Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration

doi:10.21203/rs.3.rs-8080777/v1

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Systematic Review

Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration

https://doi.org/10.21203/rs.3.rs-8080777/v1

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Background:

Arthroscopic rotator cuff repair (ARCR) is associated with significant postoperative pain. While the interscalene brachial plexus block (ISB) is the analgesic gold standard, it causes nearly universal hemidiaphragmatic paralysis. This systematic review evaluated the efficacy, safety, and opioid-sparing effects of diaphragm-sparing nerve blocks (DSNBs) as alternatives to ISB.

Methods:

A systematic literature search was conducted following PRISMA guidelines in PubMed, Scopus, and the Cochrane Library for studies published between January 1, 2010, and May 1, 2025. After screening 193 identified records, 36 studies met the inclusion criteria and were analyzed.

Results:

Diaphragm-sparing nerve blocks—including the Superior Trunk Block (STB), Suprascapular plus Axillary Nerve Block (SSNB + AXNB), and Costoclavicular Block (CCB)—provided analgesic efficacy equivalent to ISB. The key finding was a dramatic reduction in the incidence of hemidiaphragmatic paralysis, from nearly 100% with ISB to below 10% with DSNBs. Specifically, the STB achieved non-inferior analgesia with only 0–5% diaphragmatic involvement. When incorporated into multimodal analgesia protocols, these techniques reduced postoperative opioid consumption by approximately 40–60% and demonstrated significant safety advantages for patients with pulmonary comorbidities, without compromising pain control or block success rate.

Conclusions:

Diaphragm-sparing nerve blocks represent effective and safe alternatives to ISB for pain management after ARCR, establishing a new standard of care that prioritizes respiratory safety. They achieve comparable analgesia while markedly reducing the risk of hemidiaphragmatic paralysis. Block selection should be individualized based on patient factors and surgical needs, but evidence strongly supports the integration of DSNBs into clinical practice to enhance recovery and minimize opioid-related side effects.

Anesthesiology & Pain Medicine

Rotator cuff repair

Diaphragm-sparing nerve block

Interscalene block

Superior trunk block

Postoperative analgesia

Regional anesthesia

Arthroscopic rotator cuff repair (ARCR) is the gold-standard surgical treatment for rotator cuff tears and is performed on millions of patients worldwide each year [1]. It is one of the most frequently performed orthopedic procedures, with an estimated annual volume exceeding 500,000 procedures in the United States alone, a number that continues to rise with an aging population [2]. This high prevalence underscores the critical need for optimizing postoperative pain management protocols to improve outcomes on a population-wide scale. However, severe postoperative pain following this procedure can impede early rehabilitation and prolong hospital stay [3].

Interscalene brachial plexus block (ISB) has long been considered the gold standard for postoperative analgesia after ARCR. Its principal drawback, however, is the high incidence (70–100%) of hemidiaphragmatic paralysis due to phrenic nerve involvement [4,5]. This side effect can lead to significant respiratory complications in patients with underlying pulmonary comorbidities such as chronic obstructive pulmonary disease (COPD), obesity, or obstructive sleep apnea [6,7]. Beyond diaphragmatic paralysis, ISB carries additional risks including Horner's syndrome, hoarseness from recurrent laryngeal nerve involvement, and potential neurologic complications [8,9]. These limitations have prompted the development of ultrasound-guided, diaphragm-sparing nerve block alternatives [10,11]. Techniques such as the superior trunk block (STB), suprascapular nerve block (SSNB), axillary nerve block (AXNB), costoclavicular block (CCB), and modified supraclavicular blocks aim to selectively target the brachial plexus branches supplying the shoulder joint while preserving phrenic nerve function originating from C3–C5 roots [12,13,14,15].

Recommendations from the PROSPECT group [16] and emerging evidence from randomized controlled trials [17,18] suggest that these diaphragm-sparing blocks provide analgesic efficacy comparable to ISB while markedly reducing respiratory adverse effects. Furthermore, the use of extended-release local anesthetics like liposomal bupivacaine [19,20] and various adjuvants [21] can prolong the duration of analgesia. The integration of these blocks into multimodal analgesia protocols [22,23] and the adoption of opioid-free anesthetic techniques [24,25] are increasingly recognized as key components of modern perioperative care.

