British Journal of Anaesthesia 111 (3): 44552 (2013)

Advance Access publication 15 April 2013 . doi:10.1093/bja/aet109

PAIN

I.V. and perineural dexamethasone are equivalent

in increasing the analgesic duration of a single-shot
interscalene block with ropivacaine for shoulder surgery:
a prospective, randomized, placebo-controlled study
M. Desmet1*, H. Braems 2, M. Reynvoet 1, S. Plasschaert 1, J. Van Cauwelaert3, H. Pottel 4, S. Carlier1,
C. Missant 2 and M. Van de Velde2
1

Department of Anesthesiology, AZ Groeninge, Loofstraat 43, 8500 Kortrijk, Belgium

Department of Anesthesiology, University Leuven, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
3
Department of Orthopedic Surgery, AZ Groeninge, Burg. Vercruysselaan 5, 8500 Kortrijk, Belgium
4
Interdisciplinary Research Center Catholic University Leuven, Campus Kortrijk, Etienne Sabbelaan 53, 8500 Kortrijk, Belgium
2

Editors key points

Regional analgesia can
be effective in improving
postoperative pain
control after shoulder
surgery.

Background. Interscalene brachial plexus block (ISB) provides excellent, but time-limited
analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a singleshot ISB. However, systemic glucocorticoids also improve postoperative analgesia.
The hypothesis was tested that perineural and i.v. dexamethasone would have an
equivalent effect on prolonging analgesic duration of an ISB.

Perineural
dexamethasone can
prolong the duration of
analgesia, although not
specifically licensed for
this use.

Methods. We performed a prospective, double blind, randomized, placebo-controlled study.

Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into
three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD);
and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was
the duration of analgesia, defined as the time between performance of the block and
the first analgesic request. Standard hypothesis tests (t-test, MannWhitney U-test) were
used to compare treatment groups. The primary outcome was analysed by KaplanMeier
survival analysis with a log-rank test and Coxs proportional hazards regression.

This study compares

effects of perineural or i.v.
dexamethasone on the
duration of ropivacaine
analgesia.

Results. One hundred and fifty patients were included after obtaining ethical committee
approval and patient informed consent. The median time of a sensory block was equivalent
for perineural and i.v. dexamethasone: 1405 min (IQR 10151710) and 1275 min (IQR 1095
2035) for RD and RDiv, respectively. There was a significant difference between the
ropivacaine group: 757 min (IQR 635910) and the dexamethasone groups (P,0.0001).

Route of dexamethasone
administration did not
impact on improved
duration for interscalene
brachial plexus block
(ISB).

Conclusions. I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the

analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for
perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an
increased duration of ISB.
Keywords: anaesthetic techniques, i.v. regional; anaesthetic techniques, regional, brachial
plexus; anaesthetics local, ropivacaine; analgesia, postoperative; analgesics antiinflammatory, steroid
Accepted for publication: 24 January 2013

Shoulder surgery can be very painful surgery after which the

use of opioids is often required. The well-known side-effects
of opioids (e.g. respiratory depression, somnolence, nausea,
vomiting, and pruritus) limit their use in so called fast
track surgery and anaesthesia programmes. ISB provides excellent analgesia minimizing the side-effects of opioids and

is widely accepted as the gold standard in the management

of acute pain after shoulder surgery.1
Although a single-shot ISB is useful for pain relief in the
early postoperative period, it is often insufficient as postoperative pain can persist for several days. For patients requiring analgesia for .24 h, a continuous ISB (CISB) can be

& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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* Corresponding author. E-mail: matthias.desmet@azgroeninge.be

