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Diaphragm-Sparing Nerve Blocks for Shoulder Surgery

Tran, De Q.H. MD, FRCPC; Elgueta, Maria Francisca MD; Aliste, Julian MD; Finlayson, Roderick J. MD, FRCPC

Regional Anesthesia and Pain Medicine: January/February 2017 - Volume 42 - Issue 1 - p 32–38
doi: 10.1097/AAP.0000000000000529
REGIONAL ANESTHESIA AND ACUTE PAIN: DARING DISCOURSE
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Shoulder surgery can result in significant postoperative pain. Interscalene brachial plexus blocks (ISBs) constitute the current criterion standard for analgesia but may be contraindicated in patients with pulmonary pathology due to the inherent risk of phrenic nerve block and symptomatic hemidiaphragmatic paralysis. Although ultrasound-guided ISB with small volumes (5 mL), dilute local anesthetic (LA) concentrations, and LA injection 4 mm lateral to the brachial plexus have been shown to reduce the risk of phrenic nerve block, no single intervention can decrease its incidence below 20%. Ultrasound-guided supraclavicular blocks with LA injection posterolateral to the brachial plexus may anesthetize the shoulder without incidental diaphragmatic dysfunction, but further confirmatory trials are required. Ultrasound-guided C7 root blocks also seem to offer an attractive, diaphragm-sparing alternative to ISB. However, additional large-scale studies are needed to confirm their efficacy and to quantify the risk of periforaminal vascular breach. Combined axillary-suprascapular nerve blocks may provide adequate postoperative analgesia for minor shoulder surgery but do not compare favorably to ISB for major surgical procedures. One intriguing solution lies in the combined use of infraclavicular brachial plexus blocks and suprascapular nerve blocks. Theoretically, the infraclavicular approach targets the posterior and lateral cords, thus anesthetizing the axillary nerve (which supplies the anterior and posterior shoulder joint), as well as the subscapular and lateral pectoral nerves (both of which supply the anterior shoulder joint), whereas the suprascapular nerve block anesthetizes the posterior shoulder. Future randomized trials are required to validate the efficacy of combined infraclavicular-suprascapular blocks for shoulder surgery.

From the *Department of Anesthesia, Montreal General Hospital, McGill University, Montreal, Quebec, Canada; and †Department of Anesthesia, Hospital Clinico Universidad de Chile, University of Chile, Santiago, Chile.

Accepted for publication October 8, 2016.

Address correspondence to: De Q. H. Tran, MD, FRCPC, Department of Anesthesia, Montreal General Hospital, 1650 Ave Cedar, D10-144, Montreal, Quebec, Canada H3G 1A4 (e-mail: de_tran@hotmail.com).

The authors declare no conflict of interest.

Copyright © 2017 by American Society of Regional Anesthesia and Pain Medicine.