Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration

Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration Sadık Emre Erginoğlu, Nuri Koray Ülgen, Ali Said Nazlıgül, Nihat Yiğit, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8080777/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Arthroscopic rotator cuff repair (ARCR) is associated with significant postoperative pain. While the interscalene brachial plexus block (ISB) is the analgesic gold standard, it causes nearly universal hemidiaphragmatic paralysis. This systematic review evaluated the efficacy, safety, and opioid-sparing effects of diaphragm-sparing nerve blocks (DSNBs) as alternatives to ISB. Methods: A systematic literature search was conducted following PRISMA guidelines in PubMed, Scopus, and the Cochrane Library for studies published between January 1, 2010, and May 1, 2025. After screening 193 identified records, 36 studies met the inclusion criteria and were analyzed. Results: Diaphragm-sparing nerve blocks—including the Superior Trunk Block (STB), Suprascapular plus Axillary Nerve Block (SSNB + AXNB), and Costoclavicular Block (CCB)—provided analgesic efficacy equivalent to ISB. The key finding was a dramatic reduction in the incidence of hemidiaphragmatic paralysis, from nearly 100% with ISB to below 10% with DSNBs. Specifically, the STB achieved non-inferior analgesia with only 0–5% diaphragmatic involvement. When incorporated into multimodal analgesia protocols, these techniques reduced postoperative opioid consumption by approximately 40–60% and demonstrated significant safety advantages for patients with pulmonary comorbidities, without compromising pain control or block success rate. Conclusions: Diaphragm-sparing nerve blocks represent effective and safe alternatives to ISB for pain management after ARCR, establishing a new standard of care that prioritizes respiratory safety. They achieve comparable analgesia while markedly reducing the risk of hemidiaphragmatic paralysis. Block selection should be individualized based on patient factors and surgical needs, but evidence strongly supports the integration of DSNBs into clinical practice to enhance recovery and minimize opioid-related side effects. Anesthesiology & Pain Medicine Rotator cuff repair Diaphragm-sparing nerve block Interscalene block Superior trunk block Postoperative analgesia Regional anesthesia Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Arthroscopic rotator cuff repair (ARCR) is the gold-standard surgical treatment for rotator cuff tears and is performed on millions of patients worldwide each year [1]. It is one of the most frequently performed orthopedic procedures, with an estimated annual volume exceeding 500,000 procedures in the United States alone, a number that continues to rise with an aging population [2]. This high prevalence underscores the critical need for optimizing postoperative pain management protocols to improve outcomes on a population-wide scale. However, severe postoperative pain following this procedure can impede early rehabilitation and prolong hospital stay [3]. Interscalene brachial plexus block (ISB) has long been considered the gold standard for postoperative analgesia after ARCR. Its principal drawback, however, is the high incidence (70–100%) of hemidiaphragmatic paralysis due to phrenic nerve involvement [4,5]. This side effect can lead to significant respiratory complications in patients with underlying pulmonary comorbidities such as chronic obstructive pulmonary disease (COPD), obesity, or obstructive sleep apnea [6,7]. Beyond diaphragmatic paralysis, ISB carries additional risks including Horner's syndrome, hoarseness from recurrent laryngeal nerve involvement, and potential neurologic complications [8,9]. These limitations have prompted the development of ultrasound-guided, diaphragm-sparing nerve block alternatives [10,11]. Techniques such as the superior trunk block (STB), suprascapular nerve block (SSNB), axillary nerve block (AXNB), costoclavicular block (CCB), and modified supraclavicular blocks aim to selectively target the brachial plexus branches supplying the shoulder joint while preserving phrenic nerve function originating from C3–C5 roots [12,13,14,15]. Recommendations from the PROSPECT group [16] and emerging evidence from randomized controlled trials [17,18] suggest that these diaphragm-sparing blocks provide analgesic efficacy comparable to ISB while markedly reducing respiratory adverse effects. Furthermore, the use of extended-release local anesthetics like liposomal bupivacaine [19,20] and various adjuvants [21] can prolong the duration of analgesia. The integration of these blocks into multimodal analgesia protocols [22,23] and the adoption of opioid-free anesthetic techniques [24,25] are increasingly recognized as key components of modern perioperative care. 2. Methods 2.1. Study Design This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This review was not registered in the PROSPERO database, as it was deemed unnecessary for a qualitative synthesis that did not involve meta-analytic pooling of patient-level data. 2.2. Search Strategy A comprehensive literature search was performed in the following electronic databases: PubMed, Scopus, and the Cochrane Library. The search covered the period from January 1, 2010, to May 1, 2025. The search strategy utilized a combination of keywords and Medical Subject Headings (MeSH) terms: ("rotator cuff repair" OR "shoulder arthroscopy") AND ("interscalene block" OR "suprascapular nerve block" OR "axillary nerve block" OR "superior trunk block" OR "costoclavicular block" OR "diaphragm-sparing") AND ("postoperative pain" OR "phrenic nerve palsy" OR "regional anesthesia"). No language filters were applied during the initial search; however, only studies published in English were included in the final analysis due to practical constraints in translation and resources. 2.3. Eligibility Criteria Studies were selected based on the following pre-defined criteria: Inclusion Criteria : Study Types: Randomized controlled trials (RCTs), prospective or retrospective comparative cohort studies, systematic reviews, and meta-analyses. Population: Adult patients (≥ 18 years) undergoing elective arthroscopic rotator cuff repair (ARCR). Intervention and Comparison: Direct comparison between interscalene brachial plexus block (ISB) and at least one diaphragm-sparing nerve block technique (e.g., superior trunk block [STB], suprascapular nerve block [SSNB], axillary nerve block [AXNB], costoclavicular block [CCB]). Outcomes: Reporting of at least one of the following: postoperative pain scores, opioid consumption, incidence of hemidiaphragmatic paralysis, or block success rate. Exclusion Criteria : Case reports, case series, editorials, letters, conference abstracts, and animal studies. Studies involving other types of shoulder surgery. Studies where the full text was not accessible or which contained insufficient data for extraction and analysis. 2.4. Study Selection Process The study selection process followed the PRISMA flow diagram (Fig. 1 ). After removing duplicates, two reviewers independently screened the titles and abstracts of all identified records against the eligibility criteria. The full texts of potentially relevant studies were then retrieved and assessed independently by the same two reviewers. Any disagreements at any stage of the selection process were resolved through discussion and consensus. A third reviewer was consulted if a consensus could not be reached. 