BJA

Methods
The trial was registered on clinicaltrials.be (#B396201110645).
The AZ Groeninge Institutional Review board approved all
aspects of the trial (#11 009, 16/02/2011, Chairman Dr
L. Van Lysebeth). The Federal Agency of Medicines and
Health Products has been informed regarding the study protocol with the off-label use of dexamethasone. It did not
request an Investigational New Drug approval. Written
informed consent was obtained from all patients. All patients
planned for arthroscopic shoulder surgery (rotator cuff repair
and shoulder decompressions) were eligible for inclusion in
the study. Exclusion criteria were: age ,18 yr, brachial
plexus neuropathies, severe bronchopulmonary disease, coagulopathies, systemic glucocorticoid use, pregnancy, routine
use of opioid medications, intolerance for one or more medications of the study protocol and diabetes. All the patients
were operated by the same surgeon (J.V.C.) and the ISB was
performed by experienced staff anaesthesists, with at least
10 yr experience with interscalene blocks.
Using a computer generated random number table,
patients were randomized in three-treatment groups: ropivacaine 0.5% (Group R), ropivacaine 0.5% and perineural

446

dexamethasone 10 mg (Group RD), and ropivacaine 0.5%

with i.v. dexamethasone 10 mg (Group RDiv). Sealed
opaque envelopes with the study group allocation were
opened before the blocks were performed. Medication was
prepared by a staff member who was not involved in the
study and delivered in unidentifiable syringes.
Patients were premedicated with lorazepam 2.5 mg p.o.
1 h before the surgical procedure, monitored with electrocardiography, pulse oximetry and non-invasive arterial pressure,
and sedated with i.v. midazolam (2 mg) and sufentanil
(2.5 mg).
After skin disinfection and infiltration with lidocaine 1%,
the interscalene brachial plexus was identified using a short
bevel 50 mm, 22 gauge stimulating needle (Stimuplex A;
B. Braun Melsungen AG, Germany) connected to a Stimuplex
(Stimuplex-HNS II A; B. Braun Melsungen AG, Germany)
nerve stimulator. The initial setting was a current of 0.8 mA
with a stimulating frequency of 2 Hz. The direction of the
needle was similar as in the modified lateral approach of
Borgeat and Ekatodramis10 was applied in all patients. Contractions of the biceps, triceps, or any muscle contraction of
the hand or forearm with a current of 0.30.5 mA indicated
correct placement of the needle. A 2 ml solution containing
normal saline for Groups R and RDiv and 10 mg dexamethasone for Group RD was administered perineurally. Then,
without repositioning the needle, all patients received 30 ml
ropivacaine 0.5%. At the time of the ISB, a 2 ml solution containing normal saline for Groups R and RD and dexamethasone 10 mg for Group RDiv was administered i.v. Thus, all
patients received an ISB with 30 ml of ropivacaine 0.5%
with an i.v. and perineural solution of 2 ml containing the
study drugs according to randomization.
All brachial plexus injections were administered slowly
with repeated aspiration to prevent or detect early intravascular injection.
General anaesthesia was induced and maintained using
propofol (target controlled infusion 35 mg ml21), remifentanil (loading dose 1 mg kg21, continuous infusion 0.05 0.3 mg
kg21 min21), and cisatracurium (0.15 mg kg21). Patients were
intubated and ventilated with an oxygen/air admixture.
Maintenance of anaesthesia was left to the discretion of
the attending anaesthesiologist. Intraoperatively, no other
analgesics were administered. At the beginning of the procedure finger stick blood glucose was measured.
On arrival in the recovery room pain was evaluated using a
4-point verbal rating score (VRS) (1no pain, 2mild pain,
3moderate pain, and 4severe pain). Paracetamol i.v.
(1 g) was administered for VRS2 or on patient request.
In case of insufficient analgesia, diclofenac i.v. (50 mg)
was administered. Rescue analgesia with piritramide i.m.
(15 20 mg) was administered if necessary. Piritramide is a
synthetic opioid with relatively fast onset after i.m. administration (15 20 min) with the duration of action of 46 h.
It has a relative potency of 0.7 compared with morphine.11
A motor block was evaluated using a 3-point motor
block score (MBS) (1unable to move fingers, 2able to
move fingers but weaker than the non-operated arm, and

