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PHRENIC SPARING NERVE BLOCKS

Rose Tang, MD

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BACKGROUND

  • Shoulder surgeries are among the most painful orthopedic procedures.
  • Interscalene block is the gold standard for pain control.
    • Lower pain scores, reduced opioid consumption, improved patient satisfaction
  • Interscalene block results in phrenic nerve palsy.
    • Well tolerated by healthy patients
    • May not be tolerated by patients with pre-existing pulmonary comorbidities

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PHRENIC NERVE

  • Innervation from C3-5
  • Sensory innervation to pleura, fibrous pericardium, diaphragm
  • Sole motor innervation to diaphragm
  • Diaphragm movement 🡪 75% of tidal volume

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Campbell et al, 2023

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HEMIDIAPHRAGMATIC PARESIS

  • PN blockade results in hemidiaphragmatic paresis
  • Due to spread of local anesthetic from brachial plexus to PN
    • Anteriorly to reach PN
    • Proximally to reach C3-5
  • PFT: Reduction in FVC and FEV1 by 25-30%
  • Detected on CXR, US, PFT

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PATIENT SELECTION

  • Severe restrictive lung disease (morbid obesity, interstitial lung disease, neuromuscular disease, scoliosis, pneumonia)
  • Severe obstructive lung disease (COPD, asthma, bronchiectasis, A1AD)
  • Pulmonary hypertension
  • Contralateral phrenic nerve palsy

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INNERVATION OF SHOULDER

+ musculocutaneous

Laumonerie et al, 2020

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STRATEGIES TO REDUCE HDP

  • Adjustments to interscalene block
  • Blockade of brachial plexus at more distal points
    • Superior trunk block
    • Supraclavicular block
    • Infraclavicular block
  • Combination blocks
    • Suprascapular + infraclavicular block
    • Suprascapular + axillary nerve block

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INTERSCALENE BLOCK

  • Lower volume down to 5 cc
  • Lower concentration of local anesthetic
  • Periplexus vs intraplexus approach
  • Injection below C6
  • No single intervention could decrease incidence of HDP under 20%

Tran, 2017

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DISTAL BRACHIAL PLEXUS BLOCKS

  • Superior trunk block
    • Effective analgesia
    • High incidence of HDP
  • Supraclavicular nerve block
    • Effective analgesia
    • High incidence of HDP (50-70%)
  • Infraclavicular block
    • Less effective analgesia (misses suprascapular nerve)
    • Very low incidence of HDP (0-3%)

subscapular

Tse, 2023

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COMBINATION NERVE BLOCKS

  • Suprascapular + infraclavicular nerve block
  • Suprascapular + axillary nerve block

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SUPRASCAPULAR NERVE BLOCK

  • Provides majority of shoulder innervation
  • Better than sham, inferior to ISB
  • Anterior vs posterior approach
    • Anterior:
      • Blocks all sensory branches of SSN
      • Risk of spreading to PN
    • Posterior:
      • Might not get all branches
      • No risk to PN

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SUPRASCAPULAR NERVE BLOCK: IMAGING AND TECHNIQUE

  • Patient sitting upright
  • Linear probe directed downwards into chest cavity
  • Landmarks: supraspinatus fossa, supraspinatus muscle, trapezius, spinoglenoid notch
  • 10 ccs local
  • Approach
    • In plane, medial to lateral (preferred)
    • Out of plane
  • No need to go into spinoglenoid notch

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SUPRASCAPULAR NERVE BLOCK: IMAGING AND TECHNIQUE

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AXILLARY NERVE BLOCK

  • Arises from posterior cord of brachial plexus
  • Provides ~10% of shoulder innervation
  • Often combined with SSNB for improved efficacy
    • Better than SSNB alone

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Scholzen, 2022

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AXILLARY NERVE BLOCK: IMAGING AND TECHNIQUE

  • Patient seated upright
  • Linear probe parasagittal orientation
  • Landmarks: proximal humerus, deltoid, teres minor, posterior circumflex humeral artery
  • 10 cc local
  • In plane or out of plane

Rothe, 2020

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BUT WAIT, THERE’S MORE!

