Erector Spinae Plane Block Spares Common Complications After Shoulder Surgery

Using an erector spinae plane block (ESPB) for postoperative analgesia from total shoulder arthroplasty offers advantages over the more commonly used interscalene brachial plexus nerve block, including avoiding phrenic nerve complications and upper-extremity mobility issues, researchers from Stanford University in Stanford, CA, reported in findings from a new study.

Lisa Sun, Shruthi Basireddy, Lynn Ngai Gerber, Jason Lamano, John Costouros, Emilie Cheung, Jan Boublik, Jean-Louis Horn, and Ban Tsui received a Resident/Fellow Travel Award for their abstract of the study, “Erector Spinae Plane Block for Total Shoulder Arthroplasty Avoids Phrenic Nerve Complication: A Randomized Trial,” which was accepted for the 45th Annual Regional Anesthesia and Acute Pain Medicine Meeting. The meeting was scheduled for April 23-25 but was cancelled due to COVID-19. 

Although commonly used for analgesia after total shoulder arthroplasty, interscalene brachial plexus nerve blocks have a high incidence of phrenic nerve palsy, which can lead to shortness of breath in 9%–12% of patients. They can also cause upper-extremity motor blocks that may create postoperative mobility issues. Sun et al. conducted a double-blind, randomized study in 30 patients comparing the high thoracic (HT)-ESPB catheter (n = 12) as a phrenic-sparing alternative to the interscalene block (n = 14) to prevent the incidence of hemidiaphragmatic paralysis while providing sufficient pain control.

The HT-ESPB catheter group had a significantly lower incidence of partial or full hemidiaphragmatic paralysis compared to 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 were not significantly different for postoperative days 1 and 2. The groups had no statistically significant difference in cumulative 48-hour opioid consumption, but cumulative opioid consumption was significantly higher on postoperative day 0 in the HT-ESPB group compared to 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 versus 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,” Sun et al. concluded.

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