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used. The placement of a CISB is more invasive and complex

than a single-shot ISB and requires an extensive postoperative follow-up. As there is a trend towards shorter hospital admissions after arthroscopic shoulder surgery, CISB
has been promoted in the ambulatory setting.2 However,
the practical problems of the postoperative follow-up limit
the use of CISB in an outpatient setting.
The use of additives to local anaesthetics can prolong the
duration of a single-shot ISB which can be useful when a
CISB is not possible. Various additives such as vasoconstrictors, clonidine, ketamine, and steroids have been studied,
but most of them failed to prolong the duration of peripheral
nerve blocks.3 5
I.V. dexamethasone attenuates the postoperative need
for analgesics in different clinical settings (orofacial,
general, urological, and orthopaedic surgery).6 In a study
with paediatric patients receiving a caudal block for orchidopexy, i.v. dexamethasone decreased postoperative pain and
analgesia requirements.7 Dexamethasone also prolongs peripheral nerve block when added to short-acting local anaesthetics.8 Cummings and colleagues9 observed a 1.9-fold and
1.5-fold increase in the duration of ISB when dexamethasone
was added to ropivacaine and bupivacaine, respectively.
Whether the main mechanism of action of glucocorticoids
is a systemic anti-inflammatory effect or a local effect on
peripheral nerves remains unknown.
We hypothesized that dexamethasone prolongs analgesia
after a single-shot ISB regardless of the route of administration. We, therefore, conducted a prospective, double blind,
randomized, placebo-controlled study to evaluate the effect
of i.v., and perineural dexamethasone on the duration of a
single-shot ISB with ropivacaine 0.5% for postoperative analgesia after shoulder surgery.

Desmet et al.

BJA

The effect of dexamethasone on interscalene block

Sample size considerations

At the time of our study, no studies were published concerning the effect of dexamethasone on interscalene plexus
blocks with ropivacaine. Based on our experience with ropivacaine 0.5%, we assumed a block duration of 720 min with a
standard deviation (SD) of 500 min. A difference of 360 min
between the treatment and the control group was considered clinically relevant and a sample size (power90% and
a0.05) of 42 patients per group was calculated (twosample t-test). To correct for failed blocks and patient drop
out, 50 patients per group were included in the study.

Statistical analysis
The primary endpoint was the length of the sensory block
defined as the time between the performance of the block
and the first administration of analgesia. Secondary outcomes were pain scores, MBSs, analgesic need, sleep disturbance, and overall satisfaction as measures for patient
comfort. Finally, pre- and postoperative blood glucose measures were analysed and compared between groups. Descriptive statistics are used to present baseline characteristics for
the three groups. Standard hypothesis tests (t-test, Mann
Whitney U-test) were used to compare these baseline
values between treatment groups. Continuous variables
were assessed for normality and are presented as mean
(SD) or median with interquartile range (IQR) as appropriate.
Categorical variables were assessed using frequency tables
and x 2 or Fishers exact test. The interval between the
onset of the sensory block and the initial use of analgesia
was analysed by KaplanMeier survival analysis with a
log-rank test and Coxs proportional hazards regression to
estimate likelihood ratios adjusted for covariates. The
primary analysis is the comparison between survival curves.

All other statistical tests are secondary and performed at

the 5% significance level, without correction for multiple
testing, and should be interpreted accordingly.
All statistical analyses were performed with SAS 9.3 (SAS
Institute, Cary, NC, USA).

