An update on regional anesthesia in shoulder surgery: a narrative review

Introduction

Orthopedic surgery is notorious for causing severe postoperative pain, with shoulder procedures reported to be the most painful (1). As a result, poor postoperative pain management has been a longstanding issue in Orthopedics, especially in shoulder surgery (2). As the number of shoulder procedures continues to rise, pain management after surgery has become more important than ever and is a major focus of orthopedic research (3-6).

Inadequate postoperative pain control is associated with a multitude of poor outcomes, including prolonged hospitalizations, readmissions, poor patient satisfaction, increased risk of chronic pain, and increased costs of care (7-11). Poor pain control is also associated with increased postoperative opioid requirements, leading to higher risks of opioid-related adverse effects, including respiratory depression, nausea, pruritus, and ileus (12-17). These complications not only impact patient safety but also result in longer hospital stays and increased healthcare costs (18).

Perhaps even more importantly, the United States opioid crisis has a dramatic influence on the pursuit of more effective pain control strategies (19). This widespread public health issue, characterized by rapidly rising opioid use and abuse in the United States, led to significant changes in pain management approaches, aiming to reduce reliance on opioids and their associated risks (20).

Due to the high pain levels associated with orthopedic surgery (1), orthopedic surgeons make up a substantial portion of opioid prescriptions, with up to 8.8% of patients receiving their first opioid prescription for an orthopedic condition (21). With the increased knowledge about the harms of opioid prescription, much research in the 2000s and 2010s has focused on alternative analgesic strategies for treating pain, leading to growing interest in multimodal analgesia (MMA) and regional anesthesia, targeting multiple levels of the pain transmission pathway (22,23).

Efforts to improve pain control in orthopedics have displayed varying degrees of success (24-28). These include interventions such as peripheral nerve blocks, MMA, intra-articular injections or catheters, and peri-articular injections. Intra-articular catheter infusions are a glaring example of one such strategy that has fallen flat, as they quickly fell out of favor after being found to cause chondrolysis at an unacceptably high rate (29). Peripheral nerve blockade, in contrast, has shown much more favorable outcomes (28). As a result, regional anesthesia has emerged as a staple in orthopedic surgery (30,31), and has been heavily utilized, either alone or in combination with general anesthesia (GA), to manage perioperative and postoperative pain (32-36).

Regional anesthesia can be performed with a single-injection nerve block or continuous administration of local anesthetic (LA) via an indwelling catheter placed near the target nerve (37). The latter, termed continuous catheter infusion (CCI), has been well studied and has been shown to prolong analgesia compared to single injections (37-43). However, concerns about catheter migration, malpositioning, and associated complications, including severe neurological and life-threatening events (44-48) have led to a preference for single-injection nerve blocks in most situations (49,50).

Rationale and knowledge gap

Regional anesthesia for shoulder surgery has demonstrated superb efficacy, as it has been shown to reduce postoperative pain, opioid consumption, and length of stay (LOS) (28,51). Furthermore, these techniques are also useful alternatives to GA in patients at higher risk during GA, such as older patients or those with comorbidities (52,53).

Notably, opioid prescribing after shoulder surgery has seen a considerable decline over time, with mean opioid prescriptions in the U.S. falling over 50% from 2014 to 2020 for shoulder arthroplasty (SA), rotator cuff repair (RCR), and proximal humerus fixation (54). This decline, while likely multifactorial, is heavily correlated with widespread legislative changes aimed at limiting opioid prescriptions (55-58). While restrictions on opioid prescribing are imperative, improving non-opioid analgesia—particularly regional anesthesia in shoulder surgery—may facilitate these shifts in prescribing habits and mitigate postsurgical pain as opioid usage declines.

Despite significant efforts, rates of chronic opioid use after orthopedic surgery are still high (59). With regional anesthesia firmly established as a useful and effective pain management strategy for surgery, research continues to refine these strategies and improve techniques to further optimize perioperative and postoperative pain. With continued advancements, regional anesthesia is ever-evolving and changing the landscape of how patients can recover from shoulder surgery. This review will help to synthesize current techniques to address existing gaps in knowledge. In shoulder surgery, the most notable regional anesthesia techniques are interscalene brachial plexus block (ISB), supraclavicular brachial plexus block (SCB), and suprascapular nerve block (SSNB) (60-63). Several newer practices in regional anesthesia of the shoulder include the use of alternative adjuvant medications to prolong peripheral nerve blockade and the introduction of extended half-life anesthetic agents such as liposomal bupivacaine (LB) (64,65). Due to novelty, mixed evidence, or both, these techniques are not well established in clinical practice, and research has been focused on elucidating the risks and benefits of these therapies (64,66,67). Given these uncertainties, this review will help to clarify the role of these techniques in shoulder surgery.

Objective

Few published articles summarize the latest evidence available across multiple techniques for regional anesthesia of the shoulder. Additionally, because studies are published continuously, clinical practice guidelines may not reflect the most recent advancements in this area. This narrative review will summarize the most important regional anesthesia techniques utilized in shoulder surgery, covering indications, contraindications, benefits and risks, while highlighting relevant high-quality studies when appropriate. Importantly, it will also appraise key advancements in regional anesthesia, with an emphasis on presenting the most recent high-level evidence to provide a snapshot of the most current practices and conclusions. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-64/rc).

Methods

A literature review was conducted on the main regional anesthesia techniques employed for patients undergoing shoulder surgery. PubMed was queried using the keywords “regional anesthesia” AND “shoulder surgery” and limited to the previous 20 years. Studies were selected if they focused on at least one of the following: technique descriptions of individual regional shoulder anesthesia procedures, indications and contraindications of each procedure, and outcomes or complications following these procedures. Whenever possible, the most recent publications and highest-level evidence available at the time of the literature search were chosen. Articles cited within these studies that contained crucial information were retrieved when necessary, including those published more than 20 years ago. The search strategy is detailed in Table 1.

ISB

Overview

ISB is the most commonly used regional anesthesia technique utilized in shoulder surgery, and is considered the gold standard due to its versatility (52). It targets the trunks of the brachial plexus between the anterior and middle scalene muscles, providing reliable blockade of the superior and middle trunks, frequently sparing the inferior trunk (61). Early techniques utilized patient-reported paresthesia to determine the endpoint for nerve blockade (68). Later, ultrasound guidance (USG) and nerve stimulation emerged as more reliable techniques for determining the endpoint (69,70). Currently, the use of USG is widely accepted as the standard of care when performing ISB (71) due to superior block quality, decreased complication rates, shorter procedure times, and lower anesthetic volumes (72,73).

Regarding the approach for the block, multiple techniques are used in clinical practice (52). The technique first described by Winnie is an anterior approach with the needle directed medially, dorsally, and slightly caudally, penetrating the interscalene groove at the level of the cricoid line (61). Later techniques described by Meier et al. and Borgeat et al. involve a needle insertion point 2 or 3 cm cranial to that described in Winnie’s approach and direct the needle toward the distal clavicle, a more lateral trajectory (74,75). This technique better facilitates catheter placement along with decreased risk of vertebral artery injury and spinal puncture (52,76,77). With the advancements of USG, either technique is acceptable in current practice (78). Various other techniques have been described by authors (75,79,80) with similar safety and efficacy but are less commonly performed due to the safety, simplicity and practicality of the Winnie and Meier techniques (81).

Indications

ISB has utility in many shoulder procedures, including arthroscopic RCR, open shoulder or proximal humerus procedures, SA, and surgery of the distal clavicle (40,43,51,52,82). While ISB is often used as an adjunct for GA to reduce perioperative pain, it is suitable as the sole method of anesthesia for more minor shoulder procedures, such as shorter arthroscopy procedures (28,83). ISB can be performed pre-, intra-, or postoperatively, and is highly useful for managing postoperative pain in outpatient arthroscopic surgery in patients without contraindications for the technique (84). A high-powered systematic review published in 2017 showed ISB to be the most effective analgesic for arthroscopic shoulder surgery in the outpatient setting, providing excellent postoperative pain control, reductions in opioid consumption, and shorter times to reach discharge criteria (84). In open or more intense shoulder procedures, ISB is typically used in conjunction with GA or administered postoperatively to enhance pain control (85,86).

