Regional Block Strategies for Shoulder Surgery
- Valkyrie Blog Team
- Apr 4
- 5 min read
We continue our dive into blocks for shoulder surgery by continuing to explore alternatives for best patient outcomes. Although the interscalene block has long been a standard in providing regional anesthesia for these procedures, its broad coverage can lead to issues such as phrenic nerve involvement and unwanted motor blockade. Shoulder surgery demands precise and effective pain management while minimizing potential complications. Therefore, this article will review four regional block strategies that offer focused analgesia with improved safety.
Suprascapular Nerve Block
Supraclavicular Nerve Block Combined with a Suprascapular Nerve Block
Suprascapular Nerve Block Combined with an Axillary Nerve Block
Suprascapular Nerve
Block combined with an Infraclavicular Nerve block
Each approach offers unique benefits, and the choice depends on patient-specific considerations, clinical judgment, and the targeted surgical area.
Option 1: Suprascapular Nerve Block
Overview
The suprascapular nerve block as a stand-alone technique targets the nerve that carries a significant portion of the shoulder’s sensory information—approximately 70%. This block is widely used for managing chronic shoulder pain conditions (e.g., rotator cuff pathology or adhesive capsulitis) as well as providing postoperative analgesia when a broader block is unnecessary or when minimizing complications is paramount.
Technique Highlights
Ultrasound Guidance:
Position a high-frequency linear probe in the supraspinatus fossa to visualize the suprascapular notch and the course of the suprascapular nerve.
Needle Approach:
Using an in-plane technique, advance the needle within the target area and inject approximately 5–8 ml of local anesthetic adjacent to the nerve.
Clinical Considerations:
This relatively simple block is effective with minimal anesthetic volume, thereby reducing the risk of motor blockade and phrenic nerve involvement. It is particularly attractive for patients with rotator cuff disorders or chronic shoulder pain syndromes.
Benefits
Simplicity and Safety: With straightforward ultrasound guidance and a low volume of local anesthetic, this block minimizes complications.
Effective Pain Relief: For selected patients, the stand-alone suprascapular nerve block provides effective analgesia comparable to broader regional techniques while minimizing side effects.
Option 2: Supraclavicular Block Plus Suprascapular Nerve Block
Overview
The supraclavicular block targets the brachial plexus in the supraclavicular fossa, providing a broad field block to the upper extremity. However, its coverage may not fully address the specific sensory pathways of the shoulder—particularly the posterior joint capsule. Adding a suprascapular nerve block directly supplements shoulder analgesia by anesthetizing the major nerve responsible for sensory transmission from the shoulder joint.
Technique Highlights
Supraclavicular Block:
Ultrasound Guidance: Using a high-frequency linear probe, identify the brachial plexus clusters lateral and superior to the subclavian artery in the supraclavicular fossa.
Needle Approach: Apply an in-plane technique to carefully deposit approximately 20–25 ml of local anesthetic, ensuring safe distances from critical structures such as the pleura.
Suprascapular Nerve Block:
Ultrasound Technique: Locate the suprascapular notch in the supraspinatus fossa, where the nerve courses beneath the transverse scapular ligament.
Injection: With an in-plane approach, administer 5–10 ml of local anesthetic adjacent to the nerve.
Benefits
Enhanced Analgesia: This combination offers broad upper extremity anesthesia with additional, targeted shoulder supplementation.
Improved Safety: Reduced anesthetic spread minimizes the risk of phrenic nerve involvement, which is particularly beneficial for patients with respiratory concerns.
Option 3: Suprascapular Block Plus Axillary Nerve Block
Overview
Often referred to as the “shoulder block,” this combined approach specifically targets the two main sensory nerves of the shoulder. While the suprascapular nerve contributes roughly 70% of the sensory input to the shoulder joint, the axillary nerve covers the lateral shoulder region—including the skin over the deltoid. Together, these blocks provide very focused analgesia that rivals that of an interscalene block but with fewer side effects.