Results
From March to December 2011, 234 patients presented for
arthroscopic shoulder surgery, 84 were ineligible because of
exclusion criteria or refusal to participate, and 150 patients
were enrolled in the study. Six patients had no primary
or secondary outcome result because of inadherence to
the protocol. These patients were not included in the
intention-to-treat (ITT) analysis. Figure 1 presents the allocation process according to the Consolidated Standards of
Reporting Trials (CONSORT) statement.
A total of 144 patients were included for the ITT analysis
(Group R n46, Group RD n49, Group RD iv n49). Five
patients, evenly distributed over the three study groups
(Group R n2, Group RD n1, Group RD iv n2) were
deemed to have failed blocks, but were analysed in their
assigned groups according to ITT principles. These patients
were given the outcome at the time of recovery. Eleven
patients did not require analgesics during the first 48 h
after operation (no primary outcome). These patients were
also evenly distributed over the three study groups (Group
R n2, Group RD n4, Group RDiv n5, respectively) and
were censored in the survival analysis. The mean age of
the study population was 52 (14) yr, the mean body mass
index (BMI) was 27.2 (4.4), and 45% were men. There were
significantly more cuff repairs in men than in women (78.9
vs 59.5%, P0.002) but the different procedures were
equally distributed in the three groups (Table 1).
Dexamethasone significantly prolonged the duration of
analgesia, independent of the mode of administration. In
Group R, the primary endpoint of the study was reached
after a median of 757 min with an IQR of 635 2910 min,
for Groups RD and RDiv this was 1405 (1015 1710) and
1275 (1095 2035), respectively. Kruskal Wallis followed by
the correction for multiple testing showed statistically significant differences between Groups R and RD (P,0.0001),
Groups R and RDiv (P,0.0001), but not between Groups RD
and RDiv. KaplanMeier curves for the first analgesic
request with patients not receiving any analgesics after 48
h censored to the right are presented in Figure 2. Significant
differences between these curves (log-rank test) were
obtained between Group R and the combined groups RD
and RDiv (P,0.0001), but not between Groups RD and RDiv
(P0.6254).
A Cox proportional hazards model for time to first analgesic was performed using the following variables: study
group, sex, age, and type of surgery. Patients included in
Group R had a 3.91 times (95% CI 2.635.81) higher probability for analgesic need during the first 48 h compared
with patients in Groups RD and RDiv (P,0.0001). None of
the other variables differed significantly.

447

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3equal strength in both hands). If patients had a pain score

3 and a MBS of 3 on arrival in the recovery room the ISB
was qualified as failed.
Recovery room discharge criteria were stable vital parameters, absence of nausea and vomiting, and a VRS,2.
VRS, MBS, and blood glucose concentrations were assessed
upon recovery room discharge.
The morning after surgery, all patients were reassessed for
pain, motor block, and overall satisfaction. The timing and
dosage of analgesics was recorded and also the quality of
sleep (1no sleep disturbance because of pain, 2sleep disturbance because of pain). Patients were contacted by telephone on Day 2 after surgery to evaluate the same
parameters. Patient satisfaction concerning the procedure
was assessed using a 2-point scale (1satisfied, I would
want the same anaesthesia/analgesia method for the next
surgery, 2unsatisfied, I would want a different anaesthesia/analgesia method for the next surgery). Specific reasons
for dissatisfaction were noted. A telephone assessment
34 months after surgery was performed to detect late
complications. All postoperative scoring was performed by
an independent, blinded investigator.

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Desmet et al.

234 patients
assessed for eligibility
Primary exclusion:
Exclusion criteria: 72
Refusal by patient: 12
150 patients randomized

Group RD
n = 50

Group R
n = 50

Exclusion:
inadherence to
protocol: 4

Group RDiv
n = 50

Exclusion:
inadherence to
protocol: 1

Exclusion:
inadherence to
protocol: 1

Analysed:
49

Analysed:
49

Fig 1 Allocation process according to CONSORT.