Contraindications

Contraindications to ISB include ipsilateral brachial plexus neurologic deficits and general contraindications to peripheral nerve blockade (87,88). Respiratory insufficiency is a relative contraindication due to the significant risk of phrenic nerve blockade and consequent hemidiaphragmatic paralysis (HDP) (89-91). Thus, ISB is often avoided in patients with moderate to severe pulmonary disease (89,92). Patients with existing vocal cord dysfunction are also poor candidates for ISB due to the risk of blockade of the recurrent laryngeal nerve, which could lead to complete airway obstruction (93).

Advantages/disadvantages

ISBs have the considerable advantage of being suitable as the sole mode of anesthesia for shoulder surgery (82,83), making it useful for patients at high risk for GA morbidity. A randomized controlled trial (RCT) by Hadzic et al. compared patients undergoing outpatient RCR receiving fast-track GA to those receiving an ISB alone (28). The GA group received incisional infiltration of 5–10 mL and an intra-articular injection of 10–15 mL of 0.25% bupivacaine after surgery, whereas the ISB group received 35–40 mL of 0.75% ropivacaine for the nerve blocks. The ISBs resulted in less patient-reported pain and shorter time to discharge (28).

Whether used alone or with GA, decreases in postoperative pain scores for both open and arthroscopic surgery have been well demonstrated in numerous RCTs and several meta-analyses (51,82,84). In the systematic review by Hughes et al. published in 2013, the use of single injection ISB during arthroscopic shoulder surgery was associated with significant reductions in pain scores at various time points up to 24 hours after surgery in all 10 included studies (51). Analgesic effects of single-shot blocks with non-liposomal anesthetic agents appear to last somewhere between 6 and 24 hours (83,94,95). Abdallah et al. reported in a large meta-analysis of RCTs published in 2015 that pain relief after single-injection ISB with LA did not extend beyond 6 to 8 hours (82).

Pain relief from ISBs also translates to reductions in opioid requirements. The same meta-analysis showed that postoperative opioid consumption was lower in the first 12 hours following surgery, but not afterward (82). ISB may also reduce the postoperative nausea and vomiting (NV) associated with opioid use. RCTs investigating this claim have yielded variable results, however, the high-powered meta-analysis by Abdallah et al. demonstrated that the incidence of postoperative NV after ISB was significantly reduced, with an odds ratio of 0.41 (82).

ISB also accelerates discharge from the hospital. Abdallah et al. showed in their meta-analysis that ISB reduced time spent in the post-anesthesia care unit and reduced hospital LOS (82).

Complications

Neurovascular injury is the major concern with ISB (96,97). In particular, injury to the brachial plexus or nearby structures is a potential risk, theorized to be due to direct needle trauma or chemical neurotoxicity from the LA (97,98). Albaum et al. reported in a systematic review and meta-analysis published in 2022 that of all regional anesthesia techniques for shoulder surgery, ISB was associated with the greatest risk of postoperative neurologic symptoms, with an overall risk of 13% (96).

One noteworthy neurologic complication experienced with ISB is Horner syndrome, which is caused by the spread of LA to the sympathetic cervical ganglia (51,83,99). Though it typically has a relatively benign course, Horner syndrome may cause considerable distress to patients and thus is one of the main disadvantages of this technique (99). The reported incidence of Horner syndrome as a result of ISB varies considerably, with single studies reporting rates from 5% to 48% (83,100). Horner syndrome is significantly more common with ISB than with other shoulder blocks (101,102), and this risk should be clearly communicated.

Although common, most neurologic symptoms resulting from ISB are transient. Of patients who were symptomatic after ISB, only 1% had symptoms persisting beyond 90 days (96). While rare, severe permanent neurological deficits have been reported following ISB. These devastating complications typically involve spinal cord injury due to needle trauma or direct LA injection into the cervical spinal cord. Those reported include high spinal anesthesia, syringomyelia, upper or lower extremity paresis, hemiplegia, and quadriplegia (47,48,103). Vascular structures at risk during ISB include the subclavian and vertebral arteries, and if injured, may result in hematoma (61,104). Utilization of USG with regional anesthesia can reduce the incidence of neurovascular complications in ISB, as it allows for direct visualization of anatomic structures and reductions in LA volume (34,90,105).

Notably, phrenic nerve blockade is a well-known complication of ISB (106-108). Early techniques for ISB carried an incidence of phrenic nerve palsy approaching 100% (89), thought to be partially attributable to similar appearances of the phrenic nerve and the cervical ventral rami (108). With increased usage of USG in ISB, the incidence of phrenic nerve blockade has decreased (53,90,108,109). Furthermore, multiple studies have demonstrated that using lower volumes of LA is associated with decreased risk of diaphragmatic paresis (90,105). Despite these mitigation strategies, phrenic nerve palsy after ISB remains common, with more recent studies citing rates from 27% to 73% (110-112). Therefore, respiratory insufficiency remains a relative contraindication for this type of block (89,91,92). Recent research has focused on how variations in injection technique affect the incidence of phrenic paralysis. Some authors suggest LA infiltration outside the brachial plexus sheath reduces the risk of HDP while preserving analgesic benefits, a claim backed by several studies (113,114). ISB has also been associated with additional respiratory complications such as pneumothorax, pleural effusion, and vocal cord paresis, particularly with CCI (52,84,115).

Other potential complications of ISB include infection and LA systemic toxicity (52,78,84,116).

SCB

Overview

The SCB is a regional anesthesia technique for both shoulder and upper extremity procedures, providing rapid onset of motor and sensory blockade of all nerves of the brachial plexus (117,118). Several variations in technique have been described. The classic approach described by Winnie consists of needle insertion at the lowest possible point in the interscalene groove near the clavicle and advancing it caudally toward the subclavian perivascular space, where the brachial plexus trunks are stacked (119). The modified “plumb bob” technique differs from the classic approach by using a more posterior needle trajectory, perpendicular to the table, with insertion at the lateral border of the sternocleidomastoid near the clavicle. In this technique, the needle is incrementally redirected cephalad or caudad until paresthesia is adequately achieved (120,121). Due to the location of the block and required needle trajectory, the risk of pneumothorax is considered higher for SCB than other upper extremity regional anesthesia techniques (120,122). Because of these concerns, SCB is typically performed with USG (121,123). As USG became more widely available, SCB was suggested as a safer alternative to ISB, especially for patients with pulmonary disease at higher risk of morbidity from HDP, however, the assertion that SCB affords a decreased risk of pulmonary complications has been called into question (41,124).

Indications

SCB can be used for perioperative pain control for various shoulder procedures, including arthroscopy, RCR, and open shoulder surgery, similar to the indications of ISB (41). Due to the compact location of brachial plexus blockade, SCB is also suitable for anesthesia in humeral, elbow, forearm, wrist, and hand procedures (87,125-127). For procedures of the shoulder, it is primarily used as an adjunct to GA as it does not adequately provide blockade of the supraclavicular nerve (128,129). This is in contrast to ISB, which blocks the supraclavicular nerve, affording complete coverage of the shoulder (61). However, for operations including and distal to the distal 2/3 of the humerus, it can be used as the primary mode of anesthesia (125,130-132).

Contraindications

Contraindications for SCB include respiratory insufficiency, contralateral vocal cord paresis, ipsilateral neurologic deficits in the distribution of the brachial plexus, and general contraindications to peripheral nerve blockade (41,87,126,133).

Advantages

SCB is effective in reducing postoperative pain and opioid consumption following shoulder surgery. In the high-powered systematic review and meta-analysis by Hussain and colleagues, SCB was shown to be noninferior to ISB in both pain scores and morphine consumption in the 24 hours after shoulder surgery, which was true for both single-injection and continuous block techniques (134). Their review included both studies with patients receiving arthroscopic surgery and open surgery.

Although widely considered second-line to ISB, SCB appears to be an effective mode of postoperative analgesia following major shoulder surgery in light of the available evidence (134). Furthermore, SCB affords a lower risk for respiratory dysfunction and minor block-related complications than ISB, as shown by Hussain et al. in their meta-analysis (134).