2.5. Data Extraction and Quality Assessment Data from the included studies were extracted independently by two reviewers using a standardized data extraction form. The extracted data included: study characteristics (first author, publication year, study design, sample size), patient demographics, details of the nerve block techniques and local anesthetics used, and primary outcomes (pain scores, opioid consumption, diaphragmatic function). The methodological quality and risk of bias of the included randomized controlled trials were assessed using the Cochrane Risk of Bias (RoB 2) tool. The quality of non-randomized studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. The certainty of the body of evidence for key outcomes (postoperative pain scores, opioid consumption, and incidence of hemidiaphragmatic paralysis) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. 3. Results 3.1. Study Selection The systematic literature search and selection process are summarized in the PRISMA flow diagram (Fig. 1 ). Of the 193 records identified, 36 studies met the inclusion criteria and were included in the qualitative synthesis. 3.2. Interscalene Block (ISB) and Its Modifications Interscalene brachial plexus block (ISB) has been extensively used for postoperative pain control after ARCR, demonstrating a 70–80% reduction in both rest and movement pain scores [4, 5]. Its principal limitation remains the high incidence (70–100%) of hemidiaphragmatic paralysis [5, 26]. To mitigate this adverse effect, modified techniques such as low-volume (e.g., 10–15 mL of 0.5% ropivacaine) and extrafascial injections have been developed. While low-volume injections reduce the rate of diaphragmatic paralysis to approximately 50%, this is often associated with a shorter duration of analgesia [4]. Extrafascial ISB has been reported to reduce the incidence of hemidiaphragmatic paralysis from 85% to 25% compared to the conventional intrafascial approach [26]. The minimum effective volume (MEV90) of 0.5% ropivacaine for ISB has been estimated to be 14.3 mL [27]. 3.3. Diaphragm-Sparing Nerve Blocks 3.3.1. Superior Trunk Block (STB) The ultrasound-guided superior trunk block (STB) provides non-inferior analgesia compared to ISB while markedly reducing the incidence of diaphragmatic paralysis to as low as 0–5% [13]. Meta-analyses have confirmed a significant reduction in the risk of diaphragmatic paralysis with STB (Odds Ratio [OR]: 0.02; 95% Confidence Interval [CI]: 0.01–0.08) [8]. Using a volume of 15 mL ropivacaine, STB minimally affects diaphragmatic excursion and results in 24-hour opioid consumption comparable to ISB [14]. Furthermore, STB has been reported to offer a longer duration of analgesia than an isolated suprascapular nerve block [18]. 3.3.2. Suprascapular and Axillary Nerve Blocks (SSNB + AXNB) The suprascapular nerve provides approximately 70% of the shoulder joint's sensory innervation. As a single injection, it may provide insufficient coverage, so it is frequently combined with an axillary nerve block (AXNB). Compared to ISB, the SSNB + AXNB combination reduces the incidence of diaphragmatic paralysis to near 0%, albeit with a marginally lower quality of analgesia in some studies [11]. This combination has been shown to provide approximately 45% better pain control than periarticular infiltration alone [28]. An infraclavicular-suprascapular nerve block combination has also been reported to offer analgesia comparable to ISB with negligible effects on diaphragmatic function [29]. 3.3.3. Costoclavicular Block (CCB) The costoclavicular block (CCB), targeting the brachial plexus in the costoclavicular space, provides analgesic efficacy equivalent to ISB while significantly reducing the incidence of diaphragmatic paralysis to around 5–15% [10]. A local anesthetic volume of 20 mL achieves similar efficacy to 40 mL but with reduced diaphragmatic involvement [30]. The wide and reliable sensory coverage of CCB is considered a notable advantage. 3.3.4. Supraclavicular Block (SCB) The supraclavicular block (SCB) serves as another effective diaphragm-sparing alternative. It delivers analgesia comparable to ISB while significantly reducing the incidence of hemidiaphragmatic paralysis [12, 31]. Studies have reported no significant adverse impact on pulmonary function parameters with this approach [6, 32]. 3.4. Pharmacological Advances and Adjuvants Liposomal bupivacaine, with its sustained-release formulation, can provide prolonged analgesia for up to 72 hours [17]. Meta-analyses have demonstrated that its use leads to significant improvements in pain scores and reductions in opioid consumption [19]. A combination of conventional bupivacaine with liposomal bupivacaine provides a longer duration of analgesia than plain bupivacaine alone [20]. The addition of adjuvants such as dexmedetomidine or dexamethasone to ropivacaine solutions has been shown to extend the duration of the nerve block by approximately 40% [21]. 3.5. Multimodal and Opioid-Sparing Protocols Multimodal analgesia, which integrates regional nerve blocks with systemic non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabapentinoids, effectively minimizes postoperative opioid requirements. In opioid-free ARCR protocols, the combination of SSNB with periarticular infiltration has proven highly effective [24]. Comprehensive educational programs and multimodal strategies have achieved success rates of up to 85% for opioid-free postoperative recovery [23]. Patients managed with such multimodal regimens experience shorter hospital stays and lower associated healthcare costs [7, 22, 25]. Figure 2 visually summarizes the comparative reduction in postoperative opioid consumption across the different nerve block types. The pronounced opioid-sparing effect achieved by integrating diaphragm-sparing blocks into multimodal regimens is further illustrated in Fig. 3 . Table 1 Comparative characteristics of diaphragm-sparing nerve blocks. Feature Superior Trunk Block Suprascapular + Axillary Block Costoclavicular Block Supraclavicular Block Interscalene Block Anatomical Target Brachial plexus superior trunk Suprascapular + axillary nerves Brachial plexus costoclavicular fascia Brachial plexus supraclavicular Brachial plexus C5–C7 Diaphragmatic Effect 0–5% 0–5% 5–15% 15–25% 70–100% Recommended LA Volume 15–20 mL 10–15 mL (SSNB) + 5–10 mL (AXNB) 20–30 mL 20–25 mL 15–20 mL Analgesic Quality High Moderate-high High Moderate-high Very high Opioid Sparing 40–60% 35–55% 35–50% 30–45% 50–70% Technical Difficulty Moderate Low-moderate Moderate-high Moderate Low Evidence Level High (Multiple RCTs) Moderate-high (Several RCTs) Moderate (Limited RCTs) Moderate-high (Several RCTs) Very high (Extensive RCTs) LA : Local Anesthetic Table 2 Statistical efficacy data of diaphragm-sparing nerve blocks. Block Technique Studies (n) Diaphragmatic Paralysis (ISB vs Alternative) Statistical Significance (p-value or OR [95% CI]) Opioid Sparing %, Mean [Range] VAS Improvement (Mean Score Reduction) Evidence Level (GRADE) Superior Trunk Block 4 RCTs 100% vs 5% OR: 0.02 [0.01–0.08]; p < 0.001 47.5% [40–60] -3.2 points High SSNB + AXNB 3 RCTs 95% vs 2.5% OR: 0.03 [0.01–0.15]; p < 0.001 45.8% [35–55] -2.8 points Moderate–high Costoclavicular Block 2 RCTs 100% vs 10% OR: 0.05 [0.01–0.30]; p < 0.001 42.3% [35–50] -3.0 points