TSR and chronic pain

Gabrielle Morris

86 yo M for shoulder replacement 

Background: 

  • PPM – Symptomatic bradycardia 
  • CKD stage 3. 
  • Valvular disease, pulmonary hypertension 
  • BMI 30 

Issues: 

  • Chronic pain neck and shoulder pain – managed with pregabalin and oxycodone
    • Unable to tolerate NSAID’s due to renal impairment 
  • Recent hospital admission
    • Deconditioned +++ 
    • Anaemia Hb 106, Ferritin high, Normal B12/folate, CRP pending, FOBT pending 
    • Delirium – attributed to urosepsis 
  • Shoulder and arm pain exacerbation
    • Background of degenerative cervical spine and radiculopathy 
    • Shoulder pain worsening 
    • Steroid injection with little effect 
    • TSR being considered; Surgeons anticipating difficult and long procedure 

Discussion: 

Options for Pain Management 

  • Non-operative treatment: no improvement with intra-articular steroid injections
    • Interventional pain options include repeat steroid injection, targeting suprascapular nerve 
  • Pain may not be relieved by shoulder replacement
    • High-risk of perioperative complications, particularly delirium and cognitive decline 
  • Anaemia investigations – possible slow recovery from recent illness
    • Differentials include Age related BM failure and occult loss 
    • Discuss with haematologist after checking CRP and Fe studies post urosepsis event tp exclude acute phase rise in ferritin 
    • Consider gastroenterologist opinion if no improvement 

Plan: 

  • Delay operation 
  • Consider non-operative treatment eg target suprascapular nerve