Complications

Early on, one of the biggest concerns with SCB was the risk of pneumothorax, with incidence estimated to be between 0.6% to 6.1% (135). With refined techniques and increased use of ultrasound, that incidence has fallen dramatically. Franco et al. reported in a prospective sample of 1,001 expert-guided supraclavicular blocks performed with nerve stimulation that no clinical pneumothorax was observed (136). Similarly, in a large survey of 510 USG SCBs, Perlas et al. reported no occurrences of pneumothorax (135). In current practice, pneumothorax is considered an extremely rare complication of SCB when performed correctly.

Although SCB carries a lower risk of pulmonary complications compared to ISB (134), phrenic nerve paresis remains a significant risk of SCB. In a meta-analysis comparing SCB to ISB, Guo et al. found no differences in the rate of dyspnea (41). In a prospective study, Ferré et al. observed a 59.5% incidence of HDP in 42 SCBs (137). Variations in technical approach SCB may alleviate the risk of diaphragm dysfunction. In 2024, Kim et al. described a new technique, termed the proximal longitudinal oblique approach (91). Under USG, the needle is advanced in a posterolateral-to-anteromedial direction, targeting the space beneath the brachial plexus just before the suprascapular nerve branch point. This method resulted in no pneumothoraces in 38 patients without compromising analgesia (91).

Brachial plexus injury can occur after SCB by the same mechanisms as those of ISB (102,135). However, these neurologic complications are nearly always transient (96). Unlike ISB, SCB does not carry the risk of spinal cord injury (135,136). Similar to ISB, other complications of SCB include vascular injury, Horner syndrome, and hoarseness (135).

SSNB

Overview

The suprascapular nerve provides 70% of the sensory innervation to the glenohumeral joint in addition to the acromioclavicular joint (138), making the SSNB a reasonable choice for pain management following shoulder surgery (139) in addition to having uses in the treatment of acute and chronic shoulder pain (138,140,141). Multiple techniques for performing SSNB have been described, however, most blocks are performed with one of two methods: a posterior approach directed at the suprascapular notch and an anterior approach, slightly lateral to the supraclavicular brachial plexus (137,142,143). Most are performed with USG (144).

Indications

The SSNB is often used in adjunct with GA as it does not afford sufficient analgesia to be used as the sole intraoperative anesthetic agent (43,60,138). It may be used for postoperative pain management for various shoulder procedures, including arthroscopy, RCR, Bankart repair, and SA (43,144). While it can be administered alone, it is often paired with an axillary nerve block due to demonstrated superior pain relief when the two are used together (139). Importantly, SSNB is specifically indicated for patients with underlying respiratory dysfunction who cannot tolerate phrenic nerve paresis, commonly seen with ISB and SCB (144,145).

Contraindications

SSNB is generally considered safe in most patients with the exception of patients with existing neurological deficits in this distribution and contraindications to peripheral nerve blockade (88,145,146).

Advantages

Single-shot SSNB administered alone reduces postoperative pain for patients after shoulder surgery (1). In the meta-analysis of RCTs by Kay et al., SSNB significantly reduced pain scores after shoulder surgery compared to control groups (147). These benefits appear to be strengthened when the injection is combined with an axillary nerve block (ANB). Zhao et al. showed in their systematic review and meta-analysis of RCTs that SSNB and ANB provided superior pain relief than SSNB alone after arthroscopic shoulder surgery (139). When compared to ISB, SSNB has comparable analgesic benefit, however, ISB appears to be more effective in the first few hours after surgery. In their systematic review and meta-analysis of RCTs, Sun et al. reported higher pain scores in the first 6 hours postoperatively for patients receiving SSNB compared to ISB, after which pain scores were similar (144). SSNB reduces opioid consumption in the postoperative period in comparison to no block (1). Compared to ISB, opioid reduction is the same for SSNB (148,149).

A key advantage of SSNB is its significantly decreased incidence of respiratory compromise compared to other blocks, which has been affirmed by multiple high-powered MAs (139,144), making it the regional technique of choice for patients at high risk of respiratory complications.

Complications

Pneumothorax is a serious but rare complication of SSNB, the risk of which can be mitigated by proper technique (142). HDP has been reported and is correlated with the choice of anatomical approach: the anterior approach has been reported to have an HDP incidence of up to 40% (137), while the posterior approach has rates of 0–2% (137,150). Systemic LA toxicity can occur, but can be avoided with frequent aspiration and USG (142,151). Other complications include transient peripheral nerve injury, Horner syndrome, hoarseness, NV, infection, and bleeding (146,148).

CCI

The use of CCI is intended to enhance postoperative pain control provided by single-shot blocks and can be performed for all three previously described nerve block techniques (38-40). CCI has been shown to prolong the duration of anesthesia, reduce opioid consumption, and decrease pain with movement, allowing for earlier postoperative mobilization (40).

For ISBs, CCI has demonstrated superiority over single injections, as a meta-analysis by Vorobeichik et al. found improved pain control and reduced opioid consumption at 24 and 48 hours in addition to shorter hospital stays after major surgery, without increasing adverse effects compared to single-shot ISB (152). A retrospective study comparing continuous to single-shot brachial plexus blocks (both interscalene and supraclavicular) found no difference in complication rates but noted more barriers to discharge and longer hospital stays in patients with continuous blocks (153). Fewer studies have examined continuous SSNB; however, the RCT by Kim et al. showed it to be noninferior to continuous ISB (154).

Given the available evidence, continuous catheters appear to be safe and effective when utilized in analgesic regimens for shoulder surgery (39,40,152-154). Because CCI is associated with increased costs and concerns about catheter migration (155), it is typically reserved for major procedures, such as SA and RCR (52).

Newer adjuvants

Anesthetic adjuvants may be administered with various peripheral nerve blocks for the purpose of prolonging analgesia (156-159). In the context of shoulder surgery, administration of dexamethasone or dexmedetomidine either perineurally or intravenously (IV) may increase the duration of brachial plexus nerve blockade (152,159). A recent meta-analysis showed both agents to be effective in prolonging analgesia and reducing opioid consumption, with the greatest effect observed when the two were administered together via the IV route (160). Due to concerns regarding the safety of perineural adjuvant injection (161,162), the IV route is typically preferred; however, either is acceptable (156).

Introduction of LB

Overview

Regional anesthesia is often performed with long-acting LA agents, including bupivacaine and ropivacaine (120). One of the limitations of nerve blocks is their transient effect, which is influenced by the duration of action of the anesthetic agent chosen (163,164). In the interest of prolonging the benefits of nerve blockade, efforts have been made to develop longer-acting LA agents. LB, sold as Exparel^® (Pacira Pharmaceuticals, Parsippany, NJ, USA), is a slow-release formulation of bupivacaine designed to extend analgesia beyond that of standard bupivacaine (165). Since its initial approval in 2011 by the U.S. Food and Drug Administration for surgical site infiltration for postoperative pain, LB has also received approval for use in ISBs (166,167). It has an extended half-life reported to have effects lasting 48–72 hours, in contrast to standard bupivacaine, which has waning effects after 8 hours (163,164,168). In shoulder surgery, it has been used extensively with both local infiltration techniques and interscalene blocks (169). However, despite its purported advantages, high-quality evidence has demonstrated minimal clinical benefits of LB over traditional anesthetics, and it cannot be considered superior to existing alternatives (66,170-175).

Outcomes

Local infiltration of LB is effective in relieving postoperative pain for patients undergoing shoulder surgery (170). In the meta-analysis of RCTs by Wang et al., LB infiltration at the surgical site yielded similar pain scores and opioid consumption compared to ISB following total SA (170). However, LB infiltration may not afford the same level of analgesia in the immediate postoperative period, as several studies have reported elevated postoperative pain scores and opioid consumption on the day of surgery (176,177). Lower cost in comparison to interscalene block has been cited as a rationale for choosing infiltration over ISB (178,179). Performing local LB infiltration in combination with a standard ISB does not appear to offer any additional benefit, as Namdari et al. reported no difference in pain scores at all time points up to 72 hours following SA (171).

