Original Article

Ultrasound‑guided anterior suprascapular nerve

block versus interscalene brachial plexus block
for arthroscopic shoulder surgery: A randomised
controlled study
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Address for correspondence: Kapil Gupta, Malvika Gupta1, Nikki Sabharwal, Balavenkat Subramanium2,
Dr. Kapil Gupta
Kumar G. Belani3, Vincent Chan4
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Professor, Department of
Anaesthesia and Critical Care,
Vardhaman Mahavir Medical
College and Safdarjung
Hospital, New Delhi ‑ 110 029,
India.
E‑mail: kapilguptauhn@gmail.
com
Submitted: 19‑Feb‑2023
Revised: 24‑Mar‑2023
Accepted: 26‑Mar‑2023
Published: 14-Jul-2023
Access this article online
Website: https://journals.lww.
com/ijaweb
DOI: 10.4103/ija.ija_126_23
Quick response code
Department of Anaesthesia and Critical Care, Vardhaman Mahavir Medical College and Safdarjung Hospital,
New Delhi, India, 1Department of Anaesthesia and Critical Care, Medanta Medicity, Delhi (NCR), India,
2
Department of Anaesthesia, Ganga Hospital, Coimbatore, Tamil Nadu, India, 3Department of Anaesthesia,
M Health Fairview Masonic Children’s Hospital, University of Minnesota, Minneapolis, MN, USA, 4Department
of Anaesthesia and Pain Medicine, University of Toronto, Toronto, Canada
ABSTRACT
Background and Aims: The interscalene brachial plexus block (ISB) affects the phrenic nerve,
resulting in hemi‑diaphragmatic paresis (HDP) and, possibly, respiratory distress. Suprascapular
nerve block via an anterior approach (SSB‑A) is performed more distally at the level of the trunk of the
brachial plexus and, thus, may spare the phrenic nerve. This study compares the analgesic efficacy
and decline of hemi‑diaphragmatic excursion  (HDE) following ultrasound  (US)‑guided  SSB‑A
versus ISB for arthroscopic shoulder surgery. Methods: This study was conducted on 60 adult
participants undergoing arthroscopic shoulder surgery under general anaesthesia. Both US‑guided
SSB‑A (n = 30) and ISB (n = 30) were performed with a combination of 10 ml bupivacaine (0.5%)
and 4 mg dexamethasone. The primary objective was to compare the duration of analgesia (time
to first rescue analgesia), and secondary objectives were to compare 24‑h postoperative numerical
rating scale  (NRS) scores, 24‑h morphine consumption and post block change in HDE, and
pulmonary function tests (PFTs) between the two groups. For analysing intergroup differences of
NRS, HDE and PFT; Pearson’s Chi‑squared test or Fisher’s exact test, unpaired t test, and Mann–
Whitney U test were used. For intragroup differences, paired t test was used. A P value <0.05
was considered significant. Results: The duration of analgesia (mean ± Standard Deviation) was
similar in two groups (SSB‑A = 1,345 ± 182 min, ISB = 1,375 ± 156 min; P = 0.8). The reduction in
HDE was significantly greater in the ISB group (44%) than in the SSB‑A group (10%). Pulmonary
function was better preserved in the SSB‑A group. Conclusion: Compared to ISB, SSB‑A has
a similar analgesic efficacy for arthroscopic shoulder surgeries, but it is superior in preserving
diaphragmatic function and pulmonary function.

Key words: Analgesia, brachial plexus block, morphine, ultrasonography, arthroscopy,

suprascpular nerve block

INTRODUCTION
Interscalene brachial plexus block (ISB) is the gold
standard analgesic technique for shoulder surgeries,
but it also blocks the phrenic nerve (C3–C5), thereby
leading to ipsilateral hemi‑diaphragmatic paresis (HDP)
and, possibly, respiratory distress in patients with
pre‑existing respiratory disease, obstructive sleep
apnoea, or morbid obesity.[1–3] Different strategies
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Gupta K, Gupta M, Sabharwal N,
Subramanium B, Belani KG, Chan V. Ultrasound‑guided anterior
suprascapular nerve block versus interscalene brachial plexus block
for arthroscopic shoulder surgery: A randomised controlled study.
Indian J Anaesth 2023;67:595-602.