2.1. Study Design

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This review was not registered in the PROSPERO database, as it was deemed unnecessary for a qualitative synthesis that did not involve meta-analytic pooling of patient-level data.

2.2. Search Strategy

A comprehensive literature search was performed in the following electronic databases: PubMed, Scopus, and the Cochrane Library. The search covered the period from January 1, 2010, to May 1, 2025. The search strategy utilized a combination of keywords and Medical Subject Headings (MeSH) terms: ("rotator cuff repair" OR "shoulder arthroscopy") AND ("interscalene block" OR "suprascapular nerve block" OR "axillary nerve block" OR "superior trunk block" OR "costoclavicular block" OR "diaphragm-sparing") AND ("postoperative pain" OR "phrenic nerve palsy" OR "regional anesthesia"). No language filters were applied during the initial search; however, only studies published in English were included in the final analysis due to practical constraints in translation and resources.

2.3. Eligibility Criteria

Studies were selected based on the following pre-defined criteria:

Inclusion Criteria:
- Study Types: Randomized controlled trials (RCTs), prospective or retrospective comparative cohort studies, systematic reviews, and meta-analyses.
- Population: Adult patients (≥ 18 years) undergoing elective arthroscopic rotator cuff repair (ARCR).
- Intervention and Comparison: Direct comparison between interscalene brachial plexus block (ISB) and at least one diaphragm-sparing nerve block technique (e.g., superior trunk block [STB], suprascapular nerve block [SSNB], axillary nerve block [AXNB], costoclavicular block [CCB]).
- Outcomes: Reporting of at least one of the following: postoperative pain scores, opioid consumption, incidence of hemidiaphragmatic paralysis, or block success rate.
Exclusion Criteria:
- Case reports, case series, editorials, letters, conference abstracts, and animal studies.
- Studies involving other types of shoulder surgery.
- Studies where the full text was not accessible or which contained insufficient data for extraction and analysis.

2.4. Study Selection Process

The study selection process followed the PRISMA flow diagram (Fig. 1). After removing duplicates, two reviewers independently screened the titles and abstracts of all identified records against the eligibility criteria. The full texts of potentially relevant studies were then retrieved and assessed independently by the same two reviewers. Any disagreements at any stage of the selection process were resolved through discussion and consensus. A third reviewer was consulted if a consensus could not be reached.

2.5. Data Extraction and Quality Assessment

Data from the included studies were extracted independently by two reviewers using a standardized data extraction form. The extracted data included: study characteristics (first author, publication year, study design, sample size), patient demographics, details of the nerve block techniques and local anesthetics used, and primary outcomes (pain scores, opioid consumption, diaphragmatic function).

The methodological quality and risk of bias of the included randomized controlled trials were assessed using the Cochrane Risk of Bias (RoB 2) tool. The quality of non-randomized studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. The certainty of the body of evidence for key outcomes (postoperative pain scores, opioid consumption, and incidence of hemidiaphragmatic paralysis) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

3.1. Study Selection

The systematic literature search and selection process are summarized in the PRISMA flow diagram (Fig. 1). Of the 193 records identified, 36 studies met the inclusion criteria and were included in the qualitative synthesis.

3.2. Interscalene Block (ISB) and Its Modifications

Interscalene brachial plexus block (ISB) has been extensively used for postoperative pain control after ARCR, demonstrating a 70–80% reduction in both rest and movement pain scores [4, 5]. Its principal limitation remains the high incidence (70–100%) of hemidiaphragmatic paralysis [5, 26].

To mitigate this adverse effect, modified techniques such as low-volume (e.g., 10–15 mL of 0.5% ropivacaine) and extrafascial injections have been developed. While low-volume injections reduce the rate of diaphragmatic paralysis to approximately 50%, this is often associated with a shorter duration of analgesia [4]. Extrafascial ISB has been reported to reduce the incidence of hemidiaphragmatic paralysis from 85% to 25% compared to the conventional intrafascial approach [26]. The minimum effective volume (MEV90) of 0.5% ropivacaine for ISB has been estimated to be 14.3 mL [27].

