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    Phrenic Nerve Complications Less Common with Erector Spinae Plane Block in TSA Patients

    Using an erector spinae plane block (ESPB) for postoperative analgesia following total shoulder arthroplasty (TSA) offers advantages over the more commonly used interscalene brachial plexus nerve block, including avoiding phrenic nerve complications and upper-extremity mobility issues, according to research from Stanford University.

    The study received a Resident/Fellow Travel Award for the 45th Annual Regional Anesthesia and Acute Pain Medicine Meeting, which was canceled due to the COVID-19 pandemic. The abstract has been posted on the website of the American Society of Regional Anesthesia and Pain Medicine.

    RELATED: A video presentation of the study is available here.

    Although commonly used for analgesia after TSA, interscalene brachial plexus nerve blocks have a high incidence of phrenic nerve palsy, which can lead to shortness of breath in 9% to 12% of patients. They can also cause upper-extremity motor blocks that may create postoperative mobility issues.

    Erector spinae plane blocks have been proposed as a phrenic-sparing alternative to interscalene blocks in these patients. In this small double-blind, randomized study, the researchers compared outcomes of a high thoracic (HT)-ESPB catheter (n=12) with those of an interscalene block (n=14). The goal was to provide pain control while preventing the incidence of hemidiaphragmatic paralysis.

    The researchers found that:

    • Patients in the HT-ESPB catheter group had a significantly lower incidence of partial or full hemidiaphragmatic paralysis compared with those in the interscalene catheter group (0% versus 100%, respectively).
    • Average median pain scores in the postoperative anesthesia care unit were significantly lower in the interscalene group than in the HT-ESPB group, but they were not significantly different for POD1 and POD2.
    • The groups had no statistically significant difference in cumulative 48-hour opioid consumption, although cumulative opioid consumption was significantly higher on POD0 in the HT-ESPB group compared with the interscalene group.
    • Patients in the interscalene group had a significantly higher incidence of partial or full motor function loss compared to the HT-ESPB group (8 vs 0, respectively), but no statistically significant differences were seen in basic mobility and activity scores.
    • The interscalene group had a significantly higher number of patients with any adverse events, with 29% of patients reporting dyspnea, hoarseness, Horner’s syndrome, or decreased motor or sensory function. No differences occurred in time to discharge or patient satisfaction (100% in both groups).

    “This study demonstrates that the HT-ESPB is a viable alternative to the interscalene brachial plexus block, particularly for patients with severe pulmonary disease in which any risk of phrenic nerve palsy would be concerning,” the researchers concluded.

    Source

    Sun L, Basireddy S, Gerber LN, Lamano J, Costouros J, Cheung E, Boublik E, Horn J-L, Tsui B. Erector Spinae Plane Block for Total Shoulder Arthroplasty Avoids Phrenic Nerve Complication: A Randomized Trial, abstract 790.