SUPRASCAPULAR NERVE BLOCK FOR POSTOPERATIVE PAIN MANAGEMENT IN A PATIENT WITH PERSISTENT DYSPNEA POST-COVID

INTRODUCTION
• 64-year-old male
• Left rotator cuff repair following left subscapularis and supraspinatus tear, labral complex injury, and subacromial impingement
• Previous uncomplicated right-sided rotator cuff repair at an outside hospital
Past Medical History:
• COVID infection in 2021, complicated by persistent post-COVID dyspnea requiring BiPAP and oxygen supplementation for 3 months
• Cardiovascular evaluation was normal
• Pulmonary evaluation showed normal PFTs, and chest CT showed persistent peripheral subpleural ground glass and reticular opacities, potentially related to COVID scarring
• Mild coronary artery disease, hyperlipidemia, essential tremor and bilateral sensorineural hearing loss

PERIOPERATIVE PLAN
• Anesthesiologist discussed anticipated phrenic nerve impairment with interscalene block; patient hesitant to proceed and opted for a suprascapular and isolated axillary nerve block
• He had an uncomplicated procedure and was discharged home
• On postoperative day 3, he reached out to the surgical team for persistent numbness without motor weakness of his left 2nd , 3rd, and 4th digits
• Surgical team thought this could be related to nerve blockade, however, his symptoms were not consistent with expected sensory blockade
• Symptoms had resolved on the 10th postoperative at follow-up appointment

DISCUSSION
• Suprascapular nerve: upper trunk of the brachial plexus (C5-C6).
• Motor innervation: infraspinatus (external rotation) and supraspinatus (abduction) muscles
• Sensory innervation: acromioclavicular and glenohumeral joints
• Initially utilized for chronic shoulder pain
• Alternative for patients with significant pulmonary comorbidities by avoiding phrenic nerve blockade
• Metanalysis by Hussain et al, found no significant difference after 24 hours in morphine equivalent consumption between patients with a suprascapular nerve block versus interscalene nerve block with a reduction in pulmonary complications.
• Posterior approach complication risk: pneumothorax
• Limited and conflicting evidence in the benefit of adding an axillary nerve block
• Importance of thoughtful regional anesthesia, consideration of brachial plexus alternatives

REFERENCES
1. Wertheim, H.M. and E.A. Rovenstine, Suprascapular Nerve Block. Anesthesiology, 1941. 2(5): p. 541-545.
2. Urmey, W.F., K.H. Talts, and N.E. Sharrock, One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg, 1991. 72(4): p. 498-503.
3. Hussain, N., et al., Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology, 2017. 127(6): p. 998-1013.
4. Chan, C.W. and P.W. Peng, Suprascapular nerve block: a narrative review. Reg Anesth Pain Med, 2011. 36(4): p. 358-73.
5. Tran, D.Q., et al., Diaphragm-Sparing Nerve Blocks for Shoulder Surgery. Reg Anesth Pain Med, 2017. 42(1): p. 32-38.
6. Rothe, C., et al., A randomized controlled trial evaluating the impact of selective axillary nerve block after arthroscopic subacromial decompression. BMC Anesthesiol, 2020. 20(1): p. 33.