Regional anaesthesia for awake shoulder surgery

Regional Anaesthesia for "Awake" Shoulder Surgery

Patient Information

Anaesthetics Services

• Author ID: MH
• Leaflet ref: Ana 003
• Version: 3
• Leaflet Title: Regional anaesthesia for “awake” shoulder surgery
• Last Review: May 2025
• Expiry date: May 2027

Regional Anaesthesia for "Awake" Shoulder Surgery

This leaflet contains information about regional anaesthesia for "awake" shoulder surgery. Any further questions can be directed to your Anaesthetist, who will see you on the day of your operation.

Inter-scalene Block

• Any surgery will result in some pain after the operation. Shoulder surgery can lead to pain, particularly in the first 24 hours after the procedure.
• One of the best ways to relieve this pain is a nerve block, which numbs the nerves carrying pain from the shoulder for a period of time. This is called an Inter-scalene Brachial Plexus Block.
• It provides excellent pain relief and avoids the side effects of strong pain killers like morphine. These commonly include sickness, drowsiness, and itching.

Regional “awake” anaesthesia is routine for many operations on the hip, knee, ankle, and foot. Some shoulder operations can be done using an Inter-scalene block alone. The shoulder is numb for the operation and there is effective pain relief afterwards for a period of time. You will be fully awake and may feel sensations of movement and pressure, but no pain. Your Anaesthetist may also offer you the option of some sedation, meaning you feel a little sleepy during the operation but are not fully unconscious. You may want to bring headphones and some music to help you relax during the procedure.

Benefits of Regional “Awake” Anaesthesia

• You will avoid potential risks and side effects of a general anaesthetic, which commonly include drowsiness after the operation, sickness, and a sore throat.
• Your immediate recovery will be shorter and you will be able to eat and drink more quickly after the operation. This is particularly helpful if you have diabetes. Often, you may be able to go home sooner.
• It may be a safer option if you have other medical problems, such as heart or lung conditions, as regional “awake” surgery puts less stress on your system.
• For keyhole operations, where the surgeon puts a small camera into the shoulder joint, you may have the option of watching the procedure on a television screen and to ask questions about the problems with your shoulder (you do not have to).

Important Information

You should follow the fasting instructions on your letter from the hospital, even if you are expecting to have your procedure awake. This is because you need to be fasted if you would like sedation, or plans change, and you need a general anaesthetic.

What to Expect

You will be asked to confirm your name and the site/side of surgery multiple times as a safety measure. You will be taken to the anaesthetic room to have your nerve block.

Firstly, an oxygen monitor will be placed on to your finger and a blood pressure cuff on your arm. A needle will be put in the back of your hand on the arm not being operated on, so we can give you fluids and medicines during your surgery if needed. Your Anaesthetist will position you for your nerve block. This may be in a reclining position or on your side. An inter-scalene block is done in the lower part of your neck, on the same side as the shoulder being operated on. Your skin will be cleaned with antiseptic, and local anaesthetic may be used to numb your skin before the nerve block injection. Your Anaesthetist may also offer you some sedation to make you feel more relaxed. If you have sedation, you will be given some oxygen using a light plastic face mask.

In order to perform the nerve block correctly, ultrasound is commonly used to see the nerves and the block needle in real time. This involves putting some gel on the surface of your skin, and is the same kind of scan used to see babies in pregnant women. The Anaesthetist may use a nerve stimulator, which passes a tiny current near the nerves to be blocked. This is not painful but may feel a bit odd. Once the block needle is in the correct place, the numbing medicine will be injected slowly around the nerves. Usually the arm will become numb in about 30 minutes, and your Anaesthetist will check the nerve block is working properly before you go into the operating theatre.

Once your arm is numb it will feel very heavy and not under your control. The theatre staff will take care of your arm until the operation is ready to start. The Surgeon will also put some extra numbing medicine into the back of your shoulder at the start of the operation. The anaesthetic team will sit with you during your surgery. If you have sedation, you may only remember your time in the operating theatre in patches.

After the operation, your arm will still be numb. This provides excellent pain relief and can last for up to 24 hours. You will be given a sling to wear and should follow the aftercare instructions you are given. As you cannot feel your arm until the nerve block wears off, it is possible to injure your arm without noticing. Take the pain killers you are provided with regularly, as prescribed. This applies while your arm is still numb, so the pain killers will be in your system as the nerve block wears off and your pain will be better controlled.

What are the Side Effects & Risks?

Side effects of an Inter-scalene block are related to the spread of local anaesthetic to surrounding nerves, and should only persist until the local anaesthetic has worn off. Your arm will be numb and may feel heavy. You will be unable to move it. To protect your arm, you will have a sling to take home after your operation. You will need to be careful of injuring your arm as you may not notice.

Commonly:

• You may temporarily get a droopy eye.
• You may find it difficult to take a deep breath.
• You may have a hoarse voice.
• You may experience tingling in your arm as the numbness wears off.

Complications

Inadequate Block: There is a small chance that the Inter-scalene block does not work as effectively as it should. If this is the case, you may need additional painkillers. The Anaesthetist will be with you for the duration of the operation and if you indicate that you are in pain, they will ask the Surgeon to stop. The Surgeon will be able to give you more local anaesthetic. If this is not effective, the Anaesthetist will give you a general anaesthetic for the rest of the procedure. You may also need additional painkillers after your operation.

Injury to Surrounding Structures: There may be some injury to blood vessels, causing a small amount of bleeding under the skin. This is usually dealt with by a member of staff applying pressure to the area for a short period of time (like after a blood test).

Reaction to Local Anaesthetic: In rare cases you may have a reaction to the local anaesthetic. Your Anaesthetist will monitor you closely for signs of this, and will be ready to treat it if it occurs.

Nerve Injury: There is a small risk of nerve damage. It is rare and your Anaesthetist will take steps to reduce this risk. It may occur from the nerve block or from the surgery. If it happens, in the vast majority of cases symptoms will get better by themselves over time. Symptoms of nerve damage include: numb patches of skin, weakness in your arm, or persistent pain in areas distant from the operation site. The risk of permanent nerve damage is very small (between 1 in 2000 – 1 in 5000 patients). 

If you are worried about any of these symptoms after your surgery you should contact the hospital for assessment.

Further information about the risks of nerve damage can be found in the following document online (produced by the Royal College of Anaesthetists): Nerve Damage Peripheral NB 2017

What are the Alternatives?

You do not have to have an “awake” procedure if you do not want to. However, your Anaesthetist may have recommended it as the safest option. Alternatives are a general anaesthetic and a nerve block (the nerve block is still usually performed whilst you are awake), or a general anaesthetic alone. The Anaesthetist will then give you painkillers into your drip during and after your operation.

References

Royal College of Anaesthetists.  Nerve blocks for surgery on the shoulder; arm or hand.                                                                 https://www.rcoa.ac.uk/system/files/10-NerveBlocksweb.pdf [Accessed April 2018].

Queen Elizabeth Hospital, Gateshead.  Regional “awake” anaesthesia for shoulder surgery.   https://www.qegateshead.nhs.uk/sites/default/files/users/user15624/IL437v2%20Awake%20Shoulder%20Surgery.pdf [Accessed April 2018].

The Rotherham NHS Foundation Trust.  Inter-scalene brachial plexus block for shoulder surgery.                            http://www.therotherhamft.nhs.uk/Patient_Information/Patient_Information_Leaflets/Inter-scalene_brachial_plexus_block_for_shoulder_surgery [Accessed April 2018].