Rotator cuff surgery is one of the most common orthopedic procedures performed today. The rotator cuff is made up of four muscles and tendons that stabilize and strengthen the shoulder joint. These can become damaged due to injury or wear and tear over time, often causing significant pain and loss of function. If nonsurgical treatments like rest, physical therapy, and injections do not relieve the symptoms, rotator cuff surgery may be recommended.
One of the decisions that patients and their surgeons must make prior to a rotator cuff repair procedure is whether to perform it with the patient awake (under regional anesthesia) or asleep (under general anesthesia). Both options have their potential benefits and downsides to consider. Here is an overview of the awake versus asleep options for rotator cuff surgery.
What is the rotator cuff and what does it do?
The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint and connect the upper arm bone (humerus) with the shoulder blade (scapula). The rotator cuff muscles include:
– Teres minor
These muscles and tendons work together to perform several important functions for shoulder movement and stability:
– Keep the head of the humerus firmly within the shoulder socket as the arm elevates and rotates
– Assist with shoulder abduction and lateral rotation
– Provide stability and keep appropriate alignment/mechanics during overhead arm motions
– Help transfer forces efficiently from the body to the arm
When the rotator cuff tendons become damaged, inflamed, or torn, it can lead to significant loss of shoulder function. Typical symptoms of rotator cuff problems include:
– Pain with overhead reaching or lifting
– Difficulty sleeping on the affected shoulder
– Weakness and decreased range of motion
– Catching, clicking, or popping in the shoulder
Some of the most common causes of rotator cuff injury include:
– Repetitive shoulder motion due to sports or work
– Degeneration due to age-related wear and tear
– Trauma from a fall onto an outstretched arm
– A shoulder dislocation
Why might rotator cuff surgery be necessary?
For patients with persistently painful rotator cuff tears that have not improved with conservative treatments, surgery may be recommended. The goals of rotator cuff repair surgery are to:
– Reattach the torn tendon(s) to the bone
– Reduce pain and inflammation
– Restore more normal shoulder mechanics and strength
– Allow return to full activity and sports participation
Rotator cuff surgery involves reattaching the torn tendon(s) using sutures and bone anchors placed in the humerus. The recovery time following surgery typically involves resting the repaired tendon for 6-12 weeks to allow proper healing before beginning gentle shoulder motion and physical therapy.
Some of the main factors that indicate rotator cuff surgery may be appropriate include:
– Full-thickness rotator cuff tears diagnosed on MRI
– Persistent shoulder pain > 3-6 months despite conservative treatment
– Significant weakness and loss of function
– Failure of the tear to heal or worsenning of the tear over time
– Age of patient – younger, active patients may be better surgical candidates
Early surgery may lead to better outcomes in some cases, while very large tears in elderly, low-demand patients may be treated non-operatively if pain can be managed. An orthopedic surgeon can help determine if rotator cuff surgery is the right choice.
What are the options for anesthesia during rotator cuff surgery?
Two main options exist for anesthesia during a rotator cuff repair procedure – general anesthesia or regional anesthesia.
General anesthesia involves being completely unconscious and asleep throughout the surgery. Medications are administered intravenously and/or via inhaled gases to achieve a state of total sedation, amnesia, pain control, and muscle relaxation. A breathing tube is placed after going to sleep and removed before waking up. General anesthesia must be administered by an anesthesia professional.
Regional anesthesia means injecting medication near clusters of nerves to numb just a particular region of the body, such as the shoulder and arm. Some common choices include:
– Interscalene block – injects local anesthetic next to the brachial plexus nerves supplying the shoulder/arm
– Cervical epidural – numbs the cervical spinal nerve roots with injection into the neck
– General + regional – combination of both general and regional anesthesia
The regional anesthesia is placed while the patient is awake using ultrasound or nerve stimulator guidance. Sedation medications are sometimes also given intravenously to maximize comfort, but the patient remains breathing on their own. The anesthetic medication can last anywhere from 4-24+ hours into the postoperative period to help with pain control.
What are the potential benefits of having rotator cuff surgery while awake?
There are several potential advantages to having rotator cuff repair performed under regional anesthesia without general anesthesia:
Earlier ambulation and discharge
Since general anesthesia affects the entire body and can cause prolonged drowsiness, patients are often required to stay immobile in the recovery room for 1-2 hours after surgery before they can be safely discharged. With regional anesthesia, patients can often start moving the arm and begin walking almost immediately after surgery since only the shoulder/arm is numb. This allows for earlier discharge home the same day in many cases.
Better pain control immediately after surgery
Because the regional anesthetic block lasts many hours beyond the surgery, patients often report significantly less pain and discomfort in the first 12-24 hours after surgery compared to general anesthesia alone. Less need for IV narcotics decreases risks like nausea, constipation, and urinary retention.
Avoid risks of general anesthesia
Though rare, there are risks related specifically to being under general anesthesia, such as adverse reactions to medications, breathing problems, blood clots, and cardiac events. Remaining awake may reduce these risks.
Reduced post-op nausea
Nausea and vomiting after surgery is a common side effect under general anesthesia, reported in about 30% of cases. This can delay discharge and be very unpleasant for patients. Regional anesthesia alone has a much lower rate of nausea which gets patients home sooner.
