Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery

Anatomical, Physiologic, and Clinical Considerations

Kariem El-Boghdadly, F.R.C.A.; Ki Jinn Chin, F.R.C.P.C.; Vincent W. S. Chan, F.R.C.P.C.

Anesthesiology. 2017;127(1):173-191.

Abstract and Introduction

Abstract

Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients. The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context. They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The most important of these include limiting local anesthetic dose and injection volume and performing the injection further away from the C5–C6 nerve roots. Targeting peripheral nerves supplying the shoulder, such as the suprascapular and axillary nerves, may be an effective alternative to brachial plexus blockade in selected patients. The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article.

Introduction

Surgery for shoulder pathology is increasingly common,^[1,2] with regional anesthesia playing an important role in multimodal analgesia for these painful procedures.^[3] Interscalene brachial plexus block is the most common regional anesthetic technique; however, phrenic nerve palsy and hemidiaphragmatic paresis have traditionally been inevitable consequences, which limit its utility in the population of patients at high risk of respiratory complications. A range of modifications and alternatives to interscalene block have been proposed to minimize the respiratory impact of phrenic nerve palsy, but to date there has been no thorough assessment of the clinical value offered by each of these strategies. In this article, we aim to describe the anatomical, physiologic, and clinical principles governing phrenic nerve palsy in the context of regional anesthesia for shoulder surgery. We also review the various techniques that seek to provide adequate regional anesthesia of the shoulder while minimizing the risk of phrenic nerve palsy, as well as methods for assessing their impact on diaphragmatic function, and thus provide a comprehensive narrative of their value in achieving these two objectives.

