduce pain during surgery and reduce pain after surgery.
This is a new technique, with many advantages when not using Morphine and morphine precursors, helping to reduce the side effects of morphine such as: nausea, vomiting, urinary retention, constipation, even causing pain. addiction.
Avoid anesthetic poisoning.
In addition, the patient remains awake during surgery without feeling pain, making the postoperative period easier, avoiding the need for anesthesia, especially for patients with cardiovascular disease or pulmonary disease. Intraoperative anesthetics are not effective, can continuously infuse anesthetic through the catheter into the nerve stem to help reduce postoperative pain. This method reduces the side effects of anesthesia and complications during anesthesia, helps patients recover faster after surgery, and improves quality of life. In particular, the analgesic effect is good due to injection into the right nerve sheath, avoiding pain when performing anesthesia according to anatomical landmarks and reducing pain in chronic diseases such as terminal cancer.
During the procedure, under the guidance of ultrasound, the anesthesiologists accurately identify the nerve to be anesthetized. Using a specialized needle for anesthesia to enter the nerve stem, combining ultrasound and a nerve detector to identify nerves located in the path of the needle, avoiding puncture of blood vessels. Inject local anesthetic and assess block area of ​​local anesthetic. Thereby reducing the risks and complications such as nerve damage, injection into blood vessels causing anesthetic poisoning, incorrect injection leading to technical failure.

3.1 Drug-induced complications Allergy, anaphylaxis to local anesthetics: This case is rare with new generation local anesthetics. Treatment requires stopping the use of local anesthetics; use anti-anaphylaxis regimen according to the Ministry of Health Anesthesia poisoning: Usually due to overdose, or mistakenly injected into a blood vessel. Treatment to stop using anesthetics, anticonvulsants, emergency respiratory and circulatory resuscitation. 3.2 Technological complications Injecting drugs into the blood vessels: Need to be handled as in the case of anesthetic poisoning. Inject local anesthetic into the subarachnoid space or the cervical epidural space: Respiratory and circulatory emergency is needed Pneumothorax : Follow-up, it is necessary to aspirate the pleural space. Blockage of the stellate ganglion causes Claude Bernard - Horner syndrome: Miosis, eyelid drooping, decreased sweating; Reversible nerve block causes temporary laryngeal paralysis: hoarseness, weak speech; Diaphragmatic nerve block: feeling of heaviness in the chest, possible dyspnea, respiratory failure. In these cases, it is necessary to monitor and wait until the effect of the anesthetic wears off. Other complications may be encountered such as: Infection, nerve damage, hematoma at the puncture site... Failure of anesthesia requires switching to another anesthetic method. Surgery to treat Delta fibromyalgia is performed early when the disease is detected in order to limit the risk of deformity secondary to shoulder stiffness. Neural plexus anesthesia is an anesthetic method used in shoulder stiffness surgery due to Delta fibromyalgia depending on each specific patient case, with the advantages of not being too difficult to perform and selective anesthesia.
Vinmec International General Hospital with a system of modern facilities, medical equipment and a team of experts and doctors with many years of experience in medical examination and treatment, patients can rest assured to visit. examination and treatment at the Hospital.
Doctor Dinh Van Loc graduated as a General Doctor in Hue in 1990, graduated as a Specialist Doctor in 2003 and as a Specialist Doctor in Anesthesiology and Resuscitation in 2017. Dr. Loc received advanced training in Anesthesiology. Anesthesiologist and has more than 23 years of experience working in pediatric intensive care anesthesia, cranial nerve anesthesia, anesthesia resuscitation for liver resection, esophagectomy at the Hospital
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