Quick cognitive recovery
Mental fogginess, confusion, and slow reaction times are common after waking up from general anesthesia. This delays the ability to eat, walk, and care for oneself. Regional anesthesia allows patients to remain in control of their faculties before, during, and after surgery.
Surgeon can test the repair
When patients are awake after repairing the rotator cuff, the surgeon can often manipulate or move the shoulder slightly to confirm everything is attached appropriately and that there are no gaps before closing the incisions. This intraoperative testing can identify technical issues to fix immediately while still in surgery.
What are the disadvantages or risks of awake rotator cuff surgery?
While regional anesthesia does provide some notable benefits, there are also some potential disadvantages or risks to consider:
No immobility or muscle relaxation
General anesthesia paralyzes the muscles and ensures the patient stays perfectly still during surgery. With regional anesthesia, the other arm and body can still move, which may negatively impact the surgeon’s technique and repair. Some involuntary muscle twitching is also possible.
Risk of conversion to general anesthesia
If the regional anesthesia block does not provide complete numbness in the shoulder or wears off too quickly, the surgeon may have to convert to general anesthesia unexpectedly. This exposes the patient to both types of anesthetics and the risks of each.
Patient anxiety or discomfort
Some patients feel very anxious being awake during surgery and hearing noises, movement, etc. Feeling any tugging or pressure during the repair can also cause discomfort. Communication and sedation medications can help reduce any distress.
Risks of regional anesthesia
Regional anesthesia does come with its own set of risks, though typically less severe than general anesthesia. This includes bleeding, infection, nerve damage, blood clots, allergic reactions, lung collapse, seizures, stroke, or cardiorespiratory problems.
Lack of amnesia
Being awake means some patients will remember more details about the surgery experience. Any discomfort may also be more memorable. Some would prefer being completely unaware under general anesthesia.
How is the decision for anesthesia type made?
The choice between regional and general anesthesia for rotator cuff surgery is made based on a shared discussion between the patient, surgeon, and anesthesiologist. Factors taken into account usually include:
– Patient preferences and comfort level
– Complexity of the case and expected repair time
– Need for immobilization during the procedure
– Specific risks of each anesthesia type for the individual
– Potential benefits of regional anesthesia for postoperative recovery
Many surgeons have a preference for regional anesthesia for standard rotator cuff repairs because it enables earlier mobilization after surgery. However, other factors can certainly dictate the use of general anesthesia in many instances.
Here is a general table outlining some of the indications favoring one anesthesia choice over the other:
|Regional anesthesia may be preferred if…
|General anesthesia may be better if…
|– Patient desires being awake and early discharge
– Lower risk for postoperative nausea desired
– Expected shorter, simpler procedure
– Patient has fewer risks for regional block
|– Patient very anxious about being awake
– Expected long, difficult, or revision surgery
– Surgeon needs absolute immobility during repair
– Patient has specific risks for regional anesthesia
What are the steps like on the day of surgery?
The flow of events on the actual day of rotator cuff surgery can vary slightly depending on whether regional or general anesthesia is planned.
– Arrive at surgical center
– IV line placed for fluids and medication availability
– Nerve block injection performed to numb shoulder/arm while awake
– Once block is working, wheeled into the OR still awake
– Given sedation medications if desired through the IV
– Remain breathing on own throughout surgery
– Procedure performed by surgeon
– Some manipulative testing done at end while awake
– Taken to recovery room while awake but numb
– Discharged home once ready to walk and take liquids
– Arrive at surgical center
– IV line placed for fluids and medications
– Wheeled into OR while awake
– General anesthesia medications administered IV to go to sleep
– Endotracheal tube placed after anesthesia induced
– Muscle relaxants given to paralyze muscles
– Surgeon performs repair procedure with patient fully asleep
– Taken still asleep to post-anesthesia care unit (PACU)
– Extubated after waking up in PACU
– Must meet discharge criteria before going home (holding liquids, walking, etc.)
What happens after rotator cuff surgery?
The initial recovery and restrictions are similar after rotator cuff repair regardless of anesthesia type. Typical post-op guidelines include:
– Wearing an arm sling for 4-6 weeks to protect repair
– Avoiding active shoulder motion for at least 4-6 weeks
– Starting gentle pendulum exercises within days after surgery
– Beginning physical therapy at 6-12 weeks post-op for mobility
– Progressive return to light activities at 2-3 months, with lifting restrictions for 4-5 months
– Most patients can expect to return to full activities, sports, and work demands by 6-12 months
Pain is well-controlled for most patients with oral medications, application of ice, and immobilization of the arm based on surgeon instructions. A gradual return to full shoulder motion occurs over 3-6 months guided by the therapist. Physical therapy focuses on safely restoring flexibility, strength, and function of the rotator cuff and entire shoulder complex.
In summary, rotator cuff surgery is a very common procedure to repair torn tendons causing shoulder pain and weakness. While both regional and general anesthesia can be utilized, being awake with a nerve block for uncomplicated cases allows for faster recovery and earlier discharge home after surgery. However, both options have their potential advantages and disadvantages that must be weighed carefully for each individual patient. Close communication between the surgical team and the patient is crucial when deciding between being awake versus asleep for rotator cuff repair surgery.