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Title: Suprascapular nerve block and posterior cord block in patient with severe pulmonary disease undergoing shoulder surgeryID5458Author(s)
Peripheral nerve blocks are often performed preoperatively prior to orthopedic surgery due to their associated decrease in perioperative pain, reduced the need for opioids post-op, and decreased length of hospital stay. Interscalene block is often used for patients undergoing shoulder surgery; however, even under ultrasound guidance the incidence of phrenic nerve paralysis is 13% . In patients with critical pulmonary disease, it is essential to avoid phrenic nerve paralysis exacerbating respiratory symptoms.
Materials and methods
A 57 year old female with a past medical history of morbid obesity, severe COPD, uncontrolled OSA, smoker, and pulmonary hypertension presented to the emergency department after a fall with left proximal humerus fracture. Patient was scheduled for ORIF of left proximal humerus fracture and acute pain service was consulted for nerve block prior to surgery. Patient complained of left shoulder pain with SpO2 in the 80s on room air. She was given a breathing treatment and placed on 4L of O2 facemask with improvement of SpO2 to 90s prior to peripheral nerve block. The patient underwent a left sided suprascapular nerve and infraclavicular posterior cord block under ultrasound guidance with 30cc .5% ropivacaine. Patient was not a candidate for interscalene block due to concern for phrenic nerve paralysis. The surgery and anesthesia was well tolerated, and the patient did not require any narcotics in the OR. Patient had remained intubated post-op due to decreased respiratory drive and CO2 retention. She was transported to ICU for post-op care where she received aggressive diuresis, steroids, antibiotics treatments and was extubated on post-op day one. Oral pain medication including Tylenol and oxycodone was minimal post-op. Patient spent 4 days in the ICU and 1 day on the floors with no complications before being discharged in stable condition.
Interscalene approach which targets the nerves of the upper brachial plexus is often used for shoulder surgery; however, phrenic nerve palsy is a significant complication that limits the use of this technique in high-risk patients with significant pulmonary disease. Phrenic nerve palsy with hemidiaphragmatic paresis has been as high as 13% under ultrasound guidance.  In healthy patients, minimizing local anesthetic doses and injection volumes to less than 10 ml, as well as performing injection further distal to the C5–C6 nerve roots (superior trunk or supraclavicular brachial plexus) is a reasonable alternative that can also significantly reduce the incidence of phrenic nerve palsy.  Given the patient’s history of severe COPD, pulmonary hypertension, and uncontrolled OSA, with low SpO2 at baseline, we opted for suprascapular nerve and infraclavicular approach for posterior cord block to eliminate phernic nerve palsy. Alternatively patient could have opted for surgery without regional anesthesia; however, patient would have required additional IV narcotics with a concern for respiratory depression. In conclusion, Suprascapular nerve block and posterior cord block may be an alternative for patients with significant pulmonary disease undergoing shoulder surgery.
1. Renes SH, Rettig HC, Gielen MJ, et al. Ultrasound-guided low dose interscalene brachial plexus block reduces the incidence of hemidiaphragmic paresis. Reg Anesth Pain Med. 2009; 34(5):498-502
2. Kariem El-Boghdadly, Ki Jinn Chin, Vincent W. S. Chan; Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations. Anesthesiology 2017;127(1):173-191. doi: 10.1097/ALN.0000000000001668.