Moderate Supraclavicular Block 3 RCTs 92% vs 20% OR: 0.15 [0.08–0.30]; p < 0.01 37.6% [30–45] -2.5 points Moderate–high Liposomal Bupivacaine 3 (2 RCT + 1 MA) – – 38.2% [30–45] -2.1 points High RCT: Randomized Controlled Trial; MA: Meta-analysis; VAS: Visual Analog Scale; OR: Odds Ratio; CI: Confidence Interval Table 3 Comparative summary of diaphragm paralysis incidence, analgesic efficacy, and opioid reduction across block types Block Type Diaphragm Paralysis (%) Analgesic Efficacy (VAS ↓%) Opioid Reduction (%) Evidence Level Interscalene Block (ISB) 90–100 80–90 50–70 Very high Superior Trunk Block (STB) 0–5 80–85 55–60 High Suprascapular + Axillary Block (SSNB + AXNB) 2–5 70–80 45–55 Moderate–high Costoclavicular Block (CCB) 5–15 75–80 45–50 Moderate Supraclavicular Block (SCB) 15–25 70–75 40–45 Moderate–high These comparative findings collectively highlight the clinical hierarchy of diaphragm-sparing blocks and provide a quantitative foundation for the ensuing discussion 4. Discussion This systematic review demonstrates that diaphragm-sparing nerve blocks represent an effective and safe alternative to interscalene block (ISB) for pain management following arthroscopic rotator cuff repair (ARCR). Current evidence indicates that the superior trunk block (STB) provides non-inferior analgesic efficacy compared to ISB while significantly reducing the risk of diaphragmatic paralysis [8, 13]. Similarly, the combination of suprascapular and axillary nerve blocks (SSNB + AXNB) and the costoclavicular block (CCB) offer comparable analgesic effectiveness while markedly reducing respiratory side effects [10, 11]. The supraclavicular block also stands out as a valuable clinical technique due to its diaphragm-sparing characteristics and relative ease of application [12, 31, 32]. 4.1. Clinical Practice Perspective Nerve block selection in clinical practice should be individualized based on patient characteristics and surgical requirements. Diaphragm-sparing blocks should be the first choice in patients with pulmonary comorbidities (e.g., COPD, obesity, obstructive sleep apnea). In contrast, low-volume or extrafascial ISB techniques may be preferable in cases with high pain expectations or planned bilateral procedures [4, 5]. Systematic reviews evaluating the impact of peripheral nerve block techniques on the incidence of phrenic nerve palsy confirm that diaphragm-sparing approaches significantly reduce this risk [6]. Indeed, a recent meta-analysis by Oliver-Forniés et al. [33] statistically demonstrated that diaphragm-sparing blocks (STB, SSNB + AXNB) reduce the risk of diaphragmatic paralysis by 80–95% compared to interscalene block. These findings highlight the critical role of block selection in reducing postoperative respiratory complications. 4.2. Pharmacological Optimization and Patient Comfort Beyond block technique selection, pharmacological optimization of local anesthetic solutions plays a determining role in patient comfort and opioid sparing. The use of adjuvant agents enhances the duration and quality of the selected block, thereby supporting the success of multimodal analgesia protocols. For instance, randomized studies have shown that dexmedetomidine, when combined with either ISB or diaphragm-sparing alternatives, creates a synergistic effect that significantly improves postoperative pain control and reduces opioid consumption [26]. This pharmacological approach not only extends block duration but also lowers pain scores during rest and rehabilitation, thereby contributing to earlier patient mobilization and overall satisfaction. 4.3. Clinical Implementation, Pharmacological Advances, and Future Directions The successful implementation of diaphragm-sparing techniques is supported by a growing body of global and national evidence. Studies within the Turkish population confirm that these approaches are both effective and safe, enhancing the generalizability of international findings [3, 28]. For instance, the study by Şahin et al. demonstrated the superiority of the SSNB + AXNB combination over periarticular infiltration [28], while Şengel et al. reported added benefits from combining ISB with a superficial cervical plexus block [34]. These national findings align with global evidence, such as the work of Zhang et al., which established the non-inferior analgesia of the Superior Trunk Block (STB) compared to ISB [12]. The translation of this evidence into routine practice necessitates a focused educational strategy. The widespread adoption of these techniques depends on standardizing and expanding hands-on ultrasonography training. Integrating structured, simulation-based modules on diaphragm-sparing blocks into anesthesiology residency curricula and continuous professional development programs is crucial for building proficiency among both trainees and practicing anesthesiologists. Pharmacological optimization continues to play a key role. The use of liposomal bupivacaine and adjuvants like dexamethasone and dexmedetomidine significantly extends block duration and reduces opioid requirements [17, 19, 21]. However, the higher acquisition cost of these agents mandates careful cost-effectiveness analyses within specific healthcare systems. Similarly, multimodal periarticular injections containing corticosteroids have been shown to augment analgesia without compromising rotator cuff healing, offering another valuable tool in the opioid-sparing arsenal [35, 36]. Future research should be channeled along three critical pathways to consolidate and advance this field: Head-to-Head Comparisons : Well-designed randomized controlled trials are needed to directly compare the clinical utility, safety, and cost-effectiveness of different diaphragm-sparing blocks (e.g., STB vs. CCB). Long-Term Functional Impact : Investigation must move beyond short-term analgesia to assess the impact of these blocks on long-term functional recovery, including rehabilitation quality, range of motion, and the incidence of chronic post-surgical pain. Systematic Integration : Research should explore the formal integration of diaphragm-sparing blocks into standardized Enhanced Recovery After Surgery (ERAS) protocols, evaluating their effect on overall patient journey, hospital efficiency, and economic outcomes. A proposed clinical algorithm to guide block selection in shoulder arthroscopy is presented in Fig. 4 . 4.4. Study Limitations This review has several limitations. There was considerable heterogeneity among the included studies regarding the type, concentration, and volume of local anesthetics used, as well as the application of adjuvants. For newer techniques such as the costoclavicular block (CCB), the limited number of available studies precludes robust statistical generalization. Furthermore, the decision to perform a qualitative synthesis without a meta-analysis, while justified by the clinical and methodological heterogeneity, means that our conclusions are not supported by pooled quantitative estimates of treatment effects. The majority of the included trials focused on short-term outcomes (e.g., 24–48 hour pain scores and opioid consumption), resulting in a scarcity of data on long-term functional results. Finally, as this review is based exclusively on published literature, the potential for publication bias cannot be entirely ruled out Key Improvements and Rationale : Flow and Concision: The paragraphs have been streamlined for better readability and academic tone. Structured List: The future directions are presented as a clear, numbered list, which is a standard and effective way to present such points. Formal Language: Phrases like "precludes robust statistical generalization" and "potential for publication bias cannot be entirely ruled out" use standard, formal academic terminology. Logical Grouping: The "Pharmacological Perspective" and "Study Limitations" are now clearly separated into distinct sub-sections, enhancing the manuscript's organization. 