© 2023 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow 595

Page no. 27
 Gupta, et al.: Anterior suprascapular nerve block
to mitigate phrenic nerve involvement after
ultrasound (US)‑guided ISB have been attempted, like
decreasing the concentration and volume of the local
anaesthetic (up to 5 ml); however, HDP is still present
in up to 45% of such patients.[4]
Suprascapular nerve block via the anterior approach
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(SSB‑A) is performed distally at the trunk/division
level of the brachial plexus, thereby potentially
sparing the phrenic nerve and minimising many
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adverse effects of ISB.[5] There are a few studies
that have compared the analgesic efficacy and
diaphragm‑sparing effect of SSB‑A and ISB[6] but
none that have compared the duration of analgesia of
these two blocks.
We hypothesised that SSB‑A would have a similar
analgesic efficacy as ISB, while preserving the
hemi‑diaphragmatic excursion (HDE) and pulmonary
function. The primary aim of this study was to
compare the duration of analgesia of US‑guided SSB‑A
and US‑guided ISB in adults undergoing arthroscopic
shoulder surgery under general anaesthesia. The
secondary objectives were to compare the 24‑h
postoperative numerical rating scale (NRS) scores,
morphine consumption over 24 h, and change in HDE
and pulmonary function after block administration.
METHODS
This randomised, double‑blinded, interventional,
clinical trial was conducted over a period of 12 months,
after obtaining research ethics committee approval
(vide approval No. IEC/VMMC/SJH/2020‑07/CC‑16
dated 10/08/2020). The clinical trial was registered
prospectively with the Clinical Trials Registry - India
(Registration No. CTRI/2020/09/027534, https://ctri.
nic.in). The study was carried out in accordance with
the principles of the Declaration of Helsinki, 2013.
A written informed consent after explanation of the
study protocol was obtained for participation in the
study and use of the patient data for research and
educational purposes.
All consenting adults (aged 18–65 years) who were
graded as American Society of Anesthesiologists (ASA)
physical status I or II and who were scheduled
for elective unilateral arthroscopic shoulder
surgery were included in the study. Patients with
pre‑existing respiratory, cardiac, renal, neurological,
or hepatic disease, neuropathy affecting brachial
plexus, contraindication to peripheral nerve block
596
Page no. 28
(e.g. coagulopathy), local anaesthetic allergy, or who
required revision/open surgeries were excluded.
The participants were randomly allocated to one of
the two groups (total 60) using a computer‑generated
randomisation sequence, with the results concealed
in sealed envelopes which, in turn, were opened just
before administering the block.
• Group SSB‑A: Ultrasound‑guided SSB‑A
(n = 30)
• Group ISB: Ultrasound‑guided ISB (n = 30)
All blocks were administered by a single
anaesthesiologist who had successfully performed
more than 50 SSB‑A and ISB blocks (before starting
the study). The patients, research personnel, outcome
assessors, and caregivers were blinded to the group
allocation, and the anaesthesiologist administering the
block was not involved in recording outcome measures.
Pre‑anaesthetic evaluation was performed,
