Continuous interscalene versus phrenic nerve-sparing high-thoracic erector spinae plane block for total shoulder arthroplasty: a randomized controlled trial

Lisa Y. Sun, Shruthi Basireddy, Lynn Ngai Gerber, Jason Lamano, John Costouros, Emilie Cheung, Jan Boublik, Jean Louis Horn, Ban C.H. Tsui

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


PURPOSE: The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty.

METHODS: Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption.

RESULTS: The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04).

CONCLUSIONS: This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed.


CLINICALTRIALS: gov (NCT03807505); registered 17 January 2019.

Original languageEnglish (US)
Pages (from-to)614-623
Number of pages10
JournalCanadian Journal of Anesthesia
Issue number5
StatePublished - May 2022

Bibliographical note

Funding Information:
Lisa Y. Sun contributed to study design/conception; data acquisition, analysis and interpretation; and manuscript preparation. Shurthi Basireddy contributed to data acquisition, data analysis, and manuscript preparation. Lynn Ngai Gerber contributed to study design, data interpretation, and manuscript preparation. Jason Lamano contributed to data acquisition and data analysis. Emilie Cheung , John Costouros , Jan Boublik , and Jean-Louis Horn contributed to study design/conception and manuscript review. Ban Chi-Ho Tsui contributed to study design/conception, data interpretation, and manuscript preparation. None. None. This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

Publisher Copyright:
© 2022, Canadian Anesthesiologists' Society.


  • Analgesics, Opioid
  • Arthroplasty, Replacement, Shoulder
  • Brachial Plexus Block/adverse effects
  • Humans
  • Pain, Postoperative/diagnosis
  • Paralysis/complications
  • Phrenic Nerve
  • Shoulder/surgery

PubMed: MeSH publication types

  • Journal Article
  • Randomized Controlled Trial


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