Regional Block Strategies for Shoulder Surgery

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.  

1. Suprascapular Nerve Block

2. Supraclavicular Nerve Block Combined with a Suprascapular Nerve Block

3. Suprascapular Nerve Block Combined with an Axillary Nerve Block

4. Suprascapular Nerve

5. 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. 

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Valkyrie offers simulators for teaching and learning these highly effective blocks

Suprascapular

Interscalene

Infraclavicular

References

1. Phrenic-Sparing Upper Extremity Nerve Blocks

2. Diaphragm-Sparing Nerve Blocks for Shoulder Surgery

3. Suprascapular Nerve Block - Physiopedia

4. Combined Suprascapular and Axillary Nerve Block

5. Ultrasound-Guided Infraclavicular Brachial Plexus Block

6. Combined Infraclavicular-Suprascapular Nerve Blocks