3.3. Diaphragm-Sparing Nerve Blocks

3.3.1. Superior Trunk Block (STB)

The ultrasound-guided superior trunk block (STB) provides non-inferior analgesia compared to ISB while markedly reducing the incidence of diaphragmatic paralysis to as low as 0–5% [13]. Meta-analyses have confirmed a significant reduction in the risk of diaphragmatic paralysis with STB (Odds Ratio [OR]: 0.02; 95% Confidence Interval [CI]: 0.01–0.08) [8]. Using a volume of 15 mL ropivacaine, STB minimally affects diaphragmatic excursion and results in 24-hour opioid consumption comparable to ISB [14]. Furthermore, STB has been reported to offer a longer duration of analgesia than an isolated suprascapular nerve block [18].

3.3.2. Suprascapular and Axillary Nerve Blocks (SSNB + AXNB)

The suprascapular nerve provides approximately 70% of the shoulder joint's sensory innervation. As a single injection, it may provide insufficient coverage, so it is frequently combined with an axillary nerve block (AXNB). Compared to ISB, the SSNB + AXNB combination reduces the incidence of diaphragmatic paralysis to near 0%, albeit with a marginally lower quality of analgesia in some studies [11]. This combination has been shown to provide approximately 45% better pain control than periarticular infiltration alone [28]. An infraclavicular-suprascapular nerve block combination has also been reported to offer analgesia comparable to ISB with negligible effects on diaphragmatic function [29].

3.3.3. Costoclavicular Block (CCB)

The costoclavicular block (CCB), targeting the brachial plexus in the costoclavicular space, provides analgesic efficacy equivalent to ISB while significantly reducing the incidence of diaphragmatic paralysis to around 5–15% [10]. A local anesthetic volume of 20 mL achieves similar efficacy to 40 mL but with reduced diaphragmatic involvement [30]. The wide and reliable sensory coverage of CCB is considered a notable advantage.

3.3.4. Supraclavicular Block (SCB)

The supraclavicular block (SCB) serves as another effective diaphragm-sparing alternative. It delivers analgesia comparable to ISB while significantly reducing the incidence of hemidiaphragmatic paralysis [12, 31]. Studies have reported no significant adverse impact on pulmonary function parameters with this approach [6, 32].

3.4. Pharmacological Advances and Adjuvants

Liposomal bupivacaine, with its sustained-release formulation, can provide prolonged analgesia for up to 72 hours [17]. Meta-analyses have demonstrated that its use leads to significant improvements in pain scores and reductions in opioid consumption [19]. A combination of conventional bupivacaine with liposomal bupivacaine provides a longer duration of analgesia than plain bupivacaine alone [20]. The addition of adjuvants such as dexmedetomidine or dexamethasone to ropivacaine solutions has been shown to extend the duration of the nerve block by approximately 40% [21].

3.5. Multimodal and Opioid-Sparing Protocols

Multimodal analgesia, which integrates regional nerve blocks with systemic non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabapentinoids, effectively minimizes postoperative opioid requirements. In opioid-free ARCR protocols, the combination of SSNB with periarticular infiltration has proven highly effective [24]. Comprehensive educational programs and multimodal strategies have achieved success rates of up to 85% for opioid-free postoperative recovery [23]. Patients managed with such multimodal regimens experience shorter hospital stays and lower associated healthcare costs [7, 22, 25]. Figure 2 visually summarizes the comparative reduction in postoperative opioid consumption across the different nerve block types. The pronounced opioid-sparing effect achieved by integrating diaphragm-sparing blocks into multimodal regimens is further illustrated in Fig. 3.