which included history‑taking, examination, and
investigations. A patient information sheet and
informed consent form were distributed to participants.
The details of the study, including blocks used and
associated risks/benefits, were explained. Participants
were also educated about the NRS pain score (0
indicating no pain and 10 indicating worst unbearable
pain) and use of intravenous (IV) patient‑controlled
analgesia (PCA) pump in the postoperative period.
They were instructed to press the PCA button when
NRS was  ≥4. Preoperatively, the patients were told
to maintain fasting (solids for eight hours and clear
liquids for two hours).
The patient was shifted to the block room. HDE
was measured and pulmonary function tests (PFT)
conducted before administration of the block, by
a single investigator who had been blinded to the
group allocations. HDE was measured on both sides,
with the patient being in the supine position using a
5–2 MHz curvilinear probe and M‑mode of USG (M
Turbo, Sonosite, USA) in the subcostal area between
the mid‑clavicular and anterior axillary line, and the
liver/spleen was used as an acoustic window. The
measurements were taken during normal breathing
and sniff manoeuvre.[7] Forced vital capacity (FVC),
forced expiratory volume in one second (FEV1), and
peak expiratory flow rate (PFR) values were measured
using an electronic handheld spirometer (Contec
SP 10, China). In the sitting position, the patient
was instructed to inspire (inhale) maximally and
Indian Journal of Anaesthesia | Volume 67 | Issue 7 | July 2023
 Gupta, et al.: Anterior suprascapular nerve block
expire (exhale) into the spirometer as fast and as strong
as possible.[8] Three reading were taken for each of
these parameters and highest values were recorded.[8]
Standard ASA monitors including electrocardiography
(ECG), non‑invasive blood pressure (NIBP) cuff, and
pulse oximeter were attached to the patient, and
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baseline parameters were recorded. Oxygen was
administered using a face mask (5 L/min). A 20‑G IV
cannula was secured on the hand opposite to the side of
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the block. Institutional pre‑procedural safety checklist
was performed. One milligram of IV midazolam was
administered for sedation and anxiolysis. The patient
was laid in the supine position, with the head lifted at
30° and the head/neck turned 45° to the non‑operative
side. The supraclavicular anterolateral area of the
neck was sterilised using 2% chlorhexidine in 70%
isopropyl alcohol. The block was performed under
aseptic conditions using a high‑frequency (13–6 MHz)
linear probe (M Turbo, Sonosite, USA). Their skin
was infiltrated with 1% lidocaine (1 ml), and a 22‑G,
50‑mm insulated needle (UniPlex NanoLine, Pajunk,
Geisingen, Germany) was used for the block. The
probe was placed transversely in the supraclavicular
fossa and brachial plexus which was identified to be
posterolateral to the subclavian artery. The probe was
then moved cranially to identify the ventral rami of
the C5 and C6 nerves, and back‑and‑forth scanning
of the brachial plexus was done. The superior trunk
of the brachial plexus was identified by tracing the
ventral rami of the C5–C6 nerves to their convergence
point. More distally, the suprascapular nerve (SSN)