Technique Highlights
Suprascapular Nerve Block:
Ultrasound Guidance: Identify the suprascapular nerve in the supraspinatus fossa beneath the transverse scapular ligament using a high-frequency probe.
Injection: Utilize an in-plane technique to inject 5–10 ml of local anesthetic near the nerve.
Axillary Nerve Block:
Ultrasound Technique: Position the probe over the quadrangular space, near the humeral head, to visualize the axillary nerve.
Needle Insertion: With an in-plane approach, inject 5–10 ml of local anesthetic around the nerve.
Benefits
Targeted Analgesia: This dual block delivers selective pain relief for the shoulder while preserving motor function in the remainder of the upper limb.
Reduced Complication Risk: With a lower overall anesthetic volume and a confined area of blockade, the risk of respiratory compromise and unwanted motor effects is further reduced.
Option 4: Suprascapular + Infraclavicular Nerve Block
Overview
The infraclavicular block targets the brachial plexus cords, providing extensive upper limb anesthesia. Combining it with a suprascapular nerve block ensures comprehensive shoulder analgesia while avoiding phrenic nerve involvement.
Technique Highlights
Infraclavicular Block:
Identify the axillary artery deep to the pectoralis muscles.
Inject 20–30 mL of anesthetic around the artery.
Suprascapular Block:
Locate the suprascapular notch and inject 5–10 mL of anesthetic.
Benefits
Comprehensive Upper Limb Anesthesia: Achieves broad regional coverage while securing shoulder pain relief.
Balanced Sensory and Motor Control: Provides surgical anesthesia without unnecessary paralysis.
Phrenic-Sparing Advantage: Avoids hemidiaphragmatic paresis, making it a strong alternative to interscalene blocks.
Aspect | Suprascapular Block | SSC + Supraclavicular Block | SSC + Axillary Block | SSC + Infraclavicular Block |
Coverage | Focused shoulder analgesia (~70%) | Broad upper limb + targeted shoulder | Highly selective shoulder analgesia | Extensive upper limb anesthesia + shoulder coverage |
Risk Profile | Minimal anesthetic volume; low risk | Reduced phrenic nerve involvement | Lower volume with minimal respiratory risk | No phrenic nerve involvement; broad coverage |
Technical Complexity | Simple ultrasound guidance | Requires deeper brachial plexus visualization | Precise nerve identification needed | Requires proficiency in infraclavicular approach |
Patient Suitability | Ideal for chronic shoulder pain | Suitable for broader anesthesia needs | Best for targeted shoulder analgesia | Ideal for extensive upper limb procedures |
Clinical Implications and Future Directions
These four methods represent significant advancements over traditional interscalene blocks. By tailoring regional anesthesia to the specific innervation patterns of the shoulder, clinicians can select the most appropriate technique based on respiratory status, pain severity, and surgical approach. The addition of the Suprascapular + Infraclavicular Nerve Block expands options for patients requiring extensive upper limb anesthesia while still avoiding phrenic nerve involvement.
Future research and ongoing clinical trials will continue to refine these strategies, improving protocols and quantifying efficacy and safety. Additionally, the emergence of ultrasound-guided techniques has enabled safer and more precise administration of these blocks, making phrenic-sparing anesthesia increasingly viable across diverse patient populations.
Clinicians are encouraged to pursue additional training in ultrasound-guided regional anesthesia and regularly review emerging literature to remain current on evolving best practices.
Conclusion
Individualized regional anesthesia is the cornerstone of optimized postoperative analgesia for shoulder surgery. Whether opting for the stand-alone suprascapular nerve block, the combined supraclavicular-suprascapular approach, the suprascapular-axillary block, or the suprascapular-infraclavicular combination, each method offers distinct advantages. The choice depends on patient-specific factors, clinical goals, and technical expertise.
By embracing these alternative strategies, physicians can enhance patient outcomes, improve postoperative pain control, and tailor anesthetic protocols to the ever-evolving demands of shoulder surgery.
Valkyrie offers simulators for teaching and learning these highly effective blocks
References
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