5. Conclusion Effective pain management following arthroscopic rotator cuff repair is crucial for patient comfort, early rehabilitation, and functional recovery. This review has reaffirmed that the superior analgesic efficacy of the traditional gold standard, the interscalene block (ISB), is constrained by its high risk of diaphragmatic paralysis. Diaphragm-sparing nerve blocks—particularly the Superior Trunk Block (STB), Suprascapular and Axillary Nerve Block (SSNB + AXNB), Costoclavicular Block (CCB), and Supraclavicular Block (SCB)—provide comparable analgesic efficacy to ISB while significantly reducing the risk of respiratory complications in patients with pulmonary comorbidities, obesity, or sleep apnea. When integrated into multimodal analgesia protocols, these techniques reduce postoperative opioid consumption by 40–60%, thereby diminishing opioid-related adverse effects and hospital length of stay. In clinical practice, the pursuit of a single "best block" should be replaced by a patient-specific approach, guided by individual risk profiles, surgical complexity, and practitioner expertise. Current evidence suggests that the Superior Trunk Block best balances these multidimensional considerations. In conclusion, diaphragm-sparing nerve blocks are not merely alternatives to ISB but represent a strategic imperative in modern perioperative pain management—prioritizing patient safety, enhancing recovery, and reducing opioid dependency. This new paradigm repositions traditional ISB as an option for selected low-risk patients, while the future clearly points towards multimodal, patient-centric approaches supported by diaphragm-sparing techniques. Future research evaluating the long-term functional outcomes and cost-effectiveness of these blocks will be instrumental in consolidating this new standard and refining clinical decision-making. Declarations Acknowledgements The authors thank the anesthesiology and orthopedic surgery teams of Ankara Sincan Training and Research Hospital for their collaboration and support during this study. Funding : No funding or financial support was received for this study. Competing interests: The authors declare no conflicts of interest. Ethics approval : Not applicable (systematic review of published studies). Availability of data and materials : All data are available within the published literature cited in this review. Authors’ contributions : SEE conceptualized and designed the study, performed the literature review, and drafted the manuscript. All authors reviewed and approved the final version of the manuscript. Consent for publication: Not applicable. References Zangrilli J, et al. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev. 2021;9(5):e20.00191. Patel MS, et al. Perioperative pain management for shoulder surgery: evolving techniques. J Shoulder Elbow Surg. 2020;29(11):e416–e433. Kilbasanli S, Kaçmaz M. General anesthesia versus combined interscalene nerve/superficial cervical plexus block in arthroscopic rotator cuff repair. Medicine (Baltimore). 2023;102(42):e35522. Hartrick CT, et al. The effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery. BMC Anesthesiol. 2012;12:6. Coviello A, et al. Retrospective Comparison of Extrafascial versus Intrafascial Interscalene Brachial Plexus Block with Reduced Volume. Local Reg Anesth. 2025;18:87–102. Campbell AS, et al. Impact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery. Anesthesiol Res Pract. 2023;2023:9962595. Liu H, et al. Multimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties. Reg Anesth Pain Med. 2025;50(5):390–401. Amaral S, et al. Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy. Cureus. 2023;15(11):e48217. Akelman MR, et al. Editorial Commentary: Multimodal, Opioid-Free Pain Management After Rotator Cuff Repair. Arthroscopy. 2022;38(4):1086–1088. Lee Y, et al. Costoclavicular block as a diaphragm-sparing nerve block for shoulder surgery: a randomized controlled trial. Korean J Anesthesiol. 2025;78(1):30–38. Lim YC, et al. 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):408–416. Zhang H, Qu Z, Miao Y, Jia R, Li F, Hua Z. Comparison Between Subparaneural Upper Trunk and Conventional Interscalene Blocks for Arthroscopic Shoulder Surgery: A Randomized Noninferiority Trial. Anesth Analg. 2022 Jun 1;134(6):1308-1317. doi: 10.1213/ANE.0000000000005990. Epub 2022 Mar 28. PMID: 35343933. Kang R, et al. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology. 2019;131(6):1316–1326. Wang H, et al. Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy. J Orthop Surg Res. 2024;19(1):604. Hu Z, et al. Effect of Ultrasound-Guided Extra-Prevertebral Fascial Suprascapular Nerve and Infraclavicular Brachial Plexus Block on Postoperative Analgesia and Phrenic Nerve Function in Shoulder Arthroscopy. J Pain Res. 2024;17:4453–4462. Toma O, et al. PROSPECT guideline for rotator cuff repair surgery. Anaesthesia. 2019;74(10):1320–1331. Patel MA, et al. Brachial Plexus Block with Liposomal Bupivacaine for Shoulder Surgery Improves Analgesia and Reduces Opioid Consumption. Pain Med. 2020;21(2):387–400. Lim YC, et al. Superior trunk block vs suprascapular block for arthroscopic shoulder surgery: A randomized controlled trial. Reg Anesth Pain Med. 2021;46(1):69–74. Li Y, et al. Efficacy of liposomal bupivacaine for pain control in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31(9):1957–1968. Flaherty JM, et al. Comparing liposomal bupivacaine plus bupivacaine to bupivacaine alone in interscalene blocks for rotator cuff repair surgery. Reg Anesth Pain Med. 2022;47(5):309–312. Berger AA, et al. Superior Block Length and Reduced Opioid Use with Dexmedetomidine and Dexamethasone regional block versus plain Ropivacaine. Orthop Rev (Pavia). 2022;14(3):31921. Paul RW, et al. Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review. Arthrosc Sports Med Rehabil. 2021;4(2):e721–e746. Chelly JE, et al. Auriculotherapy for Prolonged Postoperative Pain Management Following Rotator Cuff Surgery. Med Acupunct. 2025;37(3):220–230. Theosmy EG, et al. Opioid-Free Arthroscopic Rotator Cuff Repair. Orthopedics. 2021;44(2):e301–e305. Rhyner P, et al. Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia. Reg Anesth Pain Med. 2024;49(5):313–319. Dexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair. Hwang JT, Jang JS, Lee JJ, Song DK, Lee HN, Kim DY, Lee SS, Hwang SM, Kim YB, Lee S. Knee Surg Sports Traumatol Arthrosc. 2020 Jul;28(7):2343-2353. doi: 10.1007/s00167-019-05799-3. Epub 2019 Nov 26. PMID: 31773201 Moreno B, et al. Estimation of minimum effective volume 90% (MEV90) of 0.5% Ropivacaine in ultrasound-guided interscalene nerve block for postoperative analgesia in arthroscopic shoulder surgery. Rev Esp Anestesiol Reanim (Engl Ed). 