Article Text

other Versions

Download PDFPDF
Diaphragm-sparing nerve blocks for shoulder surgery, revisited
  1. De Q Tran1,
  2. Sebastián Layera2,
  3. Daniela Bravo2,
  4. Iver Cristi-Sanchéz3,
  5. Loreley Bermudéz4 and
  6. Julián Aliste2
  1. 1Anesthesia, McGill University, Montreal, Quebec, Canada
  2. 2Anesthesia and Perioperative Medicine, University of Chile, Santiago, Chile
  3. 3Escuela de Kinesiología, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
  4. 4Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
  1. Correspondence to Dr De Q Tran, Anesthesia, McGill University, Montreal, QC H3T 1M5, Canada; de_tran{at}


Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence <10%.

  • hemidiaphragmatic paralysis
  • shoulder surgery

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors DQHT, SL, DABA, IC-S, LB and JA participated in the planning, conception and writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.