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Next Section

Abstract and Introduction
Materials and Methods
Discussion
References

Table 1. Characteristics of Relevant Studies of Regional Anesthesia Techniques for Shoulder Surgery
Study	Characteristics
Study	Interscalene Block Technique	Comparison	Target	Drug	Concentration	Volume	Dose
Noncomparative studies
Urmey et al.,¹⁴ 1991, n = 13	SS, LM	—	IS (Winnie approach, C5, C6)	Mepivacaine	1.5%	34–52 ml	510–780 mg
Urmey and McDonald,¹³ 1992, n = 8	SS, LM	—	IS (Winnie approach, C5, C6)	Mepivacaine	1.5%	45 ml	675 mg
Neal et al.,¹¹ 1998, n = 8	SS, LM	—	SC (plumb-bob technique)	Lidocaine	1.5%	30 ml	450 mg
Volume effect
Urmey and Gloeggler,⁵⁰ 1993, n = 20	SS, LM	LA volume 20 ml vs. 45 ml	IS (Winnie approach, C5, C6)	Mepivacaine	1.5%	45 ml 20 ml	675 mg 300 mg
Sinha et al.,⁵¹ 2011, n = 30	SS, USG	LA volume 10 ml vs. 20 ml	IS, intraplexus C5, C6, or C7 roots	Ropivacaine	0.5%	20 ml 10 ml	100 mg 50 mg
Riazi et al.,¹⁶ 2008, n = 40	SS, USG	LA volume 5 ml vs. 20 ml	IS, intraplexus C5, C6 roots	Ropivacaine	0.5%	20 ml 5 ml	100 mg 25 mg
Lee et al.,⁵² 2011, n = 60	SS, USG	LA volume 5 ml vs. 10 ml	IS, intraplexus C5, C6 roots	Ropivacaine	0.75%	10 ml 5 ml	75 mg 37.5 mg
Concentration effect
Al-Kaisy et al.,³⁶ 1991, n = 11	SS, NS	LA concentration 0.25% vs. 0.5%	C5, C6	Bupivacaine	0.5% 0.25%	10 ml 10 ml	50 mg 25 mg
Casati et al.,⁵³ 1999, n = 30	SS, NS	LA concentration ropivacaine 0.5% vs. ropivacaine 0.75% vs. mepivacaine 2%	IS (Winnie approach, C5, C6)	Mepivacaine Ropivacaine Ropivacaine	2% 0.75% 0.5%	20 ml 20 ml 20 ml	400 mg 150 mg 100 mg
Wong et al.,⁴³ 2016, n = 50	SS, USG	LA concentration 0.1% vs. 0.2%	IS, intraplexus around trunks	Ropivacaine	0.2% 0.1%	20 ml	40 mg 20 mg
Al-Kaisy et al.,⁵⁴ 1998, n = 30	SS, NS	LA concentration 0.125% vs. placebo	C5, C6	0.9%saline Bupivacaine	Placebo 0.125%	10 ml 10 ml	0 mg 12.5 mg
Concentration and volume effect
Pippa et al.,⁵⁵ 2006, n = 60	SS, NS	LA concentration and volume 0.25/1% vs. 0.5/2% 60 (30/30) ml vs. 30 (15/15) ml	IS (Winnie approach, C5, C6)	Bupivacaine/lidocaine	0.25/1% 0.5/2%	60 (30/30) ml 30 (15/15) ml	75/300 mg 75/300 mg
Zhai et al.,⁵⁶ 2016, n = 95	SS, USG	LA concentration and volume 0.25% vs. 0.5% vs. 0.75% 20 ml vs. 10 ml vs. 6.7 ml	IS, intraplexus C5, C6 roots	Ropivacaine	0.25% 0.5% 0.75%	20 ml 10 ml 6.7 ml	50 mg
Injection below C6
Renes et al.,¹⁵ 2009, n = 30	SS, USG/NS	Localization method USG vs. NS	IS, intraplexus C7 root	NS ropivacaine US ropivacaine	0.75%	10 ml 10 ml	75 mg 75 mg
Petrar et al.,⁴¹ 2015, n = 64	SS, USG	Injection site supraclavicular vs. infraclavicular	IS, intraplexus IC, posterior and lateral cords	SC ropivacaine IC ropivacaine	0.5%	30 ml 30 ml	150 mg 150 mg
Extrafascial injection
Palhais et al.,¹⁷ 2016, n = 40	SS, USG	Injection site extrafascial vs. intraplexus	IS, intraplexus C5, C6 roots IS, extrafascial 4 mm lateral to C5, C6 roots	Bupivacaine Bupivacaine	0.5%	20 ml 20 ml	100 mg 100 mg
Catheter technique
Renes et al.,⁵⁷ 2010, n = 20	Catheter, USG	Minimum effective volume	IS, intraplexus C7 root	Ropivacaine	0.75%	2–6 ml	15–45 mg
Stundner et al.,⁵⁸ 2016, n = 30	Catheter, USG	LA volume 5 ml vs. 20 ml	IS, intraplexus C5, C6 roots	Ropivacaine	0.75%	20 ml 5 ml	150 mg 37.5 mg
Hartrick et al.,⁴² 2012, n = 36	Catheter, USG	LA volume 20 ml vs. 10 ml vs. 5 ml	IS, intraplexus C5 root	Ropivacaine	0.75%	20 ml 10 ml 5 ml	150 mg 75 mg 37.5 mg
Thackeray et al.,⁴⁴ 2013, n = 30	Catheter, USG	LA concentration 0.125% vs. 0.25%	IS, intraplexus C6	Bupivacaine	0.25% 0.125%	20 ml	50 mg 25 mg
Koh et al.,⁵⁹ 2016, n = 75	Catheter, USG	Injection site interscalene vs. supraclavicular	IS, intraplexus C5, C6 roots SC, intraplexus	Ropivacaine Ropivacaine	0.375%	20 ml 20 ml	75 mg 75 mg
Wiesmann et al.,⁴⁰ 2016, n = 114	Catheter, USG	Injection site interscalene vs. supraclavicular	SC, between upper and middle trunks IS, between upper and middle trunks	Ropivacaine	0.2%	10 ml + 4 ml/h + 4-ml bolus	20 mg

Studies are divided into those assessing outcomes noncomparatively, as well as those describing outcomes by comparing volume effect, concentration effect, injection below C6, extrafascial injection, and catheter techniques.
IC = infraclavicular; IS = interscalene; LA = local anesthetic; LM = landmark; NS = nerve stimulator; SC = supraclavicular; SS = single shot; US = ultrasound; USG = ultrasound-guided.

