Diaphragm-sparing nerve blocks for shoulder surgery, revisited

Area of Science:

• Regional Anesthesia
• Pain Management
• Thoracic Surgery

Background:

• Interscalene brachial plexus block (ISB) is standard for shoulder surgery analgesia but risks phrenic nerve palsy.
• Patients with pulmonary compromise are at higher risk from ISB-induced hemidiaphragmatic paralysis (HDP).
• Previous research identified potential diaphragm-sparing alternatives to ISB.

Purpose of the Study:

• To review and synthesize evidence on diaphragm-sparing nerve blocks for shoulder surgery.
• To evaluate alternatives to ISB regarding postoperative analgesia and HDP incidence.
• To identify areas for future research in shoulder surgery anesthesia.

Main Methods:

• Systematic review of randomized controlled trials investigating various nerve blocks.
• Analysis of cumulative evidence on supraclavicular, upper trunk, anterior suprascapular, costoclavicular, and combined blocks.
• Comparison of efficacy and safety profiles against ISB.

Main Results:

• Costoclavicular blocks show promise for ISB-level analgesia with 0% HDP incidence, but require larger trials.
• Anterior suprascapular nerve blocks provide surgical anesthesia and analgesia comparable to ISB, with unquantified HDP risk.
• Supraclavicular, upper trunk, and combined blocks demonstrate <10% HDP incidence and similar analgesia to ISB.

Conclusions:

• Costoclavicular blocks are a potential diaphragm-sparing alternative for shoulder surgery analgesia, pending further research.
• Anterior suprascapular nerve blocks and other reviewed techniques warrant further investigation for safety and efficacy.
• Optimizing diaphragm-sparing nerve blocks is crucial for patients with pulmonary compromise undergoing shoulder surgery.