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.1Regardless, 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.3For 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 .4More importantly however, their comments are in sharp contradiction to the available literature including their own data.5Drs. 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. 6However, 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.5The cited references in our article7,8used 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,9let alone the necessary econometric statistical maneuvers thereafter.10–13
Our study was not a repetition of that by Kinnard et al. 14In 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.5Kinnard 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
*St. Luke’s-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York. ah149@columbia.edu