Table 1 Patient and procedure characteristics

Group R
(n546)

Group RD
(n549)

Group RDiv
(n549)

Sex M/F (n)

21/25

21/28

23/26

Mean age (SD)

51.1 (14.3)

53.0 (13.9)

51.6 (14.0)

Mean BMI (SD)

26.7 (4.2)

27.6 (4.7)

27.2 (4.5)

Procedure type:
decompression/
repair (n)

15/31

17/32

14/35

Failed blocks (n)

When pain scores were dichotomized in VRS scores 1 and

2 (no to mild pain) vs VRS scores 3 and 4 (moderate to severe
pain), there was a significant difference between groups after
24 and 48 h (P,0.0001) (Figs 3 and 4).
There was a statistically significant difference in analgesic
use in the three groups. We only present the data for paracetamol and diclofenac as only seven patients needed
opioids. Of note is that five of these patients had blocks
that were qualified as failed. The mean paracetamol use (in
gram) in Group R was 3.8 compared with 2.6 in Group RD
and 2.3 in Group RDiv during the first 48 h (P,0.0001). The
mean diclofenac use after 48 h was also significantly different: 101 mg for Group R compared with 59 and 56 mg for
Group RD and RDiv (P0.03).
There was no significant difference in MBS in the three
groups on admission in the post anaesthesia care unit, and
at 24 and 48 h.

448

During the first night, there was a significant higher proportion of patients with sleep disturbance because of pain
in Group R (59%) compared with Group RD (29%) and
Group RDiv (22%) (P0.0004). Overall satisfaction for the
three groups was excellent: 85 98% of the patients would
like a similar anaesthesia and analgesia protocol for future
shoulder surgery (Table 2).
There was an increase of mean postoperative blood
glucose concentrations in both groups receiving dexamethasone with a mean increase of 3.8 (1.2) mg dl21 for Group RD
(P0.026) and 5.1 (13) mg dl21 (P0.0095) for Group RDiv.
There were no differences in the incidence of hoarseness,
dyspnoea, or Horners syndrome after operation.
Patients were contacted 26 months after surgery. There
was one patient in Group RD who complained of hypoaesthesia in the deltoid region 4 months after surgery. However,
neurological and radiological examination revealed spinal
disc herniation at the level of C4 5 with a disc-radicular conflict. One patient in Group R had a superficial wound infection
requiring no further therapy but local incision and drainage.

Discussion
The present study demonstrates that dexamethasone effectively prolongs the duration of ropivacaine ISB analgesia.
There is, on average, a 1.8-fold increase in the duration of
analgesia when dexamethasone is used as an adjunct to
ropivacaine 0.5%. This is concordant with other results in
the literature.8 9 12 13 Interestingly, this effect is independent
of the route of administration as both perineural and i.v.

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Analysed:
46

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The effect of dexamethasone on interscalene block

Proportion of patients NOT requesting

analgesia

1.0
0.9
0.8

Group R
Group RDiv
Group RD

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0

500

1000
1500
2000
Time to first analgesic request (min)

2500

3000
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Fig 2 Kaplan Meier survival plot.

100
90

Percentage of patients

80
70
60

VRS <2

50

VRS >2

40
30
20
10
0

Group R

Group RD

Group RDiv

Fig 3 Maximal VRS scores at 24 h after operation (*P,0.05; NS).

administration of dexamethasone produced similar results.

Not only the analgesia duration but also the quality of analgesia indicated by outcome measures such as sleep disturbance and postoperative analgesic use were favourably
influenced by dexamethasone.
Acute postoperative pain has different components (e.g.
nociceptive, inflammatory, and neuropathic because of
direct nerve injury) all of them possible targets for

postoperative analgesic strategies. The precise mechanism

of action of dexamethasone added to local anaesthetics is
unknown. Some studies described a direct effect of glucocorticoids on nerve conduction while others reported that dexamethasone induced perineural vasoconstriction with
concomitant slower absorption of the administered local
anaesthetics.14 15 However, such effects of dexamethasone
do not explain the results of our study as the systemic

449

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Desmet et al.

100
90

Percentage of patients

80
70
60
*

50

40

VRS <2
VRS >2

30
20

Group RD

Group R

Group RDiv

Fig 4 Maximal VRS scores at 48 h after operation (*P,0.05; NS).