was identified as it originated from the superior trunk
or the ventral ramus of the C5 nerve, and its course
was traced underneath the omohyoid muscle.[9]
Block needle was inserted in‑plane to the probe and
a combination of 10 ml bupivacaine (0.5%) and 4 mg
dexamethasone was injected in 2‑ml aliquots (5 ml
above and 5 ml below the SSN) after ensuring negative
aspiration of blood and absence of pain or resistance
during injection.
The supraclavicular brachial plexus was identified,
and the probe was moved cephalad to identify the
three ventral rami of the nerves (C5, C6, and C7)
in the interscalene groove between the anterior
and middle scalene muscles. The block needle was
inserted via an in‑plane approach and advanced
towards the lateral border of the brachial plexus
sheath, between the ventral rami of the C5 and C6
nerves. The long thoracic and dorsal scapular nerves
were identified and were kept at a safe distance
Indian Journal of Anaesthesia | Volume 67 | Issue 7 | July 2023
Page no. 29
during needle advancement. The needle tip was
placed in the interspace between the C5 and C6
rami (interscalene groove), and a combination of
10 ml bupivacaine (0.5%) and 4 mg dexamethasone
was injected in 2‑ml aliquots after ensuring negative
aspiration of blood and absence of pain/resistance
during injection.
One hour after administering the block, we assessed
the affected sensory dermatomes by using a cold
alcohol swab (C3: supraclavicular fossa, C4: top of the
shoulder, C5: skin over the deltoid, C6: tip of thumb,
C7: tip of the middle finger, C8: tip of the little finger).
HDE was measured one hour after administering the
block, during quiet breathing and the sniff manoeuvre.
Severity of HDP was assessed by the percentage
decrease in HDE one hour after administration of
the block when compared to the baseline value.
A 75%–100% decrease (compared to baseline) or
paradoxical movement of diaphragm was defined as
complete HDP; a 25%–75% decrease as partial HDP;
and less than 25% decrease as absent HDP (none).[8]
PFTs (FVC, FEV1, and PFR) were conducted one hour
after block administration and were compared to
baseline values.[8]
The anaesthesiologist administering the general
anaesthesia was blinded to the group allocation. In the
operation room, ECG, NIBP, and pulse oximeter were
secured to the patient, and baseline parameters noted.
Bi‑spectral index (BIS) and neuromuscular monitoring
were established.
Anaesthesia was induced using IV 1.5 μg/kg fentanyl
and 1–2 mg/kg propofol. Neuromuscular blockade
was achieved using IV 0.1 mg/kg vecuronium, and an
appropriately sized laryngeal mask airway was secured.
The lungs were ventilated using volume control
mode (tidal volume = 6–8 ml/kg, inspired oxygen
concentration [FiO2] =0.5, positive end‑expiratory
pressure (PEEP) =4–5 cm/H2O), and respiratory rate
was adjusted to maintain an end‑tidal carbon dioxide
(EtCO2) of 35–40 mmHg. Anaesthesia was maintained,
using inhaled sevoflurane in a 50:50 mixture of
oxygen and air, to maintain minimum alveolar
concentration (MAC) of 0.8–1 and BIS of 40–60.
A train‑of‑four (TOF) count of 1–2 was maintained
for adequate muscle relaxation, and a top‑up of 1 mg
vecuronium was given IV when TOF count was >2.
Paracetamol 15 mg/kg was given IV at the beginning
of the surgery. IV fentanyl 0.5 μg/kg was injected
597
 Gupta, et al.: Anterior suprascapular nerve block