Table 2. Incidence and Magnitude of Phrenic Nerve Palsy and Analgesic Outcomes of Relevant Studies of Regional Anesthesia Techniques for Shoulder Surgery
Study	Monitoring for PNP	Incidence/Magnitude						Analgesic Outcomes		Remarks
Study	Monitoring for PNP	US Evidence of PNP	FEV₁ Change	FVC Change	PEFR Change	Oxygen Saturation	Dyspnea	Pain Scores	Analgesic Consumption	Remarks
Noncomparative studies
Urmey et al.,¹⁴ 1991, n = 13	US	Sniff +5.96 cm to −4.53 cm (176% reduction)	—	—	—	—	38%	—	—	—
Urmey and McDonald,¹³ 1992, n = 8	US, PFTs	100%	−26.4%	−27.2%	−15.4%	—	—	—	—	Magnetometry demonstrating increased chest wall movement (indicating use of intercostal and accessory muscles) with reduced ipsilateral abdominal movement
Neal et al.,¹¹ 1998, n = 8	US, PFTs	50%	Paralyzed: +6% Nonparalyzed: 0%	+2% +2%	+7% +6%	0%	0%	—	—	—
Volume effect
Urmey and Gloeggler,⁵⁰ 1993, n = 20	US, PFTs	100% 100%	−39.9% −31.6%	−40.9% −32%	−35.9% −32%	— —	— —	— —	— —	—
Sinha et al.,⁵¹ 2011, n = 30	US, PFTs	93% 93%	−35% −29%	−32% −31%	−19% −23%	– –	— —	— —	PACU fentanyl, 0 μg; home hydrocodone, 25 mg 0 μg, 30 mg	No significant difference in analgesic consumption
Riazi et al.,¹⁶ 2008, n = 40	US, PFTs	100% 45%	−1.23 l −0.83 l	−1.59 l −0.7 l	−2.50 l/min −0.83 l/min	−5.85% −1.5%	5% 0%	VAS at 30 in, 0.3; 60 min, 1; 120 min, 1.3; 12 h, 3.1; 24 h, 4.7 1.1, 1.1, 0.5, 3.4, 3.6	Intraoperative fentanyl, 107.5 μg; PACU MEQ, 1.3 mg; 24-h MEQ, 26.5 mg 140.3 μg, 2.9 mg, 23.3 mg	No significant difference in pain scores or analgesic consumption
Lee et al.,⁵² 2011, n = 60	CXR	—	—	—	—	—	—	—	—	CXR diaphragmatic paresis 60% vs. 33%
Concentration effect
Al-Kaisy et al.,³⁶ 1999, n = 11	US, PFTs	100% 16%	−21.8% −9.4%	−25.4% −13.4%	−15.2% −16.7%	— —	0% 0%	— —	— —	Volunteer study
Casati et al.,⁵³ 1999, n = 30	US, PFTs	100% 100% 100%	−40% −38% −30%	−39% −41% −40%	— — —	— — —	33% 0% 8.3%	— — —	No analgesia, 0 patients No analgesia, 0 patients No analgesia, 2 patients (20%)	No difference in pain scores. Longer time to first analgesic with both ropivacaine groups.
Wong et al.,⁴³ 2016, n = 50	US, PFTs	66% 35%	−28% −20%	−33% −22%	−34% −27%	No desaturations No desaturations	0% 0%	NRS at 30 min, 0; 60 min, 0; AUC POD 0–3, 8.4 0, 0, 12.8	PACU fentanyl, 18 μg; 72-h codeine, 55 mg 25, 102	Only difference in 72-h codeine requirement, no other pain score or analgesic consumption differences
Al-Kaisy et al.,⁵⁴ 1998, n = 30		— —	— —	— —	— —	— —	— —	VAS at 20 min, 8.1; 30 min, 6.9; 60 min, 5.0; 120 min, 3.6 3.4, 3.5, 2.5, 2.2	PACU morphine, 9.5 mg PACU morphine, 2.7 mg	—
Concentration and volume effect
Pippa et al.,⁵⁵ 2006, n = 60	US	0% 27%	— —	— —	— —	— —	— —	— —	— —	Significantly better clinical outcomes and degree of analgesia in high-volume, low-concentration group in all regions of upper limb except for lateral neck and arm
Zhai et al.,⁵⁶ 2016, n = 95	US	70% 69% 58%	— — —	— — —		— — —	— — —	NRS at PACU, 0; 4 h, 0; 8 h, 0; 24 h, 0; worst, 3 0, 0, 0, 1, 3 0, 0, 0, 1, 3	— — —	No significant difference in diaphragmatic paresis, pain scores, or satisfaction