Table 2 Secondary outcome parameters

Group R
(n546)

Group
RD
(n549)

Group
RDiv
(n549)

P-value

Mean paracetamol
use (g) at 48 h

3.8

2.6

2.3

,0.0001

Mean diclofenac
use (mg) at 48 h

101

59

56

0.03

Patients with
residual motor
block at 24 h (n)

1/46

5/49

3/49

NS

Sleep disturbance
at 24 h (n)

27/46

14/49

11/49

0.004

Percentage of
patients satisfied

84

92

94

NS

Incidence of
Horner syndrome
(%)

45

48

41

NS

Incidence of
hoarseness (%)

30

23

23

NS

Incidence of
dyspnoea (%)

NS

administration of dexamethasone was equally effective. This

interesting observation is in accordance with the work
of Yilmaz and colleagues16, who could not detect an
effect of dexamethasone on the compound action potential
of A- and C-fibres in isolated sciatic rat nerves. As a direct
effect of dexamethasone on the nerve is unlikely, the anti-

450

inflammatory properties of dexamethasone are probably

responsible for prolonged analgesia after ISB. After intracellular uptake, glucocorticoids will activate cytoplasmatic
glucocorticoid receptors which will bind to glucocorticoid response elements in the DNA. This leads to both a decreased
production of inflammatory proteins [COX-2, iNOS, cytoplasmatic PLA2, interleukins (ILs), inflammatory chemokines,
etc.], and an increased production of anti-inflammatory proteins [lipocortin-1 (IL-1) receptor antagonist].17
To our knowledge, there are no pharmacokinetic data on
the absorption of perineurally administered dexamethasone.
Because absorption in the systemic circulation and gene
transcription is time consuming, one could argue that clinically relevant anti-inflammatory effects of steroids, would
come too late after perineural administration with shortacting local anaesthetics. However, Movafegh and colleagues8 demonstrated that dexamethasone also prolongs the
duration of an axillary block when added to lidocaine (242
vs 98 min). This proves that perineural dexamethasone has
a clinical effect within 2 h of administration. Therefore, we
should aim further research towards the ideal dose and
timing of dexamethasone administration.
We acknowledge that our study has some limitations.
First, we did not assess the duration of the sensory block
in our patients using repeated neurological examinations.
As most patients were treated in an ambulatory setting, it
was impossible to perform such an assessment of the
sensory block. We, therefore, decided to use the duration
until first analgesic request as a marker of the sensory
block. With our study protocol, we were unable to discriminate if the prolonged analgesia was associated with a

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10

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The effect of dexamethasone on interscalene block

diminish the protective effects of the surrounding vasculature and fibrous tissues and is unable to study the effect
on distal axons.18 Neurone isolation techniques commonly
used to study detrimental effects of drugs may not fully
appreciate the mechanisms of neural injury after peripheral
nerve blocks. In clinical practice, neurological damage is
the result of multiple factors where there is a complex interplay between neurotoxicity of administered drugs, puncture
technique and possible pre-existing neural injury.23
Regarding the inconclusive data on the safety of perineural dexamethasone, we would like to remind clinicians
that this off-label use needs approval of the appropriate
regulatory health institutions. Fortunately, with the results
of our trial the debate on the perineural administration of
dexamethasone may become obsolete.
In conclusion, this study demonstrates that perineural or
i.v. dexamethasone in a dose of 10 mg prolongs significantly
the duration of effective postoperative analgesia resulting
from a single-shot ISB with ropivacaine 0.5%. We, therefore,
propose that i.v. dexamethasone should be considered for
routine use in patients having regional analgesia for the
postoperative pain management.

Declaration of interest
None declared.