ISB performed with LB agents has demonstrated mixed results when compared to ISB performed with non-LB agents. Several RCTs have reported that ISB with LB performs the same in both pain intensity and opioid consumption when compared to non-LB blocks (173-175). In contrast, several studies have reported improvements in pain with LB (180,181); however, this did not translate to reduced opioid consumption. One RCT showed a small reduction in opioid consumption in LB blocks, however this was determined not to be clinically meaningful (172). LB ISB was shown by Wall et al. to be as effective as an indwelling interscalene catheter and resulted in fewer complications (174). While LB blocks are as effective as non-LB blocks, their higher cost (64) has led some authors to question whether their use is justified (172).

MMA and importance of pain management

Regional analgesia techniques are just one component of the comprehensive approach in addressing postsurgical pain, which is MMA (182). As is true for most surgeries, it is standard practice to employ MMA for postoperative pain management after shoulder surgery (183,184), as it has been shown to reduce opioid consumption (185). MMA after shoulder surgery is recommended by the American Academy of Orthopaedic Surgeons, per the clinical practice guidelines for rotator cuff injury and osteoarthritis (186,187).

The nonopioid medications utilized in MMA for shoulder surgery include acetaminophen, non-steroidal anti-inflammatory drugs, and anticonvulsants such as gabapentin and pregabalin (183). Although the exact regimen may vary based on patient-specific needs, the implementation of procedure-specific MMA protocols for shoulder surgery has shown to reduce opioid prescribing (182).

Limitations

There are limitations to this narrative review. The search was limited to only one database and prioritized recent and relevant articles according to the authors’ discretion. This process leaves the potential for the exclusion of valuable studies. Additionally, the quality of referenced studies was not rigorously appraised, leading to some ambiguity in the reliability of conclusions. While the review included the most commonly used nerve block techniques, it does not encompass all methods of regional anesthesia for shoulder surgery.

Another limitation is the evolving nature of the discussed techniques, such as the use of LB. Current evidence is inconclusive regarding its cost-effectiveness and indications, making it difficult to draw meaningful conclusions about its practicality from this review.

Future research should focus on continued improvements in efficacy of regional analgesia, particularly in devising strategies to further reduce postoperative opioid consumption. Furthermore, studies aimed at reducing complications such as phrenic nerve paralysis would be beneficial. Further research on the best uses and cost-effectiveness of LB is essential before widespread adoption.

Conclusions

This narrative review details several key regional anesthetic techniques available for shoulder surgery, emphasizing their uses, advantages, disadvantages, and the high-quality evidence available on their outcomes. Key takeaways include the recognition of ISB as the gold standard for shoulder surgery, as it offers superior analgesia and the ability to replace GA in some cases. Both SCB and SSNB are mainstays as well and have the potential to reduce undesirable complications such as phrenic nerve paralysis and Horner syndrome; however, they may provide less complete analgesia. CCI is useful in extending block duration and is suitable for most types of blocks. However, it has fallen out of favor due to its association with severe complications. Adjuvants, typically dexamethasone or dexmedetomidine, may also extend block duration and are preferably administered IV to avoid safety concerns with perineural injection.

The introduction of LB represents a significant innovation, but its high cost and questionable advantages make its use difficult to justify. Some evidence indicates it may be useful when used in local infiltration in select patients who are not candidates for upper extremity nerve blockade. As we strive to optimize pain management, further research is warranted to determine the true value of LB in this arena.

The frequent use of regional anesthesia for shoulder procedures highlights the active role of orthopedics in addressing the opioid epidemic with efforts to reduce postsurgical pain and opioid consumption. As previously mentioned, opioid prescribing following shoulder surgery is decreasing, though it is unclear how much this is due to the adoption of regional anesthesia techniques. Nevertheless, regional anesthesia remains a cornerstone of postoperative pain management for shoulder surgery. Future research in this area should explore strategies for further reducing opioid consumption, limiting adverse effects, and elucidating the benefits of liposomal anesthetic agents.