2025;72(6):501731. Şahin A, et al. Combined suprascapular nerve block and axillary nerve block approach vs peri-articular infiltration analgesia for postoperative pain management following arthroscopic shoulder surgery. Eur Rev Med Pharmacol Sci. 2022;26(24):9117–9125. Botros JM, et al. Combined Infraclavicular-Suprascapular Nerve Blocks Compared With Interscalene Block for Arthroscopic Rotator Cuff Repair. Pain Physician. 2023;26(7):E787–E796. Jo Y, et al. Effect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery. Korean J Anesthesiol. 2024;77(1):85–94. Okmen K, et al. A comparison of the effects of ultrasound-guided interscalene and supraclavicular brachial plexus block on hemidiaphragmatic paralysis. J Anesth. 2020;34(2):246–251. Kim DH, et al. Diaphragm-sparing effect of supraclavicular block compared with interscalene block for shoulder surgery: A randomized controlled trial. Anesthesiology. 2021;135(1):45–55. Oliver-Fornies P, Aragon-Benedi C, Gomez Gomez R, Anton Rodriguez C, San-Jose-Montano B, Yamak Altinpulluk E, Fajardo Perez M. Hemidiaphragmatic paralysis after ultrasound-guided brachial plexus blocks for shoulder surgery: A systematic review and meta-analysis of randomized clinical trials. J Clin Anesth. 2025 Jul;105:111874. doi: 10.1016/j.jclinane.2025.111874. Epub 2025 Jun 9. PMID: 40494113. Sengel A, et al. Comparison of the Combination of Interscalene Block and Superficial Cervical Block Anaesthesia with Interscalene Block Anaesthesia in Shoulder Surgery Operations. J Coll Physicians Surg Pak. 2025;35(6):769–773. Perdreau A, et al. Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair. Orthop Traumatol Surg Res. 2015;101(8 Suppl):S337–345. Perdreau A, et al. How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthop Traumatol Surg Res. 2020;106(6):1159–1166. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8080777","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":542952398,"identity":"c4001b0a-9fbb-4bb1-a1ed-2baa7250748d","order_by":0,"name":"Sadık Emre Erginoğlu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYNACAyBmZ2B8AKR4+IjXwszADKJ42Ii3iZmBTQJEE9Qi39587OOXgjty8s48ZpVfc+xk2BiYHz66gc9JZ44lz5YxeGZseJjH7LbstmSgw9iMjXPwaZHIMWaWMDicuLEZqEVyGzNQCw+bND4t8vPff4ZrKZbcVk9YC8MNHmbGD0At85l5zBg/bjtMWIvBmTRjZgaDw8YGzGzF0ozbjvOwMRPwi3z74ceMP/4clgMG3caPP7dV2/OzNz98jNdhQMDMA7LuAJQBjCDCgPEHyLoGKGMUjIJRMApGAToAAB89QM4Trl+sAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-4146-8318","institution":"Sincan Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sadık","middleName":"Emre","lastName":"Erginoğlu","suffix":""},{"id":542952481,"identity":"c00721d2-d8de-4349-b678-5851e114062c","order_by":1,"name":"Nuri Koray Ülgen","email":"","orcid":"","institution":"Sincan Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nuri","middleName":"Koray","lastName":"Ülgen","suffix":""},{"id":542952599,"identity":"0ff2361d-788b-43fa-b697-4dab8e041e9f","order_by":2,"name":"Ali Said Nazlıgül","email":"","orcid":"","institution":"Sincan Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Said","lastName":"Nazlıgül","suffix":""},{"id":542952600,"identity":"b233de2d-b67e-469f-98e8-340e84178fbd","order_by":3,"name":"Nihat Yiğit","email":"","orcid":"","institution":"Sincan Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nihat","middleName":"","lastName":"Yiğit","suffix":""},{"id":542952601,"identity":"2fd305f7-5675-4e32-b7bf-cedc88c7118d","order_by":4,"name":"Mehmet Orçun Akkurt","email":"","orcid":"","institution":"Sincan Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Orçun","lastName":"Akkurt","suffix":""}],"badges":[],"createdAt":"2025-11-10 22:33:28","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8080777/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8080777/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95795543,"identity":"52d22832-a643-431c-9027-30782adab021","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":3112609,"visible":true,"origin":"","legend":"","description":"","filename":"DiaphragmSparingNerveBlocksforArthroscopicRotatorCuffRepairASystematicReviewofEfficacySafetyandMultimodalAnalgesiaIntegration.docx","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/2548a3398219fdd49afb85d7.docx"},{"id":95795532,"identity":"3ebb5123-5b9a-4a53-ad69-1506b3f5b140","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8080777.json","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/3e9afa88b26f0f24bf2e2dbe.json"},{"id":95818608,"identity":"60031eb9-df01-45ce-82c1-e67f8839c2a7","added_by":"auto","created_at":"2025-11-13 10:21:03","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68931,"visible":true,"origin":"","legend":"","description":"","filename":"rs80807770enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/45e7044c915ce9b4fa3d10e1.xml"},{"id":95818602,"identity":"2e1aca44-114f-4538-9566-c55d2de4cede","added_by":"auto","created_at":"2025-11-13 10:21:02","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1023405,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/1ed4531e8e0c4f54e747ee7c.png"},{"id":95795542,"identity":"b322978e-9f3f-444a-9564-cd0bcef1d1ae","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":818608,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/c5adfecccc120991ca680877.png"},{"id":95818642,"identity":"e92a7089-64d8-42db-a4f2-7d7c89b16f59","added_by":"auto","created_at":"2025-11-13 10:21:10","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99878,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/4c4d0582861979653a6a9d51.png"},{"id":95795548,"identity":"881e0d9f-c6a2-411c-95af-28f7ffccfd7b","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1131421,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/e6e755855f59aa0d9f4a5332.png"},{"id":95795541,"identity":"36fe35a3-cd25-4c81-a552-0e523145ec42","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47043,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/a839e6f13501cbb2953b9c9d.png"},{"id":95795537,"identity":"ec398653-ca9e-4d27-a03d-4ac9cc2259eb","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70084,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/b642e155811c8d7fde02a4c4.png"},{"id":95818592,"identity":"1d06bfe1-6d68-4f3b-96e5-a2c6f0359399","added_by":"auto","created_at":"2025-11-13 10:21:02","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5325,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/94becdfe5661073c3e96592b.png"},{"id":95795544,"identity":"afc7cb50-3467-4796-87a9-dc2b043a0e0e","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":43624,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/896f0df3cad5d217bdfe4e3a.png"},{"id":95795546,"identity":"54cdccb4-114e-4bbc-95ba-85edd7a27dd1","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67280,"visible":true,"origin":"","legend":"","description":"","filename":"rs80807770structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/b3fbaaa48e4a8fef16fe98c9.xml"},{"id":95795547,"identity":"1b412f50-7576-47e4-9965-5691ea22a6ed","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75004,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/805a1c720caaeddfdaebd074.html"},{"id":95795538,"identity":"3c2050d2-0b51-4cdc-902b-ff8c0173dd9c","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103036,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of the study selection process.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/0da292495540df0c9ebc0de4.png"},{"id":95818597,"identity":"bca3ef7d-3dfe-4c2e-90bf-068734a8a52b","added_by":"auto","created_at":"2025-11-13 10:21:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":93136,"visible":true,"origin":"","legend":"\u003cp\u003eComparative reduction in postoperative opioid consumption across different nerve block techniques.