Education  |   July 2017
Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations
Author Notes
  • From the Department of Anaesthesia, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, United Kingdom (K.E.-B.); and Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, Ontario, Canada (K.J.C., V.W.S.C.).
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina.
    Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina.×
  • Submitted for publication December 5, 2016. Accepted for publication March 1, 2017.
    Submitted for publication December 5, 2016. Accepted for publication March 1, 2017.×
  • Address correspondence to Dr. El-Boghdadly: Department of Anaesthesia, Guy’s and St. Thomas’ National Health Service Foundation Trust, Great Maze Pond, SE1 9RT, London, United Kingdom. elboghdadly@gmail.com. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Review Article / Central and Peripheral Nervous Systems / Pharmacology / Regional Anesthesia
Education   |   July 2017
Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations
Anesthesiology 7 2017, Vol.127, 173-191. doi:10.1097/ALN.0000000000001668
Anesthesiology 7 2017, Vol.127, 173-191. doi:10.1097/ALN.0000000000001668
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.