References
1 Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia
for shoulder surgery: a critical appraisal and review of current
techniques. Anaesthesia 2010; 65: 60824
2 Fredrickson MJ, Ball CM, Dalgleish AJ. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private
practice setting. Reg Anesth Pain Med 2008; 33: 122 8
3 Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z. Clonidine
combined with a long acting local anesthetic does not prolong
postoperative analgesia after brachial plexus block but
does induce hemodynamic changes. Anesth Analg 2001; 92:
199 204
4 Lee IO, Kim WK, Kong MH, et al. No enhancement of sensory and
motor blockade by ketamine added to ropivacaine interscalene
brachial plexus blockade. Acta Anaesthesiol Scand 2002; 46:
821 6
5 Sinnott CJ, Cogswell LP III, Johnson A, Strichartz GR. On the
mechanism by which epinephrine potentiates lidocaines peripheral nerve block. Anesthesiology. 2003; 98: 181 8
6 De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative
pain: a meta-analysis of randomized controlled trials. Anesthesiology 2011; 115: 575 88
7 Hong JY, Han SW, Kim WO, Kim EJ, Kil HK. Effect of dexamethasone in combination with caudal analgesia on postoperative
pain control in day-case paediatric orchiopexy. Br J Anaesth
2010; 105: 506 10
8 Movafegh A, Razazian M, Hajimaohamadi F, Meysamie A. Dexamethasone added to lidocaine prolongs axillary brachial plexus
blockade. Anesth Analg 2006; 102: 2637
9 Cummings KC III, Napierkowski DE, Parra-Sanchez I, et al. Effect of
dexamethasone on the duration of interscalene nerve blocks with
ropivacaine or bupivacaine. Br J Anaesth 2011; 107: 446 53

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prolongation of the sensory block. Although a point deserving further study, it is irrelevant for daily practice. Indeed,
for patients, pain is the most important parameter to
define satisfaction after surgery.
Secondly, we did not use ultrasound (US) to perform ISB.
At the time of the study, we considered our experience
with US-guided locoregional anaesthesia insufficient to use
a US-based technique. The success rate of our blocks was
97%, which is similar to that reported in the literature.18
We assume that our study results would not have been
different with the use of US.19
Thirdly, analgesics were only administered on request and
a postoperative regimen with regular analgesic administration might have impacted our secondary outcomes. Such a
regimen is often not easy to implement in an ambulatory
setting. We think that our study better represents routine
clinical practice where patient adherence to pain protocols
can be surprisingly low. The overall opioid use in our
study groups was very low. In contrast, all patients with
failed blocks needed opioids in addition to paracetamol
and diclofenac for postoperative analgesia indicating severe
postoperative pain emphasizing the efficiency of interscalene
blocks in this setting.
Fourthly, there are safety concerns regarding the perineural use of dexamethasone. In the absence of human clinical trials, we can only rely on laboratory research. Williams
and colleagues20 studied the effect of ropivacaine and different adjuvants on isolated sensory neurone cell bodies of rats.
In contrast to ropivacaine, dexamethasone did not increase
cell death after 24 h exposure. There was no increased
neurone cell death after 2 h exposure to low-dose dexamethasone and ropivacaine compared with ropivacaine
alone. Ma and colleagues21 reported on the protective
effect of dexamethasone on bupivacaine-induced neurone
injury in rats through a threonine-serine protein kinase
B-dependent mechanism. When the electrophysiological,
behavioural and histological effects of topical dexamethasone on sciatic nerve in rats was studied, it was discovered
that although dexamethasone temporarily attenuated conduction, it had no significant long term effects.14
More than 250 patients received perineural dexamethasone as an adjunct to local anaesthetics in clinical trials.
None of the clinical trials reported an increased incidence
of serious adverse effects compared with the control
groups but all were underpowered to detect an increase in
the incidence of serious adverse effect.8 10 12 It is clear
that with an incidence of 0.4%, 16 000 patients are needed
to reliably detect a doubling of adverse effects.9 So far no
safety trial on the use of perineural dexamethasone has
been performed and it is highly unlikely that such a trial
will ever be conducted. However, local, perineural steroid injection has been used for many years in the treatment of
carpal tunnel syndrome and is acknowledged to be an effective and safe therapy.22 We should also caution to extrapolate
in vitro and in vivo observations with regard to the possible
neurotoxicity of dexamethasone. The isolation technique of
neural cell bodies will inherently lead to neural damage,

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