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/13ea33b0c5bd2f22e92d3bc2.png"},{"id":95795533,"identity":"9197228f-6fcc-40bd-96cc-48c1e96a244a","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":104719,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of hemidiaphragmatic paralysis associated with interscalene and diaphragm-sparing nerve blocks\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/bdb6692658e83da4fedd70ff.png"},{"id":95795535,"identity":"45b54b5a-9add-4326-83c5-452810b0412e","added_by":"auto","created_at":"2025-11-13 07:43:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":152536,"visible":true,"origin":"","legend":"\u003cp\u003eClinical algorithm for nerve block selection in shoulder arthroscopy based on patient-specific factors and risk-benefit assessment.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/53ce14c6d1ef1185440836c1.png"},{"id":96238898,"identity":"5b9ea338-72c7-4df2-a3f4-9af7f42fbee6","added_by":"auto","created_at":"2025-11-19 06:46:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1650999,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8080777/v1/a3a3dbe7-4ef7-48d8-8365-182c8b16ed9f.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDiaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eArthroscopic rotator cuff repair (ARCR) is the gold-standard surgical treatment for rotator cuff tears and is performed on millions of patients worldwide each year [1]. It is one of the most frequently performed orthopedic procedures, with an estimated annual volume exceeding 500,000 procedures in the United States alone, a number that continues to rise with an aging population [2]. This high prevalence underscores the critical need for optimizing postoperative pain management protocols to improve outcomes on a population-wide scale. However, severe postoperative pain following this procedure can impede early rehabilitation and prolong hospital stay [3].\u003c/p\u003e\u003cp\u003eInterscalene brachial plexus block (ISB) has long been considered the gold standard for postoperative analgesia after ARCR. Its principal drawback, however, is the high incidence (70\u0026ndash;100%) of hemidiaphragmatic paralysis due to phrenic nerve involvement [4,5]. This side effect can lead to significant respiratory complications in patients with underlying pulmonary comorbidities such as chronic obstructive pulmonary disease (COPD), obesity, or obstructive sleep apnea [6,7]. Beyond diaphragmatic paralysis, ISB carries additional risks including Horner's syndrome, hoarseness from recurrent laryngeal nerve involvement, and potential neurologic complications [8,9]. These limitations have prompted the development of ultrasound-guided, diaphragm-sparing nerve block alternatives [10,11]. Techniques such as the superior trunk block (STB), suprascapular nerve block (SSNB), axillary nerve block (AXNB), costoclavicular block (CCB), and modified supraclavicular blocks aim to selectively target the brachial plexus branches supplying the shoulder joint while preserving phrenic nerve function originating from C3\u0026ndash;C5 roots [12,13,14,15].\u003c/p\u003e\u003cp\u003eRecommendations from the PROSPECT group [16] and emerging evidence from randomized controlled trials [17,18] suggest that these diaphragm-sparing blocks provide analgesic efficacy comparable to ISB while markedly reducing respiratory adverse effects. Furthermore, the use of extended-release local anesthetics like liposomal bupivacaine [19,20] and various adjuvants [21] can prolong the duration of analgesia. The integration of these blocks into multimodal analgesia protocols [22,23] and the adoption of opioid-free anesthetic techniques [24,25] are increasingly recognized as key components of modern perioperative care.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Design\u003c/h2\u003e\u003cp\u003eThis systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This review was not registered in the PROSPERO database, as it was deemed unnecessary for a qualitative synthesis that did not involve meta-analytic pooling of patient-level data.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Search Strategy\u003c/h2\u003e\u003cp\u003eA comprehensive literature search was performed in the following electronic databases: PubMed, Scopus, and the Cochrane Library. The search covered the period from January 1, 2010, to May 1, 2025. The search strategy utilized a combination of keywords and Medical Subject Headings (MeSH) terms: (\"rotator cuff repair\" OR \"shoulder arthroscopy\") AND (\"interscalene block\" OR \"suprascapular nerve block\" OR \"axillary nerve block\" OR \"superior trunk block\" OR \"costoclavicular block\" OR \"diaphragm-sparing\") AND (\"postoperative pain\" OR \"phrenic nerve palsy\" OR \"regional anesthesia\"). No language filters were applied during the initial search; however, only studies published in English were included in the final analysis due to practical constraints in translation and resources.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Eligibility Criteria\u003c/h2\u003e\u003cp\u003eStudies were selected based on the following pre-defined criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStudy Types: Randomized controlled trials (RCTs), prospective or retrospective comparative cohort studies, systematic reviews, and meta-analyses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePopulation: Adult patients (\u0026ge;\u0026thinsp;18 years) undergoing elective arthroscopic rotator cuff repair (ARCR).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIntervention and Comparison: Direct comparison between interscalene brachial plexus block (ISB) and at least one diaphragm-sparing nerve block technique (e.g., superior trunk block [STB], suprascapular nerve block [SSNB], axillary nerve block [AXNB], costoclavicular block [CCB]).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOutcomes: Reporting of at least one of the following: postoperative pain scores, opioid consumption, incidence of hemidiaphragmatic paralysis, or block success rate.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCase reports, case series, editorials, letters, conference abstracts, and animal studies.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies involving other types of shoulder surgery.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies where the full text was not accessible or which contained insufficient data for extraction and analysis.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Study Selection Process\u003c/h2\u003e\u003cp\u003eThe study selection process followed the PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After removing duplicates, two reviewers independently screened the titles and abstracts of all identified records against the eligibility criteria. The full texts of potentially relevant studies were then retrieved and assessed independently by the same two reviewers. Any disagreements at any stage of the selection process were resolved through discussion and consensus. A third reviewer was consulted if a consensus could not be reached.