الفهرس 
Acknowledgement
EPIDURAL TECHNIQUEOnly 14 pages are availabe for public view
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Abstract
Pain during the early postoperative period has a strong relationship to soft tissue and bone manipulations that occur during the surgical procedure. Despite of their benefits as the smaller incisions, less deltoid morbidity, better ability to identify and manage concomitant disorders, and greater patient acceptance (175), arthroscopic shoulder surgeries are associated with severe postoperative pain (1).
Variable options are available to optimize postoperative pain control after shoulder surgeries include; multimodal or balanced analgesia, patient controlled analgesia (PCA), sub-acromial (bursal) or intra-articular infiltration of local anesthetic (SBB), supra-scapular with or without axillary (circumflex) nerve block, single-injection interscalene nerve block (SSISB), continuous interscalene nerve block (CISB), superficial cervical plexus block and cryotherapy (176).
Peripheral regional analgesia facilitate postoperative rehabilitation as evidenced by accelerated resumption of passive joint range-of-motion, decrease in time until discharge readiness, and earlier actual discharge from the hospital or rehabilitation center (208). Interscalene brachial plexus block (ISB) provides superior pain therapy and greater patient satisfaction when compared to other analgesic techniques after arthroscopic rotator cuff surgery (4).
This prospective double blind randomized study was performed in Assiut Arthroscopy and Sports Injures Unit operative theatre in Assiut University Hospital to evaluate the efficacy of adding morphine or nalbuphine or both- morphine and nalbuphine- to local anesthetic mixture in sonar guided interscalene block in arthroscopic rotator cuff repair.
Although opioids exert their greatest effect within the central nervous system, opiate receptors have also been identified on somatic and sympathetic peripheral nerves. The distribution of opioid receptors on axons of primary sensory nerves and the clinical importance of these receptors (if present) remains speculative, despite the persisting practice of compounding of opioids in local anesthetic solutions applied to peripheral nerves (7).
In our study, 80 patients scheduled for arthroscopic repair of rotator cuff tear were allocated randomly into 4 groups; All patients had received 10 ml of lidocaine 1% with epinephrine 1:400,000, in addition, group C (control) received 5 ml 0.5% isobaric bupivacaine, group M (Morphine) received 5 mg morphine in 5 ml, group N (Nalbuphine) received 5 mg nalbuphine in 5 ml and group MN received 5 mg of both morphine and nalbuphine in 5 ml. All patients were subjected to the same anesthetic management as regard drugs used and monitoring. For the event of breakthrough pain in the postoperative period, patients received 1 gm of intravenous paracetamol.
group M and MN patients had statistically significant better VAS and patient satisfaction when compared to group C and N patients. group MN patients had less rescue analgesia compared to all other groups. None of the patients, in the four groups, develop either itching or vomiting attacks that could be a complication of morphine injected in the block.
Conclusion:
The addition of 5 mg of morphine to single injection interscalene block solutions for patients undergoing arthroscopic rotator cuff repair provides adequate and satisfactory analgesia for the first 3 postoperative days this in turn accelerates resumption of passive joint range of motion, reduces the hospital admission time and allows early discharge. The combination of 5 mg nalbuphine to 5 mg of morphine peri-neuraly had increased the analgesic effect of morphine as recorded by reduction in rescue analgesics. This was achieved with the help of the safe and simple ultrasound guidance that ensure installing the drug in close vicinity to the nerves and at the same time without any detectable side effects or complications as itching, vomiting or respiratory depression.