Newly Published
Review Article  |   May 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.).
  • 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.×
  • Acknowledgments: The authors thank Maria Fernanda Rojas Gomez, M.D., Staff Anesthesiologist, Sociedad Especializada de Anestesiologia SEA S.A. Fundacion Oftalmologica de Santander, Clinica Carlos Ardila Lulle, Floridablanca, Santander, Colombia, and Danilo Jankovic, M.D., Chief of Staff, Pain Management Center, St. Elisabeth University Hospital, Cologne, Germany, for their invaluable assistance in the production of the illustrations.
    Acknowledgments: The authors thank Maria Fernanda Rojas Gomez, M.D., Staff Anesthesiologist, Sociedad Especializada de Anestesiologia SEA S.A. Fundacion Oftalmologica de Santander, Clinica Carlos Ardila Lulle, Floridablanca, Santander, Colombia, and Danilo Jankovic, M.D., Chief of Staff, Pain Management Center, St. Elisabeth University Hospital, Cologne, Germany, for their invaluable assistance in the production of the illustrations.×
  • Research Support: Support was provided solely from institutional and/or departmental sources.
    Research Support: Support was provided solely from institutional and/or departmental sources.×
  • Competing Interests: Dr. Chan receives honoraria from SonoSite, Inc. (Bothell, Washington) and is on the medical advisory board of Smiths Medical (Ashford, United Kingdom) and Aspen Pharmacare (Durban, South Africa). The other authors declare no competing interests.
    Competing Interests: Dr. Chan receives honoraria from SonoSite, Inc. (Bothell, Washington) and is on the medical advisory board of Smiths Medical (Ashford, United Kingdom) and Aspen Pharmacare (Durban, South Africa). The other authors declare no competing interests.×
  • Correspondence: 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
Review Article / Central and Peripheral Nervous Systems / Regional Anesthesia
Review Article   |   May 2017
Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations
Anesthesiology Newly Published on May 18, 2017. doi:10.1097/ALN.0000000000001668
Anesthesiology Newly Published on May 18, 2017. 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.