Injection below C6
Renes et al.,¹⁵ 2009, n = 30	US, PFTs	Sigh, −95%; sniff, −87% −11%, + 60%	−0.9 l (−33%) −0.1 l (−4%)	−1.2 l (−36%) −0.1 l (−3%)	−105.1 l/min (−28%) −8 l/min (−2%)	—	—	NRS at 30 min, 2 NRS at 30 min, 2	13% needing morphine 13% needing morphine	No significant difference in pain scores or analgesic consumption
Petrar et al.,⁴¹ 2015, n = 64	US	Partial, 9%; complete, 34% Partial, 9%; complete, 3%	— —	— —	— —	— —	25% 16%	— —	— —	Supraclavicular vs. infraclavicular blocks
Extrafascial injection
Palhais et al.,¹⁷ 2016, n = 40	US, PFTs	90% 21%	−0.9 l (−28%) −0.6 l (−16%)	−1.2 l (−28%) −0.8 l (−17%)	−2.1 l/s (−24%) −0.7 l/s (−8%)	— —	30% 0%	NRS at PACU, 0.5; 24 h, 1.6 0.4, 1.6	PACU rescue (n), 0; 24-h MEQ, 5 mg; 48-h MEQ, 7.5 mg 5, 5, 10 mg	No significant difference in analgesic consumption after PACU
Catheter technique
Renes et al.,⁵⁷ 2010, n = 20	US, PFTs	0% in all patients at 2 h	0%	0%	0%	—	—	—	—	No changes in respiratory function with ≤6 ml injection, but changes after 24 h of infusion of 6 ml/h 0.2% ropivacaine in 100% of patients
Stundner et al.,⁵⁸ 2016, n = 30	US, PEFR	53% 27%	— —	— —	−2.66 l/min −1.69 l/min	—	— —	— —	Intraoperative fentanyl, 200 μg 150 μg	Nonsignificant difference in PNP. No significant difference in rest or dynamic pain scores or analgesic consumption.
Hartrick et al.,⁴² 2012, n = 36	US	−65% excursion −60% excursion −66% excursion	— — —	— — —	— — —	— — —	33% 0% 8.3%	NRS at PACU D/C, 0.62; 24 h, 2.54; 48 h, 2.15; 12 wk, 1.15 1.58, 3.33, 2.08, 2.42 2.67, 3.67, 2.67, 1.5	24-h MEQ, 13.4 mg 24-h MEQ, 29.8 mg 24-h MEQ, 27.7 mg	Only difference at PACU D/C between 5 ml and 20 ml, no other pain score or analgesic consumption differences
Thackeray et al.,⁴⁴ 2013, n = 30	US, oxygen saturations	78% 21%	— —	— —	— —	−4.3% −2.6%	0% 0%	0 1	Fentanyl, 0 μg Fentanyl, 7 μg
Koh et al.,⁵⁹ 2016, n = 75	US	Partial, 32%; complete, 63% Partial, 26%; complete, 24%	— —	— —	— —	— —	— —	Mean NRS, 2.84 Mean NRS, 2.57	PACU morphine, 1 mg; 24-h MEQ, 8 mg 0 mg, 7 mg	No significant difference in pain scores or analgesic consumption
Wiesmann et al.,⁴⁰ 2016, n = 114	US, PFTs	PACU, −82%; POD1, −46% PACU, −55%; POD1, –34%	−33% −32%	−38% −30%	−32% −43%	+1% +1%	8% 7%	0–1 0–0	Ward rescue opioids, 16% Ward rescue opioids, 5.2%	No significant difference in pain scores or analgesic consumption

Studies are divided into those assessing outcomes noncomparatively, as well as those describing outcomes by comparing volume effect, concentration effect, injection below C6, extrafascial injection, and catheter techniques.
CXR = chest X-ray; D/C = discharge; FEV1 = forced expiratory flow rate in 1 s; FVC = forced vital capacity; MEQ = morphine equivalents; NRS = numerical rating scale; PACU = postanesthetic care unit; PEFR = peak expiratory flow rates; PFTs = pulmonary function tests; PNP = phrenic nerve palsy; POD = postoperative day; VAS = visual analog score; US = ultrasound.