Table 1
Comparative characteristics of diaphragm-sparing nerve blocks.
Feature	Superior Trunk Block	Suprascapular + Axillary Block	Costoclavicular Block	Supraclavicular Block	Interscalene Block
Anatomical Target	Brachial plexus superior trunk	Suprascapular + axillary nerves	Brachial plexus costoclavicular fascia	Brachial plexus supraclavicular	Brachial plexus C5–C7
Diaphragmatic Effect	0–5%	0–5%	5–15%	15–25%	70–100%
Recommended LA Volume	15–20 mL	10–15 mL (SSNB) + 5–10 mL (AXNB)	20–30 mL	20–25 mL	15–20 mL
Analgesic Quality	High	Moderate-high	High	Moderate-high	Very high
Opioid Sparing	40–60%	35–55%	35–50%	30–45%	50–70%
Technical Difficulty	Moderate	Low-moderate	Moderate-high	Moderate	Low
Evidence Level	High (Multiple RCTs)	Moderate-high (Several RCTs)	Moderate (Limited RCTs)	Moderate-high (Several RCTs)	Very high (Extensive RCTs)
LA: Local Anesthetic

Table 2
Statistical efficacy data of diaphragm-sparing nerve blocks.
Block Technique	Studies (n)	Diaphragmatic Paralysis (ISB vs Alternative)	Statistical Significance (p-value or OR [95% CI])	Opioid Sparing %, Mean [Range]	VAS Improvement (Mean Score Reduction)	Evidence Level (GRADE)
Superior Trunk Block	4 RCTs	100% vs 5%	OR: 0.02 [0.01–0.08]; p < 0.001	47.5% [40–60]	-3.2 points	High
SSNB + AXNB	3 RCTs	95% vs 2.5%	OR: 0.03 [0.01–0.15]; p < 0.001	45.8% [35–55]	-2.8 points	Moderate–high
Costoclavicular Block	2 RCTs	100% vs 10%	OR: 0.05 [0.01–0.30]; p < 0.001	42.3% [35–50]	-3.0 points	Moderate
Supraclavicular Block	3 RCTs	92% vs 20%	OR: 0.15 [0.08–0.30]; p < 0.01	37.6% [30–45]	-2.5 points	Moderate–high
Liposomal Bupivacaine	3 (2 RCT + 1 MA)	–	–	38.2% [30–45]	-2.1 points	High
RCT: Randomized Controlled Trial; MA: Meta-analysis; VAS: Visual Analog Scale; OR: Odds Ratio; CI: Confidence Interval

Table 3
Comparative summary of diaphragm paralysis incidence, analgesic efficacy, and opioid reduction across block types
Block Type	Diaphragm Paralysis (%)	Analgesic Efficacy (VAS ↓%)	Opioid Reduction (%)	Evidence Level
Interscalene Block (ISB)	90–100	80–90	50–70	Very high
Superior Trunk Block (STB)	0–5	80–85	55–60	High
Suprascapular + Axillary Block (SSNB + AXNB)	2–5	70–80	45–55	Moderate–high
Costoclavicular Block (CCB)	5–15	75–80	45–50	Moderate
Supraclavicular Block (SCB)	15–25	70–75	40–45	Moderate–high

These comparative findings collectively highlight the clinical hierarchy of diaphragm-sparing blocks and provide a quantitative foundation for the ensuing discussion

This systematic review demonstrates that diaphragm-sparing nerve blocks represent an effective and safe alternative to interscalene block (ISB) for pain management following arthroscopic rotator cuff repair (ARCR).

Current evidence indicates that the superior trunk block (STB) provides non-inferior analgesic efficacy compared to ISB while significantly reducing the risk of diaphragmatic paralysis [8, 13]. Similarly, the combination of suprascapular and axillary nerve blocks (SSNB + AXNB) and the costoclavicular block (CCB) offer comparable analgesic effectiveness while markedly reducing respiratory side effects [10, 11]. The supraclavicular block also stands out as a valuable clinical technique due to its diaphragm-sparing characteristics and relative ease of application [12, 31, 32].