In conclusion, this narrative review stresses the critical role of regional anesthesia in shoulder surgery with a focus on its impact on reductions in pain and opioid consumption. Shoulder surgeons should be informed about regional anesthesia techniques available to their patients and stay attuned to new developments to ensure evidence-based and patient-centered care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-64/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-64/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-64/coif). A.K.H. is a paid consultant for Arthrex, Inc. and has previously received research support from Zimmer Biomet. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997;85:808-16. [Crossref] [PubMed]
2. Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 2002;10:117-29. [Crossref] [PubMed]
3. Guy GP Jr, Zhang K. Opioid Prescribing by Specialty and Volume in the U.S. Am J Prev Med 2018;55:e153-5. [Crossref] [PubMed]
4. Sampognaro G, Harrell R. Multimodal Postoperative Pain Control After Orthopaedic Surgery. Treasure Island (FL): StatPearls Publishing; 2025.
5. Sabatino MJ, Kunkel ST, Ramkumar DB, et al. Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures. J Bone Joint Surg Am 2018;100:180-8. [Crossref] [PubMed]
6. Peterman N, Shivdasani K, Pagani N, et al. National Trends in Orthopaedic Pain Management from 2016 to 2020. J Am Acad Orthop Surg 2024;32:e503-13. [Crossref] [PubMed]
7. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North Am 2005;23:21-36. [Crossref] [PubMed]
8. Coley KC, Williams BA, DaPos SV, et al. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J Clin Anesth 2002;14:349-53. [Crossref] [PubMed]
9. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg 1997;84:319-24. [Crossref] [PubMed]
10. Morrison SR, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain 2003;103:303-11. [Crossref] [PubMed]
11. Cousins MJ, Power I, Smith G. 1996 Labat lecture: pain--a persistent problem. Reg Anesth Pain Med 2000;25:6-21. [Crossref] [PubMed]
12. Dahan A, Aarts L, Smith TW. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology 2010;112:226-38. [Crossref] [PubMed]
13. Barletta JF, Asgeirsson T, Senagore AJ. Influence of intravenous opioid dose on postoperative ileus. Ann Pharmacother 2011;45:916-23. [Crossref] [PubMed]
14. Goettsch WG, Sukel MP, van der Peet DL, et al. In-hospital use of opioids increases rate of coded postoperative paralytic ileus. Pharmacoepidemiol Drug Saf 2007;16:668-74. [Crossref] [PubMed]
15. Bell TJ, Panchal SJ, Miaskowski C, et al. The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Med 2009;10:35-42. [Crossref] [PubMed]
16. Dorn S, Lembo A, Cremonini F. Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach. Am J Gastroenterol Suppl 2014;2:31-7. [Crossref] [PubMed]
17. Benson JL, Campbell HE, Phillips CN. Opioid-induced pruritus. Consult Pharm 2015;30:221-7. [Crossref] [PubMed]
18. Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother 2007;41:400-6. [Crossref] [PubMed]
19. Humphreys K, Shover CL, Andrews CM, et al. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022;399:555-604. [Crossref] [PubMed]
20. Lee B, Zhao W, Yang KC, et al. Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018. JAMA Netw Open 2021;4:e2036687. [Crossref] [PubMed]
21. Schoenfeld AJ, Jiang W, Chaudhary MA, et al. Sustained Prescription Opioid Use Among Previously Opioid-Naive Patients Insured Through TRICARE (2006-2014). JAMA Surg 2017;152:1175-6. [Crossref] [PubMed]
22. Maheshwari AV, Boutary M, Yun AG, et al. Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop Relat Res 2006;231-8. [Crossref] [PubMed]
23. Skinner HB. Multimodal acute pain management. Am J Orthop (Belle Mead NJ) 2004;33:5-9. [PubMed]
24. Kunkle BF, Kothandaraman V, Goodloe JB, et al. Orthopaedic Application of Cryotherapy: A Comprehensive Review of the History, Basic Science, Methods, and Clinical Effectiveness. JBJS Rev 2021;9:e20.00016.
25. Yamaguchi K, Sethi N, Bauer GS. Postoperative pain control following arthroscopic release of adhesive capsulitis: a short-term retrospective review study of the use of an intra-articular pain catheter. Arthroscopy 2002;18:359-65. [Crossref] [PubMed]
26. Breit R, Van der Wall H. Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. J Arthroplasty 2004;19:45-8. [Crossref] [PubMed]
27. Chunduri A, Aggarwal AK. Multimodal Pain Management in Orthopedic Surgery. J Clin Med 2022;11:6386. [Crossref] [PubMed]
28. Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology 2005;102:1001-7. [Crossref] [PubMed]
29. Hansen BP, Beck CL, Beck EP, et al. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med 2007;35:1628-34. [Crossref] [PubMed]
30. Gabriel RA, Nagrebetsky A, Kaye AD, et al. The Patterns of Utilization of Interscalene Nerve Blocks for Total Shoulder Arthroplasty. Anesth Analg 2016;123:758-61. [Crossref] [PubMed]
31. Gallay SH, Lobo JJ, Baker J, et al. Development of a regional model of care for ambulatory total shoulder arthroplasty: a pilot study. Clin Orthop Relat Res 2008;466:563-72. [Crossref] [PubMed]
32. Cunningham DJ, Paniagua A, LaRose M, et al. Hip Fracture Surgery: Regional Anesthesia and Opioid Demand. J Am Acad Orthop Surg 2022;30:e979-88. [Crossref] [PubMed]
33. Cunningham DJ, LaRose M, Zhang G, et al. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg 2022;134:1072-81. [Crossref] [PubMed]
34. Marhofer P, Harkanyi A, Hopkins PM. Regional anesthesia for shoulder surgery. Minerva Anestesiol 2022;88:629-34. [Crossref] [PubMed]
35. Vadivelu N, Kai AM, Maslin B, et al. Role of regional anesthesia in foot and ankle surgery. Foot Ankle Spec 2015;8:212-9. [Crossref] [PubMed]
36. O'Donnell BD, Iohom G. Regional anesthesia techniques for ambulatory orthopedic surgery. Curr Opin Anaesthesiol 2008;21:723-8. [Crossref] [PubMed]
37. Tuominen M, Pitkänen M, Rosenberg PH. Postoperative pain relief and bupivacaine plasma levels during continuous interscalene brachial plexus block. Acta Anaesthesiol Scand 1987;31:276-8. [Crossref] [PubMed]
38. Elsharkawy HA, Abd-Elsayed AA, Cummings KC 3rd, et al. Analgesic efficacy and technique of ultrasound-guided suprascapular nerve catheters after shoulder arthroscopy. Ochsner J 2014;14:259-63. [PubMed]
39. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25. [Crossref] [PubMed]
40. Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery. Cochrane Database Syst Rev 2014;2014:CD007080. [Crossref] [PubMed]
41. Guo CW, Ma JX, Ma XL, et al. Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. Int J Surg 2017;45:85-91. [Crossref] [PubMed]
42. Auyong DB, Hanson NA, Joseph RS, et al. Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology 2018;129:47-57. [Crossref] [PubMed]
43. Auyong DB, Yuan SC, Choi DS, et al. A Double-Blind Randomized Comparison of Continuous Interscalene, Supraclavicular, and Suprascapular Blocks for Total Shoulder Arthroplasty. Reg Anesth Pain Med 2017;42:302-9. [Crossref] [PubMed]
44. Gaus P, Kutz P, Bachtler JA, et al. Cave: interscalene catheters. Anaesthesist. 2017;66:961-8. [Crossref] [PubMed]
45. Marhofer D, Marhofer P, Triffterer L, et al. Dislocation rates of perineural catheters: a volunteer study. Br J Anaesth 2013;111:800-6. [Crossref] [PubMed]
46. Nöske E, Stolzer M, Racher M, et al. Central neurological complication of an interscalene plexus catheter. Anaesthesist. 2021;70:937-41. [PubMed]
47. Voermans NC, Crul BJ, de Bondt B, et al. Permanent loss of cervical spinal cord function associated with the posterior approach. Anesth Analg 2006;102:330-1. [Crossref] [PubMed]
48. Yanovski B, Gaitini L, Volodarski D, et al. Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia. Anaesthesia 2012;67:1166-9. [Crossref] [PubMed]
49. Lee JYJ, Wu JC, Chatterji R, et al. Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure. JSES Int 2023;8:282-6. [Crossref] [PubMed]
50. Moore DD, Maerz T, Anderson K. Shoulder surgeons' perceptions of interscalene nerve blocks and a review of complications rates in the literature. Phys Sportsmed 2013;41:77-84. [Crossref] [PubMed]
51. Hughes MS, Matava MJ, Wright RW, et al. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am 2013;95:1318-24. [Crossref] [PubMed]
52. Sripada R, Bowens C Jr. Regional anesthesia procedures for shoulder and upper arm surgery upper extremity update--2005 to present. Int Anesthesiol Clin 2012;50:26-46. [Crossref] [PubMed]