when the heart rate or blood pressure increased
by >20% of baseline, despite a BIS of 40–60, MAC of
0.8–1, and a TOF count ≤2. At the end of the surgery,
0.1 mg/kg ondansetron was injected IV. The residual
neuromuscular blockade was reversed using 50 μg/kg
IV neostigmine and 10 μg/kg IV glycopyrrolate. Once
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paired t test was used. A P value <0.05 was considered
significant.
RESULTS
Ninety‑two patients were assessed for eligibility
and 60 were included in this study. These 60

the patient was conscious and breathing adequately,

laryngeal mask airway was removed. The patient was participants were randomised into two groups of
transferred to the postoperative anaesthesia care unit, 30 each [Figure 1]. All patients were included for
and their vitals were monitored. Any intraoperative intention‑to‑treat analysis. Administration of the
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hypotension/hypertension/bradycardia/tachycardia block was considered successful upon visualisation

was noted. The patient controlled analgesia (PCA) of the target nerve and injection of the drug around
pump (T34L, Caesarea Medical, Electronics, Israel) the target nerve. All blocks were administered
was attached IV and set to the following: morphine at successfully.
1 mg/ml; bolus dose at 1 ml, lockout interval at 10 min,
and maximum dose at 5 mg/h. The demographic profile and surgical characteristics
of the two groups were similar [Table 1]. The mean
Postoperative values were noted by a resident difference in time to rescue analgesia (95% CI)
anaesthesiologist who had been blinded to the group was 30  min (−8, 117  min) between the ISB group
allocation. The time from block administration to (1,375 ± 156 min; mean ± SD) and SSB‑A group
the first rescue analgesia (use of IV PCA pump) was (1,345 ± 182 min; P > 0.5). Mean 24‑h morphine
recorded as the duration of analgesia. Shoulder consumption was significantly higher in the SSB‑A
pain was assessed using the NRS during rest and group (0.73 ± 1.17 mg) when compared to the ISB
activity (cough or deep breathing) 4 h, 6 h, 8 h, 12 h, group (0.17 ± 0.60 mg; P = 0.02). Morphine was not
and 24 h after block administration. A difference required by any patient in both the groups within
of >1 in NRS score was considered as clinically the first 12 h after block administration. The mean
significant.[10] The amount of morphine consumed intraoperative fentanyl requirement was similar
by the patient at these time points was also recorded. in both the groups [Table 1]. The intraoperative
Any side effects such as nausea, vomiting, dyspnoea, haemodynamic variables were also comparable
desaturation, hypotension, hypertension, bradycardia, between the two groups.
or tachycardia were documented.
At rest, NRS pain scores in Group SSB‑A were
 A previous study,[11] reported a mean difference in significantly higher 4 h, 6 h, and 8 h after block
duration of analgesia between the two groups of 1 h administration when compared to Group ISB, though
and standard deviation of 45 min. Based on this and the difference in NRS scores [Table 2] was well
to achieve a power of 80%, p‑ value of <0.05, type 1 below the clinically relevant value of 1. At other
error of 5%; and attrition rate of 10%, a sample size
of 30 participants was calculated in each group. The Table 1: Patient demographics and surgical characteristics
IBM SPSS Statistics version 24 was used for statistical Characteristics Group ISB Group SSB‑ A P
analysis. (n=30) (n=30)
Age (years) 34±15 32±13 0.570
Gender (male/female) 23/7 25/5 0.519
Quantitative variables were presented as
Weight (kg) 71±12 72±12 0.592
mean ± standard deviation (SD) for normally Height (cm) 171±5 174±9 0.082
distributed variables, and non‑normally distributed BMI (kg/m2) 24±4 24±3 0.612
variables were presented as median (interquartile ASAI/II 27/3 27/3 1.000
range). Qualitative variables were presented as Type of arthroscopic surgery
frequencies. To calculate intergroup differences, Bankart repair/rotator cuff 16/6/8 21/4/5 0.53
repair/SLAP repair
Pearson’s Chi‑squared test or Fisher’s exact test was
Duration of surgery (min) 96±26 88±12 0.135
used for categorical variables, unpaired t test for Intraoperative fentanyl (μg) 98±9 101±13 0.311
normally distributed quantitative variables, and the ISB – Interscalene brachial plexus block; SSB‑A – Suprascapular nerve block
(anterior approach); ASA – American Society of Anesthesiologists; BMI – Body
Mann–Whitney U test for non‑normally distributed mass index; SLAP – Superior labrum anterior to posterior. Values are
quantitative variables. For intragroup differences, expressed as mean±SD or number

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 Gupta, et al.: Anterior suprascapular nerve block
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Figure 1: Consolidated Standards of Reporting Trials  (CONSORT) flow diagram. Group  ISB  =  Interscalene brachial plexus block;
Group SSB‑A = Suprascapular nerve block (anterior approach); n = Number

