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Anesthesiology:
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Interscalene Block Superior to General Anesthesia: A Discussion of the Conclusions Regarding These Two Anesthesia Techniques

Hadzic, Admir M.D., Ph.D.*; Williams, Brian A. M.D., M.B.A.; Unis, Doug M.D.; Hobeika, Paul M.D.

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In Reply:—

We thank Dr. Reuben for his comment and agree with him in that a more aggressive preventative approach to multimodal pain management may have affected the outcome of our study. Our study however, was designed before the Practice Guidelines for Acute Pain Management in the Perioperative Setting were published by the American Society of Anesthesiologists Task Force on Acute Pain Management.1 Regardless, without a trial comparing interscalene block (ISB) versus general anesthesia and incorporating such a multimodal approach in patients having outpatient rotator cuff surgery, any discussion regarding the outcome can be only speculative.
We thank Dr. Brown for his comments and agree with his remarks. We would also like to apologize for failing to cite the report by Dr. Brown et al.2; this publication simply did not come up in our literature search.
We thank Drs. Weber, Parise, and Jain for taking an interest in our study.3 For the sake of completeness, we would like to clarify the terminology used—Drs. Weber, Parise, and Jain repeatedly use the term scalene anesthesia; the proper term is interscalene block.4 More importantly however, their comments are in sharp contradiction to the available literature including their own data.5 Drs. Weber, Parise, and Jain say that rotator cuff repair does not require “any extraordinary efforts to manage perioperative pain” and that the 16% admission rate for pain management in our study is unacceptable. In their own report, however, 170 (78%) of 218 patients had rotator cuff repair, of which 92% were admitted and required parenteral narcotics.5
Both in their publication and in this letter, Drs. Weber, Parise, and Jain repeatedly emphasize the risk of neurologic complications related to ISB and support their concerns by citing a report by Tetzlaff et al.6 However, as the title of the publication by Tetzlaff et al. indicates, they did not describe a neurologic complication of ISB, but an unusual case of idiopathic brachial plexitis.
We are also not surprised that these authors had difficulty with correlating the cost analysis that we presented in the Discussion section to the description of patient charges in their own article.5 The cited references in our article7,8 used economic models based on complex, transformed regression, whereas the cost analysis by Weber et al. directed no attention to the distinction between costs and charges,9 let alone the necessary econometric statistical maneuvers thereafter.10–13
Our study was not a repetition of that by Kinnard et al.14 In our study, patients received general anesthesia or ISB. In the study by Kinnard et al., all patients received general anesthesia with or without ISB at the end of surgery. The findings by Kinnard et al. are also in sharp contrast to those of Drs. Weber and Jain.5 Kinnard et al. concluded that the use of ISB was without complications, significantly improved the postoperative comfort, and reduced the need for hospitalization after shoulder surgery. These findings prompted Kinnard et al. to institute routine use of ISB for all outpatient shoulder procedures at their institution and suggest the same to the readership, whereas Drs. Weber and Jain reemphasize the dangers and limitations of ISB.5
The results of their study cannot be directly compared with those of our study because of the substantial differences in methodology. Most importantly, (1) our study was a randomized, controlled trial, whereas theirs was a combination of retrospective chart review, two case reports, and a hypothetical cost analysis; and (2) ISB in our study was successfully used in all patients, with ISB as the sole anesthetic. In contrast, in the study by Drs. Weber and Jain, 13% of blocks failed outright, and 82% of patients required general anesthesia.5
Admir Hadzic, M.D., Ph.D., *
Brian A. Williams, M.D., M.B.A.
Doug Unis, M.D.
Paul Hobeika, M.D.
*St. Luke’s-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York. ah149@columbia.edu
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References

1. Ashburn MA, Caplan RA, Carr DB, Connis RT, Ginsberg B, Green CR, Lema MJ, Nickinovich DG, Rice LJ: Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2004; 100:1573–81

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. Hadzic A, Williams BA, Kraca 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

4. Greene NM: Key words in anesthesiology, Key Words in Anesthesiology, 3rd edition. Edited by Greene NM. New York, Elsevier, 1988

5. Weber SC, Jain S: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002; 84:775–9

6. Tetzlaff JE, Dilger J, Yap E, Brems J: Idiopathic brachial plexitis after total shoulder replacement with interscalene brachial plexus block. Anesth Analg 1997; 85:644–6

7. Woolhandler S, Himmelstein DU: Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med 1997; 336:769–74

8. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH: The economics of nerve block pain management after anterior cruciate ligament reconstruction: Significant hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology 2004; 100:697–706

9. Finkler SA: The distinction between cost and charges. Ann Intern Med 1982; 96:102–9

10. Ai C, Norton EC: Standard errors for the retransformation problem with heteroscedasticity. J Health Econ 2000; 19:697–718

11. Manning WG: The logged dependent variable, heteroscedasticity, and the retransformation problem. J Health Econ 1998; 17:283–95

12. Mullahy J: Much ado about two: Reconsidering retransformation and the two-part model in health econometrics. J Health Econ 1998; 17:247–81

13. Duan N: Smearing estimate: A nonparametric retransformation method. J Am Statist Assoc 1983; 78:605–10

14. Kinnard P, Truchon R, St-Pierre A, Montruil J: Interscalene block for pain relief after shoulder surgery. Clin Orthop 1994; 304:22–4

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