53. Stundner O, Danninger T, Memtsoudis SG. Regional anesthesia in patients with significant comorbid disease. Minerva Anestesiol 2013;79:1281-90. [PubMed]
54. Fort MW, Leinweber KA, Werth PM, et al. United States opioid prescribing trends after shoulder surgery and their correlation with opioid misuse. JSES Int 2024;9:517-23. [Crossref] [PubMed]
55. Shah KN, Ruddell JH, Reid DBC, et al. Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy. Arthroscopy 2020;36:824-31. [Crossref] [PubMed]
56. Cunningham DJ, Levin J, O'Donnell J, et al. Time and State Opioid Legislation Have Reduced Opioid Filling in Elective Shoulder Surgery. J Surg Orthop Adv 2024;33:152-7. [PubMed]
57. Hutteman E. Senate approves bill to combat opioid addiction crisis. New York Times. 2016. Available online: https://www.nytimes.com/2016/07/14/us/politics/senate-opioid-addiction-bill.html
58. Christie C, Baker C, Cooper R, et al. The President’s Commission on Combating Drug Addiction and the Opioid Crisis. 2017. Available online: https://trumpwhitehouse.archives.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-15-2017.pdf
59. Marmor MT, Hu S, Mahadevan V, et al. Prolonged Opioid Use Is Associated With Poor Pain Alleviation After Orthopaedic Surgery. J Am Acad Orthop Surg 2024;32:e661-70. [Crossref] [PubMed]
60. Hewson DW, Oldman M, Bedforth NM. Regional anaesthesia for shoulder surgery. BJA Educ 2019;19:98-104. [Crossref] [PubMed]
61. Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970;49:455-66. [Crossref] [PubMed]
62. Kulenkampff D. Brachial plexus anaesthesia: its indications, technique, and dangers. Ann Surg 1928;87:883-91. [Crossref] [PubMed]
63. Dangoisse MJ, Wilson DJ, Glynn CJ. MRI and clinical study of an easy and safe technique of suprascapular nerve blockade. Acta Anaesthesiol Belg 1994;45:49-54. [PubMed]
64. Pacira Pharmaceuticals Inc. EXPAREL (bupivacaine liposome injectable suspension). 2025. Available online: https://www.exparelpro.com/
65. Memiş D, Turan A, Karamanlioğlu B, et al. Adding dexmedetomidine to lidocaine for intravenous regional anesthesia. Anesth Analg 2004;98:835-40. table of contents. [PubMed]
66. Li Y, Shen Z, Wang H, et al. Efficacy of liposomal bupivacaine for pain control in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg 2022;31:1957-68. [Crossref] [PubMed]
67. Rodrigues D, Amadeo RJJ, Wolfe S, et al. Analgesic duration of interscalene block after outpatient arthroscopic shoulder surgery with intravenous dexamethasone, intravenous dexmedetomidine, or their combination: a randomized-controlled trial. Can J Anaesth 2021;68:835-45. [Crossref] [PubMed]
68. ANSBRO FP. A method of continuous brachial plexus block. Am J Surg 1946;71:716-22. [Crossref] [PubMed]
69. Kapral S, Greher M, Huber G, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med 2008;33:253-8. [Crossref] [PubMed]
70. Boezaart AP. Continuous interscalene block for ambulatory shoulder surgery. Best Pract Res Clin Anaesthesiol 2002;16:295-310. [Crossref] [PubMed]
71. Sites BD, Brull R. Ultrasound guidance in peripheral regional anesthesia: philosophy, evidence-based medicine, and techniques. Curr Opin Anaesthesiol 2006;19:630-9. [Crossref] [PubMed]
72. Soeding PE, Sha S, Royse CE, et al. A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery. Anaesth Intensive Care 2005;33:719-25. [Crossref] [PubMed]
73. Khanna S, Gupta R, Gupta V, et al. A prospective, randomised, single-blinded controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory upper limb surgeries. Med J Armed Forces India 2023;79:399-408. [Crossref] [PubMed]
74. Meier G, Bauereis C, Heinrich C. Interscalene brachial plexus catheter for anesthesia and postoperative pain therapy. Experience with a modified technique. Anaesthesist 1997;46:715-9. [Crossref] [PubMed]
75. Borgeat A, Ekatodramis G. Anaesthesia for shoulder surgery. Best Pract Res Clin Anaesthesiol 2002;16:211-25. [Crossref] [PubMed]
76. Meier G, Bauereis C, Maurer H. The modified technique of continuous suprascapular nerve block. A safe technique in the treatment of shoulder pain. Anaesthesist 2002;51:747-53. [Crossref] [PubMed]
77. Litz RJ, Feigl GC, Radny D, et al. Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis? Medicina (Kaunas) 2024;60:233. [Crossref] [PubMed]
78. Zisquit J, Nedeff N. Interscalene block. Treasure Island (FL): StatPearls Publishing; 2024.
79. Chan VW. Applying ultrasound imaging to interscalene brachial plexus block. Reg Anesth Pain Med 2003;28:340-3. [PubMed]
80. Pippa P. Brachial plexus block using a new subclavian perivascular technique: the proximal cranial needle approach. Eur J Anaesthesiol 2000;17:120-5. [PubMed]
81. Harrop-Griffiths W, Denny NM. The cat in the kitchen: problems with the Pippa technique. Anaesthesia 2006;61:1028-30. [Crossref] [PubMed]
82. Abdallah FW, Halpern SH, Aoyama K, et al. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg 2015;120:1114-29. [Crossref] [PubMed]
83. Gonano C, Kettner SC, Ernstbrunner M, et al. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth 2009;103:428-33. [Crossref] [PubMed]
84. Warrender WJ, Syed UAM, Hammoud S, et al. Pain Management After Outpatient Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials. Am J Sports Med 2017;45:1676-86. [Crossref] [PubMed]
85. Allahabadi S, Cheung EC, Hodax JD, et al. Outpatient Shoulder Arthroplasty-A Systematic Review. J Shoulder Elb Arthroplast 2021;5:24715492211028025. [Crossref] [PubMed]
86. Bean BA, Connor PM, Schiffern SC, et al. Outpatient Shoulder Arthroplasty at an Ambulatory Surgery Center Using a Multimodal Pain Management Approach. J Am Acad Orthop Surg Glob Res Rev 2018;2:e064. [Crossref] [PubMed]
87. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med 2009;34:134-70. [Crossref] [PubMed]
88. Morgan GE, Mikhail MS, Murray MJ. Peripheral nerve blocks. Peripheral nerve blocks. In: Clinical Anesthesiology. 4th ed. New York, NY: McGraw-Hill Medical; 2006.
89. Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72:498-503. [Crossref] [PubMed]
90. Lee JH, Cho SH, Kim SH, et al. Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. Can J Anaesth 2011;58:1001-6. [Crossref] [PubMed]
91. Kim YJ, Kim H, Kim S, et al. A comparison of the continuous supraclavicular brachial plexus block using the proximal longitudinal oblique approach and the interscalene brachial plexus block for arthroscopic shoulder surgery: A randomised, controlled, double-blind trial. Eur J Anaesthesiol 2024;41:402-10. [Crossref] [PubMed]
92. Bergmann L, Martini S, Kesselmeier M, et al. Phrenic nerve block caused by interscalene brachial plexus block: breathing effects of different sites of injection. BMC Anesthesiol 2016;16:45. [Crossref] [PubMed]
93. Park HS, Kim HJ, Ro YJ, et al. Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation: A lesson why we should use low concentrated local anesthetics for continuous blocks. Medicine (Baltimore) 2017;96:e6598. [Crossref] [PubMed]
94. Fontana C, Di Donato A, Di Giacomo G, et al. Postoperative analgesia for arthroscopic shoulder surgery: a prospective randomized controlled study of intraarticular, subacromial injection, interscalenic brachial plexus block and intraarticular plus subacromial injection efficacy. Eur J Anaesthesiol 2009;26:689-93. [Crossref] [PubMed]
95. DeMarco JR, Componovo R, Barfield WR, et al. Efficacy of augmenting a subacromial continuous-infusion pump with a preoperative interscalene block in outpatient arthroscopic shoulder surgery: a prospective, randomized, blinded, and placebo-controlled study. Arthroscopy 2011;27:603-10. [Crossref] [PubMed]
96. Albaum JM, Abdallah FW, Ahmed MM, et al. What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials. Clin Orthop Relat Res 2022;480:2374-89. [Crossref] [PubMed]
97. Kim HJ, Kim H, Koh KH, et al. Initiation Timing of Continuous Interscalene Brachial Plexus Blocks in Patients Undergoing Shoulder Arthroplasty: A Retrospective Before-and-After Study. J Pers Med 2022;12:739. [Crossref] [PubMed]
98. El-Boghdadly K, Chin KJ, Chan VWS. Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations. Anesthesiology 2017;127:173-91. [Crossref] [PubMed]
99. Lehtipalo S, Koskinen LO, Johansson G, et al. Continuous interscalene brachial plexus block for postoperative analgesia following shoulder surgery. Acta Anaesthesiol Scand 1999;43:258-64. [Crossref] [PubMed]
100. Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth 2013;111:445-52. [Crossref] [PubMed]
101. Schubert AK, Dinges HC, Wulf H, et al. Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. Eur J Anaesthesiol 2019;36:427-35. [Crossref] [PubMed]
102. Liu Z, Li YB, Wang JH, et al. Efficacy and adverse effects of peripheral nerve blocks and local infiltration anesthesia after arthroscopic shoulder surgery: A Bayesian network meta-analysis. Front Med (Lausanne) 2022;9:1032253. [Crossref] [PubMed]
103. Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000;93:1541-4. [Crossref] [PubMed]
104. Howell SM, Unger MW, Colson JD, et al. Ultrasonographic evaluation of neck hematoma and block salvage after failed neurostimulation-guided interscalene block. J Clin Anesth 2010;22:560-1. [Crossref] [PubMed]
105. Berg AA, Flaherty JM, Habeck JM, et al. Evaluation of Diaphragmatic Function after Interscalene Block with Liposomal Bupivacaine: A Randomized Controlled Trial. Anesthesiology 2022;136:531-41. [Crossref] [PubMed]
106. Kaufman MR, Elkwood AI, Rose MI, et al. Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. Anesthesiology 2013;119:484-7. [Crossref] [PubMed]
107. Hogan QH. Phrenic nerve function after interscalene block revisited: now, the long view. Anesthesiology 2013;119:250-2. [Crossref] [PubMed]
108. Kessler J, Schafhalter-Zoppoth I, Gray AT. An ultrasound study of the phrenic nerve in the posterior cervical triangle: implications for the interscalene brachial plexus block. Reg Anesth Pain Med 2008;33:545-50. [Crossref] [PubMed]
109. Riazi S, Carmichael N, Awad I, et al. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2008;101:549-56. [Crossref] [PubMed]
110. Kim DH, Lin Y, Beathe JC, et al. Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial. Anesthesiology 2019;131:521-33. [Crossref] [PubMed]
111. Stundner O, Meissnitzer M, Brummett CM, et al. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial. Br J Anaesth 2016;116:405-12. [Crossref] [PubMed]
112. Kang R, Jeong JS, Chin KJ, et al. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology 2019;131:1316-26. [Crossref] [PubMed]
113. Albrecht E, Bathory I, Fournier N, et al. Reduced hemidiaphragmatic paresis with extrafascial compared with conventional intrafascial tip placement for continuous interscalene brachial plexus block: a randomized, controlled, double-blind trial. Br J Anaesth 2017;118:586-92. [Crossref] [PubMed]
114. Ayyanagouda B, Hosalli V, Kaur P, et al. Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial. Indian J Anaesth 2019;63:375-81. [Crossref] [PubMed]
115. Xu L, Gessner D, Kou A, et al. Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors. Reg Anesth Pain Med 2023;48:540-6. [Crossref] [PubMed]
116. Song MJ, Im HJ. Bupivacaine Ipsilateral Interscalene Block-Induced Localized Hypoxic Brain Injuries via Vasoconstriction. J Neurosonol Neuroimag 2020;12:87-90. [Crossref]
117. Lanz E, Theiss D, Jankovic D. The extent of blockade following various techniques of brachial plexus block. Anesth Analg 1983;62:55-8. [Crossref] [PubMed]
118. Neal JM, Hebl JR, Gerancher JC, et al. Brachial plexus anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2002;27:402-28. [Crossref] [PubMed]
119. Winnie AP, Franco CD. Supraclavicular approaches to brachial plexus anesthesia. Tech Reg Anesth Pain Manag 1997;1:144-50. [Crossref]
120. Brown DL, Cahill DR, Bridenbaugh LD. Supraclavicular nerve block: anatomic analysis of a method to prevent pneumothorax. Anesth Analg 1993;76:530-4. [Crossref] [PubMed]
121. Hanumanthaiah D, Vaidiyanathan S, Garstka M, et al. Ultrasound guided supraclavicular block. Med Ultrason 2013;15:224-9. [Crossref] [PubMed]
122. Güzeldemir ME. Pneumothorax and supraclavicular block. Anesth Analg 1993;76:685. [Crossref] [PubMed]
123. Chan VWS, Perlas A, Rawson R, et al. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003;97:1514-7. [Crossref] [PubMed]
124. Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of the brachial plexus and surrounding compartments, and their possible significance for plexus blocks. Anesthesiology 2008;108:299-304. [Crossref] [PubMed]
125. De José María B, Banús E, Navarro Egea M, et al. Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children. Paediatr Anaesth 2008;18:838-44. [Crossref] [PubMed]
126. Voskeridjian AC, Calem D, Rivlin M, et al. An Evaluation of Complications Following Ultrasound-Guided Regional Block Anesthesia in Outpatient Hand Surgery. Hand (N Y) 2021;16:183-7. [Crossref] [PubMed]
127. Ilham C, Bombaci E, Yurtlu S, et al. Efficiency of levobupivacaine and bupivacaine for supraclavicular block: a randomized double-blind comparative study. Braz J Anesthesiol 2014;64:177-82. [Crossref] [PubMed]
128. Griffin J, Nicholls B. Ultrasound in regional anaesthesia. Anaesthesia 2010;65:1-12. [Crossref] [PubMed]
129. Maybin J, Townsley P, Bedforth N, et al. Ultrasound guided supraclavicular nerve blockade: first technical description and the relevance for shoulder surgery under regional anaesthesia. Anaesthesia 2011;66:1053-5. [Crossref] [PubMed]
130. Harrison TK, Kim TE, Howard SK, et al. Comparative Effectiveness of Infraclavicular and Supraclavicular Perineural Catheters for Ultrasound‐Guided Through‐the‐Catheter Bolus Anesthesia. J Ultrasound Med. 2015;34:333-40. [Crossref] [PubMed]
131. Vazin M, Jensen K, Kristensen DL, et al. Low-Volume Brachial Plexus Block Providing Surgical Anesthesia for Distal Arm Surgery Comparing Supraclavicular, Infraclavicular, and Axillary Approach: A Randomized Observer Blind Trial. Biomed Res Int 2016;2016:7094121. [Crossref] [PubMed]
132. Bharti N, Bhardawaj N, Wig J. Comparison of ultrasound-guided supraclavicular, infraclavicular and below-C6 interscalene brachial plexus block for upper limb surgery: a randomised, observer-blinded study. Anaesth Intensive Care 2015;43:468-72. [Crossref] [PubMed]
133. Solanki SL, Jain A, Makkar JK, et al. Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block. J Anesth 2011;25:305-7. [Crossref] [PubMed]
134. Hussain N, Costache I, Kumar N, et al. Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis. Anesth Analg 2020;130:1304-19. [Crossref] [PubMed]
135. Perlas A, Lobo G, Lo N, et al. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med 2009;34:171-6. [Crossref] [PubMed]
136. Franco CD, Vieira ZE. 1,001 subclavian perivascular brachial plexus blocks: success with a nerve stimulator. Reg Anesth Pain Med 2000;25:41-6. [Crossref] [PubMed]
137. Ferré F, Mastantuono JM, Martin C, Ferrier A, et al. Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study. Braz J Anesthesiol 2019;69:580-6. [Crossref] [PubMed]
138. Vorster W, Lange CP, Briët RJ, et al. The sensory branch distribution of the suprascapular nerve: an anatomic study. J Shoulder Elbow Surg 2008;17:500-2. [Crossref] [PubMed]
139. Zhao J, Xu N, Li J, et al. Efficacy and safety of suprascapular nerve block combined with axillary nerve block for arthroscopic shoulder surgery: A systematic review and meta-analysis of randomized controlled trials. Int J Surg 2021;94:106111. [Crossref] [PubMed]
140. Ozyuvaci E, Akyol O, Sitilci T, et al. Preoperatıve ultrasound-guıded suprascapular nerve block for postthoracotomy shoulder paın. Curr Ther Res Clin Exp 2013;74:44-8. [Crossref] [PubMed]
141. Chang KV, Hung CY, Wu WT, et al. Comparison of the Effectiveness of Suprascapular Nerve Block With Physical Therapy, Placebo, and Intra-Articular Injection in Management of Chronic Shoulder Pain: A Meta-Analysis of Randomized Controlled Trials. Arch Phys Med Rehabil 2016;97:1366-80. [Crossref] [PubMed]
142. Harmon D, Hearty C. Ultrasound-guided suprascapular nerve block technique. Pain Physician 2007;10:743-6. [PubMed]
143. Siegenthaler A, Moriggl B, Mlekusch S, et al. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Reg Anesth Pain Med 2012;37:325-8. [Crossref] [PubMed]
144. Sun C, Zhang X, Ji X, et al. Suprascapular nerve block and axillary nerve block versus interscalene nerve block for arthroscopic shoulder surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021;100:e27661. [Crossref] [PubMed]
145. Tran DQ, Elgueta MF, Aliste J, et al. Diaphragm-Sparing Nerve Blocks for Shoulder Surgery. Reg Anesth Pain Med 2017;42:32-8. [Crossref] [PubMed]
146. Shams D, Sachse K, Statzer N, et al. Regional Anesthesia Complications and Contraindications. Clin Sports Med 2022;41:329-43. [Crossref] [PubMed]
