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Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials


This systematic review aimed to compare the analgesic effectiveness and complications rates for anterior suprascapular nerve blocks (ASSB) compared to interscalene brachial plexus blocks (ISB) for arthroscopic and outpatient shoulder surgery. Only randomized controlled trials (RCTs) comparing the ASSB versus ISB in the context of arthroscopic shoulder surgery were eligible for inclusion. The primary outcomes included pain scores (Numeric Rating Scale of 0 to 10) up to 24 h postoperatively and analgesic consumption. Secondary outcomes included block complications. Meta-analysis was performed using random-effects modeling and result certainty was determined using the GRADEpro tool. Six RCTs (709 patients) were included for analysis. ISB displayed a statistically significant reduction in pain scores by 0.40 (95%CI = 0.36 to 0.45; p < 0.00001) but not morphine equivalent consumption (mean difference = 0.74 mg; 95%CI = − 0.18 to 1.66 mg; I2 = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24 h were not significantly different. There was no difference in respiratory events postblock. ASSB demonstrated a significantly lower incidence of Horner’s syndrome (relative risk (RR) = 0.17; 95%CI = 0.08 to 0.39; p < 0.00001; high certainty), voice hoarseness (RR = 0.24; 95%CI = 0.10 to 0.57; p < 0.00001; high certainty) and impaired respiratory function (p < 0.00001). The ASSB could be considered an appropriate analgesic option for arthroscopic shoulder surgery with potentially fewer complications than the ISB.

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  1. 1.

    Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014;15:4.

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    Leroux TS, Basques BA, Frank RM, Griffin JW, Nicholson GP, Cole BJ, Verma NN. Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(11):1780–6.

    PubMed  Article  Google Scholar 

  3. 3.

    Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anesth Analg. 1999;88(3):508–17.

    CAS  PubMed  Google Scholar 

  4. 4.

    Jakobsson JG. Recovery and discharge criteria after ambulatory anesthesia: can we improve them? Curr Opin Anaesthesiol. 2019;32(6):698–702.

    PubMed  Article  Google Scholar 

  5. 5.

    Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Jt Surg Am. 2013;95(14):1318–24.

    Article  Google Scholar 

  6. 6.

    Atchabahian A, Schwartz G, Hall CB, Lajam CM, Andreae MH. Regional analgesia for improvement of long-term functional outcome after elective large joint replacement. Cochrane Database Syst Rev. 2015;8: CD10278.

    Google Scholar 

  7. 7.

    Warrender WJ, Syed UA, Hammoud S, Emper W, Ciccotti MG, Abboud JA, Freedman KB. Pain management after outpatient shoulder arthroscopy: a systematic review of randomized controlled trials. Am J Sports Med. 2017;45(7):1676–86.

    PubMed  Article  Google Scholar 

  8. 8.

    Hamilton GM, Ramlogan R, Lui A, McCartney CJ, Abdallah F, McVicar J, McIsaac DI. Peripheral nerve blocks for ambulatory shoulder surgery: a population-based cohort study of outcomes and resource utilization. Anesthesiology. 2019;131(6):1254–63.

    PubMed  Article  Google Scholar 

  9. 9.

    Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010;65(6):608–24.

    CAS  PubMed  Article  Google Scholar 

  10. 10.

    Fujimura N, Namba H, Tsunoda K, Kawamata T, Taki K, Igarasi M, Namiki A. Effect of hemidiaphragmatic paresis caused by interscalene brachial plexus block on breathing pattern, chest wall mechanics, and arterial blood gases. Anesth Analg. 1995;81(5):962–6.

    CAS  PubMed  Google Scholar 

  11. 11.

    El-Boghdadly K, Chin KJ, Chan VWS. Phrenic nerve palsy and regional anesthesia for shoulder surgery: anatomical, physiologic, and clinical considerations. Anesthesiology. 2017;127(1):173–91.

    PubMed  Article  Google Scholar 

  12. 12.

    Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of anterior suprascapular, supraclavicular, and interscalene nerve block approaches for major outpatient arthroscopic shoulder surgery: a randomized, double-blind. Noninferiority Trial Anesthesiol. 2018;129(1):47–57.

    Article  Google Scholar 

  13. 13.

    Seltzer JL. Hoarseness and Horner’s syndrome after interscalene brachial plexus block. Anesth Analg. 1977;56(4):585–6.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Lenters TR, Davies J, Matsen FA 3rd. The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence. J Shoulder Elbow Surg. 2007;16(4):379–87.

    PubMed  Article  Google Scholar 

  15. 15.

    Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and interscalene nerve block for shoulder surgery: a systematic review and meta-analysis. Anesthesiology. 2017;127(6):998–1013.

    Article  Google Scholar 

  16. 16.