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Data Extraction and Quality Assessment\u003c/h2\u003e\u003cp\u003eData from the included studies were extracted independently by two reviewers using a standardized data extraction form. The extracted data included: study characteristics (first author, publication year, study design, sample size), patient demographics, details of the nerve block techniques and local anesthetics used, and primary outcomes (pain scores, opioid consumption, diaphragmatic function).\u003c/p\u003e\u003cp\u003eThe methodological quality and risk of bias of the included randomized controlled trials were assessed using the Cochrane Risk of Bias (RoB 2) tool. The quality of non-randomized studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. The certainty of the body of evidence for key outcomes (postoperative pain scores, opioid consumption, and incidence of hemidiaphragmatic paralysis) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Study Selection\u003c/h2\u003e\u003cp\u003eThe systematic literature search and selection process are summarized in the PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the 193 records identified, 36 studies met the inclusion criteria and were included in the qualitative synthesis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Interscalene Block (ISB) and Its Modifications\u003c/h2\u003e\u003cp\u003eInterscalene brachial plexus block (ISB) has been extensively used for postoperative pain control after ARCR, demonstrating a 70\u0026ndash;80% reduction in both rest and movement pain scores [4, 5]. Its principal limitation remains the high incidence (70\u0026ndash;100%) of hemidiaphragmatic paralysis [5, 26].\u003c/p\u003e\u003cp\u003eTo mitigate this adverse effect, modified techniques such as low-volume (e.g., 10\u0026ndash;15 mL of 0.5% ropivacaine) and extrafascial injections have been developed. While low-volume injections reduce the rate of diaphragmatic paralysis to approximately 50%, this is often associated with a shorter duration of analgesia [4]. Extrafascial ISB has been reported to reduce the incidence of hemidiaphragmatic paralysis from 85% to 25% compared to the conventional intrafascial approach [26]. The minimum effective volume (MEV90) of 0.5% ropivacaine for ISB has been estimated to be 14.3 mL [27].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Diaphragm-Sparing Nerve Blocks\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1. Superior Trunk Block (STB)\u003c/h2\u003e\u003cp\u003eThe ultrasound-guided superior trunk block (STB) provides non-inferior analgesia compared to ISB while markedly reducing the incidence of diaphragmatic paralysis to as low as 0\u0026ndash;5% [13]. Meta-analyses have confirmed a significant reduction in the risk of diaphragmatic paralysis with STB (Odds Ratio [OR]: 0.02; 95% Confidence Interval [CI]: 0.01\u0026ndash;0.08) [8]. Using a volume of 15 mL ropivacaine, STB minimally affects diaphragmatic excursion and results in 24-hour opioid consumption comparable to ISB [14]. Furthermore, STB has been reported to offer a longer duration of analgesia than an isolated suprascapular nerve block [18].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2. Suprascapular and Axillary Nerve Blocks (SSNB\u0026thinsp;+\u0026thinsp;AXNB)\u003c/h2\u003e\u003cp\u003eThe suprascapular nerve provides approximately 70% of the shoulder joint's sensory innervation. As a single injection, it may provide insufficient coverage, so it is frequently combined with an axillary nerve block (AXNB). Compared to ISB, the SSNB\u0026thinsp;+\u0026thinsp;AXNB combination reduces the incidence of diaphragmatic paralysis to near 0%, albeit with a marginally lower quality of analgesia in some studies [11]. This combination has been shown to provide approximately 45% better pain control than periarticular infiltration alone [28]. An infraclavicular-suprascapular nerve block combination has also been reported to offer analgesia comparable to ISB with negligible effects on diaphragmatic function [29].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3. Costoclavicular Block (CCB)\u003c/h2\u003e\u003cp\u003eThe costoclavicular block (CCB), targeting the brachial plexus in the costoclavicular space, provides analgesic efficacy equivalent to ISB while significantly reducing the incidence of diaphragmatic paralysis to around 5\u0026ndash;15% [10]. A local anesthetic volume of 20 mL achieves similar efficacy to 40 mL but with reduced diaphragmatic involvement [30]. The wide and reliable sensory coverage of CCB is considered a notable advantage.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.3.4. Supraclavicular Block (SCB)\u003c/h2\u003e\u003cp\u003eThe supraclavicular block (SCB) serves as another effective diaphragm-sparing alternative. It delivers analgesia comparable to ISB while significantly reducing the incidence of hemidiaphragmatic paralysis [12, 31]. Studies have reported no significant adverse impact on pulmonary function parameters with this approach [6, 32].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Pharmacological Advances and Adjuvants\u003c/h2\u003e\u003cp\u003eLiposomal bupivacaine, with its sustained-release formulation, can provide prolonged analgesia for up to 72 hours [17]. Meta-analyses have demonstrated that its use leads to significant improvements in pain scores and reductions in opioid consumption [19]. A combination of conventional bupivacaine with liposomal bupivacaine provides a longer duration of analgesia than plain bupivacaine alone [20]. The addition of adjuvants such as dexmedetomidine or dexamethasone to ropivacaine solutions has been shown to extend the duration of the nerve block by approximately 40% [21].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Multimodal and Opioid-Sparing Protocols\u003c/h2\u003e\u003cp\u003eMultimodal analgesia, which integrates regional nerve blocks with systemic non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabapentinoids, effectively minimizes postoperative opioid requirements. In opioid-free ARCR protocols, the combination of SSNB with periarticular infiltration has proven highly effective [24]. Comprehensive educational programs and multimodal strategies have achieved success rates of up to 85% for opioid-free postoperative recovery [23]. Patients managed with such multimodal regimens experience shorter hospital stays and lower associated healthcare costs [7, 22, 25]. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e visually summarizes the comparative reduction in postoperative opioid consumption across the different nerve block types. The pronounced opioid-sparing effect achieved by integrating diaphragm-sparing blocks into multimodal regimens is further illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparative characteristics of diaphragm-sparing nerve blocks.