Table 2: Postoperative NRS scores at rest and activity side of the block in both the groups (P < 0.001; Table 3).
Time after block Group ISB Group SSB P The percentage reduction in HDE (median [IQR])
NRS NRS on the ipsilateral side of the block was significantly
4 hours
greater in Group  ISB  (quiet breathing: −44%  [−60,
Rest 0 (0, 0) 0.5 (0, 1) 0.006
Activity 1 (0, 1) 1 (0, 2) 0.171 −33)]; sniff manoeuvre: −47%  [−60, −30]) when
6 hours compared to Group  SSB‑A  (quiet breathing: −11%
Rest 0 (0, 0) 0 (0, 1) 0.025 [−26, 0]; sniff manoeuvre: −7% [−22, 4]; P < 0.001,
Activity 1 (0, 1) 1 (0, 2) 0.406 P < 0.001) [Table 3].
8 hours
Rest 0 (0, 0) 0 (0, 1) 0.040 This was associated with a compensatory increase
Activity 1 (1, 1) 1 (0, 2) 0.346
in HDE on the contralateral side in both the
12 hours
Rest 0 (0, 1) 0.5 (0, 2) 0.114 groups [Table 3]. The increase in HDE (median [IQR])
Activity 1 (1, 2) 1 (1, 2) 0.431 was significantly greater in Group ISB (quiet breathing:
24 hours +35% [5, 68], sniff manoeuvre: +30% [5, 64]) when
Rest 1 (0, 2) 1 (0, 3) 0.703 compared to Group SSB‑A (quiet breathing: +1% [−3,
Activity 2 (1, 3) 2 (1, 4) 0.768
17], sniff manoeuvre: +5%  [−9, 14]; P = 0.002,
ISB – Interscalene brachial plexus block; SSB‑A – Suprascapular nerve block
(anterior approach); NRS – Numerical rating scale, Values are expressed as P  < 0.001) [Table 3]. No patient in Group SSB‑A
median (interquartile range) developed complete HDP, whereas one patient did
in Group ISB [Table 4]. The incidence of partial
time points, NRS scores at rest were similar in the HDP was significantly higher in group ISB (80%,
two groups [Table 2]. The NRS pain scores during n = 24) compared to Group SSB‑A (33%, n = 10;
activity were similar at all the time points in both the P  < 0.001). Twenty patients (67%) in Group SSB‑A
groups [Table 2]. had no HDP compared to five patients (17%) in
Group ISB (P < 0.001) [Table 4]. There was a
After block administration, there was a significant significant decrease (P < 0.05) in FVC and FEV1
decrease in HDE compared to baseline on the ipsilateral values one hour after block administration in both the

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 Gupta, et al.: Anterior suprascapular nerve block

Table 3: Hemi‑diaphragmatic excursion before block and 60 min after block

Groups Group ISB Group SSB‑A Mean difference P
Mean±SD (cm) Mean±SD (cm) (95% CI)
Quiet breathing Ipsilateral HDE
Before block 1.32±0.31 1.51±0.36 −0.19 (−0.36, −0.02) 0.03
After block 0.73±0.30 1.27±0.37 −0.54 (−0.71, −0.37) <0.001
Difference 0.59±0.34 0.24±0.34 0.35 (0.16, 0.52) 0.0002
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Percentage change (IQR) −44 (−60, −33) −11 (−26, 0)

Sniff Ipsilateral HDE
Before block 1.99±0.64 2.12±0.52 −0.13 (−0.43, 0.17) 0.38
After block 1.10±0.53 1.88±0.51 −0.78 (−1.05, 0.51) <0.001
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Difference 0.89±0.81 0.24±0.55 0.65 (0.30, 1.01) 0.0006

Percentage change (IQR) −47 (−60, −30) −7 (−22, 4)
Quiet breathing Contralateral HDE
Before block 1.39±0.30 1.38±0.24 (−0.13, 0.15) 0.85
After block 1.90±0.54 1.49±0.34 0.41 (0.18, 0.65) 0.0008
Difference −0.51±0.53 −0.11±0.35 −0.40 (−0.63, 0.17) 0.001
Percentage change (IQR) +35 (5, 68) +1 (−3, 17)
Sniff Contralateral HDE
Before block 1.94±0.44 2.09±0.48 −0.15 (−0.39, 0.08) 0.20
After block 2.60±0.79 2.13±0.56 0.47 (0.11, 0.82) 0.01
Difference −0.66±0.70 −0.04±0.36 −0.62 (−0.91, −0.33) 0.0001
Percentage change (IQR) +30 (5, 64) +5 (−9, 14)
ISB – Interscalene brachial plexus block; SSB‑A – Supra‑scapular nerve block (anterior approach); HDE – Hemi‑diaphragmatic excursion, IQR-Interquartile Range