    Lim YC, Koo ZK, Ho VW, Chang SS, Manohara S, Tong QJ. Randomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery. Korean J Anesthesiol. 2020;73(5):408–16.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Ferré F, Pommier M, Laumonerie P, Ferrier A, Menut R, Bosch L, Balech V, Bonnevialle N, Minville V. Hemidiaphragmatic paralysis following ultrasound-guided anterior vs posterior suprascapular nerve block: a double-blind, randomised control trial. Anaesthesia. 2020;75(4):499–508.

    PubMed  Article  Google Scholar 

  18. 18.

    Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg. 2015;120(5):1114–29.

    PubMed  Article  Google Scholar 

  19. 19.

    Breivik EK, Bjornsson GA, Skovlund E. A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain. 2000;16(1):22–8.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Tashjian RZ, Hung M, Keener JD, Bowen RC, McAllister J, Chen W, Ebersole G, Granger EK, Chamberlain AM. Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale (VAS) measuring pain after shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(1):144–8.

    PubMed  Article  Google Scholar 

  21. 21.

    Kehlet H. Postoperative opioid sparing to hasten recovery: what are the issues? Anesthesiology. 2005;102(6):1083–5.

    PubMed  Article  Google Scholar 

  22. 22.

    Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JA. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:5928.

    Article  Google Scholar 

  23. 23.

    Puhan MA, Schunemann HJ, Murad MH, Li T, Brignardello-Petersen R, Singh JA, et al. A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis. BMJ. 2014;349:5630.

    Article  Google Scholar 

  24. 24.

    Abdallah FW, Wijeysundera DN, Laupacis A, Brull R, Mocon A, Hussain N, Thorpe KE, Chan VW. Subomohyoid anterior suprascapular block versus interscalene block for arthroscopic shoulder surgery: a multicenter randomized trial. Anesthesiology. 2020;132(4):839–53.

    CAS  PubMed  Article  Google Scholar 

  25. 25.

    Petroff D, Wiegel M, Pech V, Salz P, Mrongowius J, Reske AW. Differential lung ventilation assessed by electrical impedance tomography in ultrasound-guided anterior suprascapular nerve block vs interscalene brachial plexus block: a patient and assessor-blind, randomised controlled trial. Eur J Anaesthesiol. 2020;37(12):1105–14.

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Rhyner P, Kirkham K, Hirotsu C, Farron A, Albrecht E. A randomised controlled trial of shoulder block vs interscalene brachial plexus block for ventilatory function after shoulder arthroscopy. Anaesthesia. 2020;75(4):493–8.

    CAS  PubMed  Article  Google Scholar 

  27. 27.

    Wiegel M, Moriggl B, Schwarzkopf P, Petroff D, Reske AW. Anterior suprascapular nerve block versus interscalene brachial plexus block for shoulder surgery in the outpatient setting: a randomized controlled patient- and assessor-blinded trial. Reg Anesth Pain Med. 2017;42(3):310–8.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Toma O, Persoons B, Pogatzki-Zahn E, Van de Velde M, Joshi GP, Collaborators PWG. PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2019;74(10):1320–31.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  29. 29.

    Sabaté A, Porteiro L, Ibáñez B, Koo M, Pi A. Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital. Rev Esp Anestesiol Reanim. 2013;60(7):384–91.

    PubMed  Article  Google Scholar 

  30. 30.

    Misamore G, Webb B, McMurray S, Sallay P. A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia. J Shoulder Elbow Surg. 2011;20(2):308–14.

    PubMed  Article  Google Scholar 

  31. 31.

    Mostafa RM, Mejadi A. Quadriplegia after interscalene block for shoulder surgery in sitting position. Br J Anaesth. 2013;111(5):846–7.

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Münch J, Volk T. Nerve injuries associated with nerve blocks: clinic and incidence. Anasthesiol Intensivmed Notfallmed Schmerzther. 2012;47(5):320–5.

    PubMed  Article  Google Scholar 

  33. 33.

    Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Reg Anesth Pain Med. 2012;37(3):325–8.

    PubMed  Article  Google Scholar 

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Author information




All authors comply with the ICMJE recommendations. LW designed the study, extracted and analyzed the data, and drafted and critically reviewed manuscript. DR searched strategy, and drafted and critically reviewed manuscript. KD: extracted the data, and drafted and critically reviewed. GV: searched the literature, and drafted and critically reviewed. MB: designed the study, extracted the data, and drafted and critically reviewed.

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Correspondence to Leigh White.

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White, L., Reardon, D., Davis, K. et al. Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials. J Anesth (2021).

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  • Shoulder surgery
  • Arthroscopy
  • Regional anesthesia
  • Suprascapular nerve