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INFRACLAVICULAR BLOCK: DIFFERENT APPROACHES

  • Traditional
  • Retroclavicular
  • Costoclavicular

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RETROCLAVICULAR APPROACH

  • First described in 2007
  • Coined RAPTIR (retroclavicular approach to the infraclavicular region)
  • Needle insertion in supraclavicular fossa behind the clavicle and advanced underneath the clavicle
  • Advantages: shorter procedure time, better needle visualization
  • Disadvantage: “leap of faith” as needle passes under the clavicle
    • Suprascapular nerve in vicinity

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Blanco, 2019

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RETROCLAVICULAR APPROACH

Luftig, 2017

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COSTOCLAVICULAR APPROACH

  • Costoclavicular space: just inferior and deep to clavicle
  • View is similar to supraclavicular
  • Advantages: better visualization of cords, simplicity, blocks suprascapular nerve, phrenic sparing (0-2% HDP)
  • Disadvantage: less data, proximity to pleura and vessels

Amaro, 2024

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COSTOCLAVICULAR APPROACH

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COMPARISON TO ISB

  • Similar efficacy as ISB
  • Much lower rate of HDP (0-6%)

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  • Cadaver study
  • 20 ml methylene blue
  • Dye spread to supraclavicular space and suprascapular nerve, but not to phrenic nerve

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REFERENCES

  • Amaral S, Lombardi R, Drabovski N, Gadsden J. Infraclavicular versus costoclavicular approaches to ultrasound-guided brachial plexus block: a systematic review and meta-analysis. Braz J Anesthesiol. 2024 Mar-Apr;74(2):744465. doi: 10.1016/j.bjane.2023.09.004. Epub 2023 Sep 23. PMID: 37748644; PMCID: PMC10963933.
  • Blanco, A.F.G., Laferrière-Langlois, P., Jessop, D. et al. Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: a multi-centric randomized trial. BMC Anesthesiol19, 193 (2019). https://doi.org/10.1186/s12871-019-0868-6
  • Campbell, Aaron S., Johnson, Christopher D., O’Connor, Shaun, Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery, Anesthesiology Research and Practice, 2023, 9962595, 16 pages,  2023. https://doi.org/10.1155/2023/9962595
  • Laumonerie, Pierre & Dalmas, Yoann & Tibbo, Meagan & Robert, Suzanne & Faruch, Marie & Chaynes, Patrick & Bonnevialle, Nicolas & Mansat, Pierre. (2020). Sensory innervation of the human shoulder joint: the three bridges to break. Journal of Shoulder and Elbow Surgery. 29. 10.1016/j.jse.2020.07.017.
  • Luftig J, Mantuani D, Herring AA, Nagdev A. Ultrasound-guided retroclavicular approach infraclavicular brachial plexus block for upper extremity emergency procedures. Am J Emerg Med. 2017 May;35(5):773-777. doi: 10.1016/j.ajem.2017.01.028. Epub 2017 Jan 15. PMID: 28126454.
  • Rothe, C., Lund, J., Jenstrup, M.T. et al. A randomized controlled trial evaluating the impact of selective axillary nerve block after arthroscopic subacromial decompression.BMC Anesthesiol 20, 33 (2020). https://doi.org/10.1186/s12871-020-0952-y
  • Scholzen, E.A., Schroeder, K.M. (2022). Axillary Nerve Block. In: Souza, D., Kohan, L.R. (eds) Bedside Pain Management Interventions. Springer, Cham. https://doi.org/10.1007/978-3-031-11188-4_53
  • Tran DQ, Elgueta MF, Aliste J, Finlayson RJ. Diaphragm-Sparing Nerve Blocks for Shoulder Surgery. Reg Anesth Pain Med. 2017 Jan/Feb;42(1):32-38. doi: 10.1097/AAP.0000000000000529. PMID: 27941477.
  • Tse, K.C. & Chu, C.K.. (2023). Anaesthesia for shoulder surgery – phrenic nerve-sparing techniques. Anaesthesia & Intensive Care Medicine. 24. 10.1016/j.mpaic.2023.09.018.

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THANK YOU!