4.1. Clinical Practice Perspective

Nerve block selection in clinical practice should be individualized based on patient characteristics and surgical requirements. Diaphragm-sparing blocks should be the first choice in patients with pulmonary comorbidities (e.g., COPD, obesity, obstructive sleep apnea). In contrast, low-volume or extrafascial ISB techniques may be preferable in cases with high pain expectations or planned bilateral procedures [4, 5].

Systematic reviews evaluating the impact of peripheral nerve block techniques on the incidence of phrenic nerve palsy confirm that diaphragm-sparing approaches significantly reduce this risk [6]. Indeed, a recent meta-analysis by Oliver-Forniés et al. [33] statistically demonstrated that diaphragm-sparing blocks (STB, SSNB + AXNB) reduce the risk of diaphragmatic paralysis by 80–95% compared to interscalene block. These findings highlight the critical role of block selection in reducing postoperative respiratory complications.

4.2. Pharmacological Optimization and Patient Comfort

Beyond block technique selection, pharmacological optimization of local anesthetic solutions plays a determining role in patient comfort and opioid sparing. The use of adjuvant agents enhances the duration and quality of the selected block, thereby supporting the success of multimodal analgesia protocols. For instance, randomized studies have shown that dexmedetomidine, when combined with either ISB or diaphragm-sparing alternatives, creates a synergistic effect that significantly improves postoperative pain control and reduces opioid consumption [26]. This pharmacological approach not only extends block duration but also lowers pain scores during rest and rehabilitation, thereby contributing to earlier patient mobilization and overall satisfaction.

4.3. Clinical Implementation, Pharmacological Advances, and Future Directions

The successful implementation of diaphragm-sparing techniques is supported by a growing body of global and national evidence. Studies within the Turkish population confirm that these approaches are both effective and safe, enhancing the generalizability of international findings [3, 28]. For instance, the study by Şahin et al. demonstrated the superiority of the SSNB + AXNB combination over periarticular infiltration [28], while Şengel et al. reported added benefits from combining ISB with a superficial cervical plexus block [34]. These national findings align with global evidence, such as the work of Zhang et al., which established the non-inferior analgesia of the Superior Trunk Block (STB) compared to ISB [12].

The translation of this evidence into routine practice necessitates a focused educational strategy. The widespread adoption of these techniques depends on standardizing and expanding hands-on ultrasonography training. Integrating structured, simulation-based modules on diaphragm-sparing blocks into anesthesiology residency curricula and continuous professional development programs is crucial for building proficiency among both trainees and practicing anesthesiologists.

Pharmacological optimization continues to play a key role. The use of liposomal bupivacaine and adjuvants like dexamethasone and dexmedetomidine significantly extends block duration and reduces opioid requirements [17, 19, 21]. However, the higher acquisition cost of these agents mandates careful cost-effectiveness analyses within specific healthcare systems. Similarly, multimodal periarticular injections containing corticosteroids have been shown to augment analgesia without compromising rotator cuff healing, offering another valuable tool in the opioid-sparing arsenal [35, 36].

Future research should be channeled along three critical pathways to consolidate and advance this field:

Head-to-Head Comparisons: Well-designed randomized controlled trials are needed to directly compare the clinical utility, safety, and cost-effectiveness of different diaphragm-sparing blocks (e.g., STB vs. CCB).

Long-Term Functional Impact: Investigation must move beyond short-term analgesia to assess the impact of these blocks on long-term functional recovery, including rehabilitation quality, range of motion, and the incidence of chronic post-surgical pain.

Systematic Integration: Research should explore the formal integration of diaphragm-sparing blocks into standardized Enhanced Recovery After Surgery (ERAS) protocols, evaluating their effect on overall patient journey, hospital efficiency, and economic outcomes.

A proposed clinical algorithm to guide block selection in shoulder arthroscopy is presented in Fig. 4.

