Drs. Weber and Jain are to be commended for gathering retrospective data on experience with regional scalene anesthesia in 218 patients treated over a three year period in two communnity hospitals. They conclude that pre-op consent discussions should include information on the complications that can occur.

Their article seems to imply that the rate of complications when using this procedure in a community setting is so high that it is not a satisfactory adjunct for perioperative pain control. The authors also present a cost analysis which implies that it is more expensive than alternative pain control modalities.

We also work in a community hospital based surgery center about an hour away from Sacramento. Our anesthesiologists, some of whom had been performing blocks for the past two to three years, have done 230 blocks since last July. In that period,the failure rate of the initial block was between 5 and 7%,but those patients who failed to achieve pain relief with the first block were routinely re-blocked and we know of no patient who failed to achieve analgesia by the time he or she went home. Our anesthesiologists are not aware of any nerve or cardiovascular injuries. There was one seizure with no sequelae. I have encountered a few patients with some persistent sensory changes in the forearm. These residual signs have uniformly resolved and have been considered negligible by the patients in comparison to the primary shoulder problem. We agree with the authors that some blocks "wear off in the middle of the night". A handful of patients have required an emergency room visit (but not a hospital admission). Thus patients should be advised that a block will wear off eventually, and that more pain can be expected. But that event is well managed with pre-emptive analgesia with Oxycontin and rofecoxib in post op doses.

I also agree with the authors that the block does have risks. For that reason, we have never used them for post op pain in arthroscopic acromioplasties. This group of patients seems to do well with conventional analgesia and local wound infiltration. Our surgeons typically reserve scalene block for open cuff repairs, open capsulorrhaphies, arthroplasties and fracture work and refractory adhesive capsulitis.

The authors cost analysis also differs from our experience. The material cost is basically the cost of the local anesthetic, syringe, and needle. Blocks are done in 15 minutes in the preop area while the operating room is turned over, or in some cases, post-operatively on the awake patient to prolong post op pain relief. The anesthesia fee of $440 described as "usual and customary charge"in the article is a fee that no one collects. Our average fee is $150, with lower reimbursement from Medicare and Workers Compensation. Not included in the cost analysis are the cost savings of doing the block. Without blocks, many of the patients who are discharged several hours after their procedure would need over night hospitalization. Given that more than half the patients in this article were in a community hospital, the added PACU and overnight costs would be very significant.

I have personally undergone a major repair of the rotator cuff, long head of the biceps, and subscapularis. My only anesthesia was the block with supplementary oral rofecoxib, and I had little discomfort for 12 to 18 hours.

Therefore, based on our experience, I would make the following recommendations: 1.Reserve blocks for procedures traditionally requiring hospitalization,or where pain relief is essential for early passive motion. 2.Just as with introducing a new surgical procedure, blocks should be performed initially by two to four interested anesthesiologists, who will commit to extra training and devise protocols to provide the opportunity for re-block when necessary,and pre-emptive analgesia regimens. 3. Consider blocks not so much for intraoperative anesthesia as for post op pain management. I would like to credit Steve Jacobs,MD,Department of Anesthesia Sequoia Surgical Pavilion and John Muir Medical Center for most of the analysis presented. Jerome H. Davis, MD

As an anesthesiologist I had performed thousands of non-image guided blocks and never had major complications. Currently as a pain specialist, I perform almost all major blocks with fluoroscopy and wonder how I did not get into more trouble in those days.

Based on my experience in training other anesthesiologists, and in reviewing several medical malpractice cases, I would agree that the issue of potential complications and their full disclosure to patients is key.

It seems though, that the anesthesiologists in this study have an inordinately high failure rate with their blocks. If their incidence of unsuccessful blocks is higher than the norm, should they disclose this to patients as part of the informed consent process?

In analyzing the frequent need for parenteral narcotics within a short period of recovery, and given their high complication rate, I believe, in this group, that the risks of the interscalene blocks outweighed the benefits.

Kenneth Zahl, MD Diplomate American Board of Aneshtesiology, with additional Qualifications in Pain Medicine Director, Skylands Pain Relief Clinics Rockaway, Morristown, Newton and Union, New Jersey