Considerations for regional anaesthesia for the shoulder joint - Beyond the C5-C6 nerve roots

Shoulder pain in the perioperative setting remains a significant clinical challenge, with persistent postoperative discomfort reported in up to 22 % of patients following primary shoulder arthroplasty. Regional anesthesia plays a crucial role in multimodal analgesia, and the interscalene block (ISB) has traditionally been regarded as the standard technique for shoulder surgery. However, its proximity to the C5-C6 ventral rami carries risks, including phrenic nerve paresis and nerve injury. While these complications are often clinically insignificant in healthy individuals, they may cause respiratory issues in vulnerable patients, highlighting the need for safer and more customized alternatives. This educational review summarizes emerging regional anesthesia techniques that target sensory pathways of the shoulder while minimizing complications associated with ISB. It integrates evolving knowledge of shoulder innervation, surgical-specific analgesic considerations, postoperative pain trajectories, and the phenomenon of rebound pain. Additionally, the role of point-of-care diaphragmatic ultrasonography in perioperative risk stratification is explored. A strategy map aligning specific nerve block techniques with common shoulder procedures is presented to support individualized clinical decision-making. As medicine and technology advances, regional anesthesiologists are expected to expand their repertoire of shoulder analgesic techniques to deliver safer, patient-centred care. This review offers a comprehensive framework to guide evidence-informed block selection and enhance perioperative outcomes for diverse patient populations.