147. Kay J, Memon M, Hu T, et al. Suprascapular Nerve Blockade for Postoperative Pain Control After Arthroscopic Shoulder Surgery: A Systematic Review and Meta-analysis. Orthop J Sports Med 2018;6:2325967118815859. [Crossref] [PubMed]
148. Hussain N, Goldar G, Ragina N, et al. Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2017;127:998-1013. [Crossref] [PubMed]
149. White L, Reardon D, Davis K, et al. Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials. J Anesth 2022;36:17-25. [Crossref] [PubMed]
150. Campbell AS, Johnson CD, O'Connor S. Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery. Anesthesiol Res Pract 2023;2023:9962595. [Crossref] [PubMed]
151. Mörwald EE, Zubizarreta N, Cozowicz C, et al. Incidence of Local Anesthetic Systemic Toxicity in Orthopedic Patients Receiving Peripheral Nerve Blocks. Reg Anesth Pain Med 2017;42:442-5. [Crossref] [PubMed]
152. Vorobeichik L, Brull R, Bowry R, et al. Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth 2018;120:679-92. [Crossref] [PubMed]
153. Thompson M, Simonds R, Clinger B, et al. Continuous versus single shot brachial plexus block and their relationship to discharge barriers and length of stay. J Shoulder Elbow Surg 2017;26:656-61. [Crossref] [PubMed]
154. Kim H, Kim HJ, Lee ES, et al. Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: Arthroscopy-Guided Continuous Suprascapular Nerve Block Versus Ultrasound-Guided Continuous Interscalene Block. Arthroscopy 2021;37:3229-37. [Crossref] [PubMed]
155. Trompeter A, Camilleri G, Narang K, et al. Analgesia requirements after interscalene block for shoulder arthroscopy: the 5 days following surgery. Arch Orthop Trauma Surg 2010;130:417-21. [Crossref] [PubMed]
156. Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia 2021;76:100-9. [Crossref] [PubMed]
157. Schnabel A, Reichl SU, Zahn PK, et al. Efficacy and safety of buprenorphine in peripheral nerve blocks: A meta-analysis of randomised controlled trials. Eur J Anaesthesiol 2017;34:576-86. [Crossref] [PubMed]
158. Pöpping DM, Elia N, Marret E, et al. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 2009;111:406-15. [Crossref] [PubMed]
159. Albrecht E, Renard Y, Desai N. Intravenous versus perineural dexamethasone to prolong analgesia after interscalene brachial plexus block: a systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 2024;133:135-45. [Crossref] [PubMed]
160. Wei XM, Liu Z, Lv LC, et al. Comparison of dexmedetomidine and dexamethasone as adjuvants to the ultrasound-guided interscalene nerve block in arthroscopic shoulder surgery: a systematic review and Bayesian network meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023;10:1159216. [Crossref] [PubMed]
161. Williams BA, Hough KA, Tsui BY, et al. Neurotoxicity of adjuvants used in perineural anesthesia and analgesia in comparison with ropivacaine. Reg Anesth Pain Med 2011;36:225-30. [Crossref] [PubMed]
162. Zhu N, Xiang B, Shi J, et al. The effect of perineural dexamethasone on nerve injury and recovery of nerve function after surgery: A randomized controlled trial. Heliyon 2024;10:e35612. [Crossref] [PubMed]
163. Hu D, Onel E, Singla N, et al. Pharmacokinetic profile of liposome bupivacaine injection following a single administration at the surgical site. Clin Drug Investig 2013;33:109-15. [Crossref] [PubMed]
164. Prabhakar A, Ward CT, Watson M, et al. Liposomal bupivacaine and novel local anesthetic formulations. Best Pract Res Clin Anaesthesiol 2019;33:425-32. [Crossref] [PubMed]
165. Richard BM, Ott LR, Haan D, et al. The safety and tolerability evaluation of DepoFoam bupivacaine (bupivacaine extended-release liposome injection) administered by incision wound infiltration in rabbits and dogs. Expert Opin Investig Drugs 2011;20:1327-41. [Crossref] [PubMed]
166. U.S. Food and Drug Administration. New Drug Application (NDA) 022496 Approval Document for Exparel. 2011. Available online: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/022496Orig1s000Approv.pdf
167. Rabin T. FDA approves new use of Exparel for nerve block pain relief following shoulder surgeries. April 6, 2018. Available online: https://www.fda.gov/news-events/fda-brief/fda-brief-fda-approves-new-use-exparel-nerve-block-pain-relief-following-shoulder-surgeries
168. Burm AG, de Boer AG, van Kleef JW, et al. Pharmacokinetics of lidocaine and bupivacaine and stable isotope labelled analogues: a study in healthy volunteers. Biopharm Drug Dispos 1988;9:85-95. [Crossref] [PubMed]
169. Kolade O, Patel K, Ihejirika R, et al. Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg 2019;28:1824-34. [Crossref] [PubMed]
170. Wang K, Zhang HX. Liposomal bupivacaine versus interscalene nerve block for pain control after total shoulder arthroplasty: A systematic review and meta-analysis. Int J Surg 2017;46:61-70. [Crossref] [PubMed]
171. Namdari S, Nicholson T, Abboud J, et al. Interscalene Block with and without Intraoperative Local Infiltration with Liposomal Bupivacaine in Shoulder Arthroplasty: A Randomized Controlled Trial. J Bone Joint Surg Am 2018;100:1373-8. [Crossref] [PubMed]
172. Elmer DA, Coleman JR, Renwick CM, et al. Comparing bupivacaine alone to liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty: a randomized, non-inferiority trial. Reg Anesth Pain Med 2023;48:1-6. [Crossref] [PubMed]
173. Flaherty JM, Berg AA, Harrison A, et al. Comparing liposomal bupivacaine plus bupivacaine to bupivacaine alone in interscalene blocks for rotator cuff repair surgery: a randomized clinical trial. Reg Anesth Pain Med 2022;47:309-12. [Crossref] [PubMed]
174. Wall KC, Elphingstone J, Paul KD, et al. Nerve block with liposomal bupivacaine yields fewer complications and similar pain relief when compared to an interscalene catheter for arthroscopic shoulder surgery: a randomized controlled trial. J Shoulder Elbow Surg 2022;31:2438-48. [Crossref] [PubMed]
175. Hattrup SJ, Chung AS, Rosenfeld DM, et al. Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial. J Shoulder Elbow Surg 2021;30:587-98. [Crossref] [PubMed]
176. Okoroha KR, Lynch JR, Keller RA, et al. Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: a prospective randomized trial. J Shoulder Elbow Surg 2016;25:1742-8. [Crossref] [PubMed]
177. Abildgaard JT, Lonergan KT, Tolan SJ, et al. Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial. J Shoulder Elbow Surg 2017;26:1175-81. [Crossref] [PubMed]
178. Thompson KM, Smith RA, Brolin TJ, et al. Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty. J Shoulder Elbow Surg 2018;27:2257-61. [Crossref] [PubMed]
179. Weller WJ, Azzam MG, Smith RA, et al. Liposomal Bupivacaine Mixture Has Similar Pain Relief and Significantly Fewer Complications at Less Cost Compared to Indwelling Interscalene Catheter in Total Shoulder Arthroplasty. J Arthroplasty 2017;32:3557-62. [Crossref] [PubMed]
180. Vandepitte C, Kuroda M, Witvrouw R, et al. Addition of Liposome Bupivacaine to Bupivacaine HCl Versus Bupivacaine HCl Alone for Interscalene Brachial Plexus Block in Patients Having Major Shoulder Surgery. Reg Anesth Pain Med 2017;42:334-41. [Crossref] [PubMed]
181. Finkel KJ, Walker A, Maffeo-Mitchell CL, et al. Liposomal bupivacaine provides superior pain control compared to bupivacaine with adjuvants in interscalene block for total shoulder replacement: a prospective double-blinded, randomized controlled trial. J Shoulder Elbow Surg 2024;33:1512-20. [Crossref] [PubMed]
182. Hajewski CJ, Westermann RW, Holte A, et al. Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures. Orthop J Sports Med 2019;7:2325967119870753. [Crossref] [PubMed]
183. Zangrilli J, Szukics P, Austin L, et al. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev 2021;9:e20.00191.
184. Rosero EB, Joshi GP. Preemptive, preventive, multimodal analgesia: what do they really mean? Plast Reconstr Surg 2014;134:85S-93S. [Crossref] [PubMed]
185. McLaughlin DC, Cheah JW, Aleshi P, et al. Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study. J Shoulder Elbow Surg 2018;27:686-91. [Crossref] [PubMed]
186. Patzkowski JC, Patzkowski MS. AAOS/METRC Clinical Practice Guideline Summary: Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery. J Am Acad Orthop Surg 2022;30:e1152-60. [Crossref] [PubMed]
187. Weber S, Chahal J. Management of Rotator Cuff Injuries. J Am Acad Orthop Surg 2020;28:e193-201. [Crossref] [PubMed]