Table 4: Pulmonary function test and hemi‑diaphragmatic paresis (HDP) at baseline and one hour after block
administration
PFT Group ISB Group SSB‑A Mean difference P
Mean±SD Mean±SD (95% CI)
Median percentage change (%) Median percentage change (%) Median percentage change (%)
FVC (L/min) Before block: 2.87±0.90 Before block: 2.68±0.72 0.19 (−0.24, 0.61) <0.001
After block: 2.07±0.89 After block: 2.35±0.67 −0.28 (−0.69, 0.14)
(−25%); P<0.001 (−11%) *P<0.001
FEV1 (L/min) Before block: 2.61±0.73 Before block: 2.56±0.62 0.05 (−0.31, 0.40) 0.003
After block: 1.99±0.83 After block: 2.29±0.62 −0.30 (−0.68, 0.09)
(−27%); P<0.001 (−10%); *P<0.001
PFR (L/min) Before block: 6.94±1.89 Before block: 7.44±1.72 −0.51 (−1.45, 0.44) 0.08
After block: 5.76±2.15 After block: 6.88±2.34 −1.12 (−2.29, 0.05)
(−11%); P<0.001 (−5%); *P=0.07
HDP Number Number P
None <25% 5 20 <0.001
Partial 25%–75% 24 10 <0.001
Complete >75% 1 0 0.31
ISB – Interscalene brachial plexus block; SSB‑A – Suprascapular nerve block (anterior approach); FVC – Forced vital capacity; FEV1 – Forced expiratory volume in
1 second; PFR – Peak expiratory flow rate; L – Litre; HDP – Hemi‑diaphragmatic palsy; SD – Standard Deviation, Values are expressed as mean±SD, percentage
change expressed as median; Hemi‑diaphragmatic paralysis expressed as number. Tests used were paired t test and Mann–Whitney U test

groups (compared to baseline). However, Group ISB hypotension, hypertension, bradycardia, tachycardia,

had a significantly greater reduction in these values
compared to Group SSB‑A [Table 4].
The sensory dermatomes affected by the two blocks
are shown in Figure 2. The C3 dermatome was blocked
in 50% of patients (n = 15) in Group ISB and in only
3% of patients (n = 1) in Group SSB‑A (P < 0.001).
C6 dermatome was affected in 83% of patients
(n = 25) in Group ISB compared to 43% (n = 13) in
Group SSB‑A (P = 0.001). There was no perioperative
desaturation, or dyspnoea in any patient.
DISCUSSION
This study compares single‑injection, US‑guided
SSB‑A and ISB in arthroscopic shoulder surgeries
and highlights that analgesic efficacy provided by
SSB‑A is comparable to ISB while simultaneously
preserving HDE and pulmonary function. The
analgesia lasted up to 24 h in both groups. Ipsilateral

