Superior Trunk Block

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. Methods This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. Results The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. Conclusions Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

Liposomal Bupivacaine versus Dexamethasone: Comment

“…We agree with Karim et al 1 that prolonged phrenic nerve paralysis may be a concern when administering liposomal bupivacaine as reported in the recent study by Berg et al 6 Interscalene nerve blocks alone have a high probability of causing hemidiaphragmatic paralysis (71.4% with 15 ml plain bupivacaine 7 ) and should be used cautiously and sparingly in patients with pulmonary disease, regardless of duration. There are alternative phrenic nerve-sparing blocks that can be used instead.…”

Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study

“…HDP is usually well tolerated in healthy patients, but in cases of a severe respiratory history, HDP is poorly tolerated, and IBPB is contraindicated. Supraclavicular, suprascapular, or superior trunk blocks have been studied as alternatives to IBPB in arthroscopic shoulder surgery [42][43][44][45]. Although supraclavicular block is considered an acceptable choice, clinically similar to IBPB, its incidence of HDP is still up to 59% [46].…”

Recent advancements in regional anaesthesia

“…Any brachial plexus block above the clavicle—namely interscalene block (ISB) and its variants like supraclavicular block or cervical plexus block—have the potential of phrenic nerve paralysis, resulting in hemidiaphragmatic paresis (HDP); this incidence is high following ISB. This is worrisome in a patient having underlying respiratory disease as it can cause decompensation[ 21 ] due to reduction of respiratory function by almost 20%.…”

“…Alternative diaphragm-sparing blocks have been proposed. These include the US guided C7 root blocks,[ 22 ] superior trunk block,[ 21 ] suprascapular and axillary nerve block combination, infraclavicular anterior suprascapular nerve block (<10% incidence of HDP), USG-guided ESP block at T2-3 level,[ 23 ] and the costoclavicular block (0% incidence of phrenic nerve paralysis). [ 24 , 25 ] The costoclavicular block is a promising block and provides anaesthesia and analgesia equivalent to ISB.…”

“…[ 25 ] Further trials are needed to study the efficacy of these blocks as a sole anaesthetic and for postoperative pain management. [ 21 ]…”