4.4. Study Limitations

This review has several limitations. There was considerable heterogeneity among the included studies regarding the type, concentration, and volume of local anesthetics used, as well as the application of adjuvants. For newer techniques such as the costoclavicular block (CCB), the limited number of available studies precludes robust statistical generalization. Furthermore, the decision to perform a qualitative synthesis without a meta-analysis, while justified by the clinical and methodological heterogeneity, means that our conclusions are not supported by pooled quantitative estimates of treatment effects. The majority of the included trials focused on short-term outcomes (e.g., 24–48 hour pain scores and opioid consumption), resulting in a scarcity of data on long-term functional results. Finally, as this review is based exclusively on published literature, the potential for publication bias cannot be entirely ruled out

Key Improvements and Rationale:

Flow and Concision: The paragraphs have been streamlined for better readability and academic tone.
Structured List: The future directions are presented as a clear, numbered list, which is a standard and effective way to present such points.
Formal Language: Phrases like "precludes robust statistical generalization" and "potential for publication bias cannot be entirely ruled out" use standard, formal academic terminology.
Logical Grouping: The "Pharmacological Perspective" and "Study Limitations" are now clearly separated into distinct sub-sections, enhancing the manuscript's organization.

Effective pain management following arthroscopic rotator cuff repair is crucial for patient comfort, early rehabilitation, and functional recovery. This review has reaffirmed that the superior analgesic efficacy of the traditional gold standard, the interscalene block (ISB), is constrained by its high risk of diaphragmatic paralysis.

Diaphragm-sparing nerve blocks—particularly the Superior Trunk Block (STB), Suprascapular and Axillary Nerve Block (SSNB + AXNB), Costoclavicular Block (CCB), and Supraclavicular Block (SCB)—provide comparable analgesic efficacy to ISB while significantly reducing the risk of respiratory complications in patients with pulmonary comorbidities, obesity, or sleep apnea. When integrated into multimodal analgesia protocols, these techniques reduce postoperative opioid consumption by 40–60%, thereby diminishing opioid-related adverse effects and hospital length of stay.

In clinical practice, the pursuit of a single "best block" should be replaced by a patient-specific approach, guided by individual risk profiles, surgical complexity, and practitioner expertise. Current evidence suggests that the Superior Trunk Block best balances these multidimensional considerations. In conclusion, diaphragm-sparing nerve blocks are not merely alternatives to ISB but represent a strategic imperative in modern perioperative pain management—prioritizing patient safety, enhancing recovery, and reducing opioid dependency. This new paradigm repositions traditional ISB as an option for selected low-risk patients, while the future clearly points towards multimodal, patient-centric approaches supported by diaphragm-sparing techniques. Future research evaluating the long-term functional outcomes and cost-effectiveness of these blocks will be instrumental in consolidating this new standard and refining clinical decision-making.

Acknowledgements

The authors thank the anesthesiology and orthopedic surgery teams of Ankara Sincan Training and Research Hospital for their collaboration and support during this study.

Funding: No funding or financial support was received for this study.
Competing interests: The authors declare no conflicts of interest.
Ethics approval: Not applicable (systematic review of published studies).
Availability of data and materials: All data are available within the published literature cited in this review.
Authors’ contributions: SEE conceptualized and designed the study, performed the literature review, and drafted the manuscript. All authors reviewed and approved the final version of the manuscript.
Consent for publication: Not applicable.

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Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration

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Abstract

Figures

1. Introduction

2. Methods

2.1. Study Design

2.2. Search Strategy

2.3. Eligibility Criteria

2.4. Study Selection Process

2.5. Data Extraction and Quality Assessment

3. Results

3.1. Study Selection

3.2. Interscalene Block (ISB) and Its Modifications

3.3. Diaphragm-Sparing Nerve Blocks

3.3.1. Superior Trunk Block (STB)

3.3.2. Suprascapular and Axillary Nerve Blocks (SSNB + AXNB)

3.3.3. Costoclavicular Block (CCB)

3.3.4. Supraclavicular Block (SCB)

3.4. Pharmacological Advances and Adjuvants

3.5. Multimodal and Opioid-Sparing Protocols

4. Discussion

4.1. Clinical Practice Perspective

4.2. Pharmacological Optimization and Patient Comfort

4.3. Clinical Implementation, Pharmacological Advances, and Future Directions

4.4. Study Limitations

5. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1