600 Indian Journal of Anaesthesia | Volume 67 | Issue 7 | July 2023

Page no. 32

Number of Subjects with Sensory Block
30
30
25
20
15
15
10
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5
1
0 and the surrounding muscles (supraspinatus and
C3 C4
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Figure 2: Sensory dermatomes affected in Group ISB and
Group SSB‑A. Group ISB = Interscalene brachial plexus block;
Group SSB‑A = Suprascapular nerve block (anterior approach); values
are expressed as percentage (number)
HDE was better preserved after SSB‑A administration,
with only a 11% decline being observed compared
to a 44% decline after ISB administration. Decline in
pulmonary function was significantly higher after ISB
administration compared to SSB‑A.
Postoperative NRS pain scores during rest were
slightly lower in patients receiving ISB compared to
those receiving SSB‑A, and scores were less than 3 at
all the time points in both groups; thus, the difference
in pain scores was clinically insignificant.
Patients in both groups rarely required morphine (mean
consumption was <1 mg) for postoperative analgesia
within 24 h, thereby highlighting the superior quality
of both of these blocks. This may be a result of adding
4 mg dexamethasone to the local anaesthetic drug
(10 ml of 0.5% bupivacaine) for the block. Mean 24‑h
morphine requirement was significantly higher in the
SSB‑A group (0.73 mg) than in the ISB group (0.17 mg),
but the difference was 0.5 mg and clinically irrelevant.
Both blocks provided good intraoperative analgesia, as
is reflected by the absence of intraoperative requirement
of any fentanyl bolus.
The phrenic nerve was affected in the ISB group
because of its close proximity to the brachial plexus
and the cephalic spread of the local anaesthetic to
C3–C5 nerves of the cervical plexus. In most patients, a
good pulmonary reserve prevents the clinical
manifestation of unilateral diaphragmatic weakness;
but in the presence of an underlying lung disease, it
may manifest as dyspnoea.[12,13]
The suprascapular nerve (SSN) is easy to identify using
US anteriorly in the supraclavicular fossa located just
Indian Journal of Anaesthesia | Volume 67 | Issue 7 | July 2023
Gupta, et al.: Anterior suprascapular nerve block
below the omohyoid muscle.[14,15) Studies suggest the
30 30
28 sparing of phrenic nerve with SSB‑A block.[16] In our
25
study, 33% of patients developed partial HDP after SSB‑A
administration, similar to the cadaveric study where a
13
dye spread to the phrenic nerve in 21% of patients.[16]
The SSN provides the majority (70%) of sensory
3
2 2 innervation to the shoulder joint (posterosuperiorly)
0
C5 C6 C7 C8
infraspinatus muscles).[14] The axillary nerve and
Cervical Nerve Roots
Group ISB Group SSB
subscapular nerve originate from the posterior division
of the upper trunk of the brachial plexus (ventral rami
of C5 and C6 nerves)[17,18 ] and provide 30% of sensory
innervation to the shoulder joint (anterosuperiorly by
the subscapularis nerve and inferiorly by the axillary
nerve).[17,18]
The posterior division of the upper trunk of the brachial
plexus is in close proximity to the SSN.[19] Hence, a
drug injected near the SSN percolates to the posterior
division of the brachial plexus.[20–22] This is further
supported by our study, with other dermatomes being
effected by SSB‑A and thus causing a partial brachial
plexus block [Figure 2].
The major strengths of this study includes
performance of blocks by fellowship‑trained regional
anaesthesiologist and the robust methodology of
this study, including technique of double‑blinding,
allocation concealment, and randomisation method.
One major limitation of this study was the exclusion
of open shoulder surgeries. Thus, our results cannot
be generalised to such surgeries. Our results cannot
be applied to surgical anaesthesia or continuous block
using a catheter. We included only ASA I and II patients,
thereby excluding patients with underlying pulmonary
comorbidities. Hence, future studies are needed on
the safety of SSB‑A block in patients with obtunded
pulmonary function. The sample size of this study was
not large enough to comment on complications.
CONCLUSION
To conclude, SSB‑A is an effective regional analgesic
block for arthroscopic shoulder surgery. Compared
to ISB, SSB‑A has the advantage of preserving
diaphragmatic excursion and pulmonary function (by
sparing the phrenic nerve).
Acknowledgements
Dr Saveena Raheja Gulati helped us in administration
of anaesthesia in our cases and provided perioperative
601
Page no. 33
 Gupta, et al.: Anterior suprascapular nerve block
care for study patients. We also acknowledge the
contribution of Dr Mani Kelavani from AIIMS, Delhi,
in conducting the statistical analysis of this study.
Financial support and sponsorship
Nil.
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Conflicts of interest
There are no conflicts of interest.
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Indian Journal of Anaesthesia | Volume 67 | Issue 7 | July 2023