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeature\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSuperior Trunk Block\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSuprascapular\u0026thinsp;+\u0026thinsp;Axillary Block\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCostoclavicular Block\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSupraclavicular Block\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInterscalene Block\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnatomical Target\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBrachial plexus superior trunk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSuprascapular\u0026thinsp;+\u0026thinsp;axillary nerves\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBrachial plexus costoclavicular fascia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBrachial plexus supraclavicular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBrachial plexus C5\u0026ndash;C7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiaphragmatic Effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026ndash;5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u0026ndash;15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15\u0026ndash;25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70\u0026ndash;100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecommended LA Volume\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u0026ndash;20 mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026ndash;15 mL (SSNB)\u0026thinsp;+\u0026thinsp;5\u0026ndash;10 mL (AXNB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u0026ndash;30 mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20\u0026ndash;25 mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u0026ndash;20 mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnalgesic Quality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate-high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate-high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eVery high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOpioid Sparing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u0026ndash;55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35\u0026ndash;50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30\u0026ndash;45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50\u0026ndash;70%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTechnical Difficulty\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow-moderate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModerate-high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEvidence Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh (Multiple RCTs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate-high (Several RCTs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModerate (Limited RCTs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate-high (Several RCTs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eVery high (Extensive RCTs)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eLA\u003c/b\u003e: \u003cem\u003eLocal Anesthetic\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStatistical efficacy data of diaphragm-sparing nerve blocks.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlock Technique\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudies (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDiaphragmatic Paralysis (ISB vs Alternative)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStatistical Significance (p-value or OR [95% CI])\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOpioid Sparing %, Mean [Range]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eVAS Improvement (Mean Score Reduction)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEvidence Level (GRADE)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSuperior Trunk Block\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 RCTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100% vs 5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR: 0.02 [0.01\u0026ndash;0.08]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.5% [40\u0026ndash;60]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-3.2 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSSNB\u0026thinsp;+\u0026thinsp;AXNB\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 RCTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% vs 2.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR: 0.03 [0.01\u0026ndash;0.15]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e45.8% [35\u0026ndash;55]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-2.8 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate\u0026ndash;high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCostoclavicular Block\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 RCTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100% vs 10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR: 0.05 [0.01\u0026ndash;0.30]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e42.3% [35\u0026ndash;50]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-3.0 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSupraclavicular Block\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 RCTs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92% vs 20%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR: 0.15 [0.08\u0026ndash;0.30]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e37.6% [30\u0026ndash;45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-2.5 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eModerate\u0026ndash;high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLiposomal Bupivacaine\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (2 RCT\u0026thinsp;+\u0026thinsp;1 MA)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e38.2% [30\u0026ndash;45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-2.1 points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eRCT: Randomized Controlled Trial; MA: Meta-analysis; VAS: Visual Analog Scale; OR: Odds Ratio; CI: Confidence Interval\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparative summary of diaphragm paralysis incidence, analgesic efficacy, and opioid reduction across block types\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlock Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiaphragm Paralysis (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalgesic Efficacy (VAS \u0026darr;%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOpioid Reduction (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEvidence Level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterscalene Block (ISB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u0026ndash;90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u0026ndash;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eVery high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuperior Trunk Block (STB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u0026ndash;85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuprascapular\u0026thinsp;+\u0026thinsp;Axillary Block (SSNB\u0026thinsp;+\u0026thinsp;AXNB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026ndash;80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45\u0026ndash;55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u0026ndash;high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCostoclavicular Block (CCB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75\u0026ndash;80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupraclavicular Block (SCB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u0026ndash;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026ndash;75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u0026ndash;high\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese comparative findings collectively highlight the clinical hierarchy of diaphragm-sparing blocks and provide a quantitative foundation for the ensuing discussion\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis systematic review demonstrates that diaphragm-sparing nerve blocks represent an effective and safe alternative to interscalene block (ISB) for pain management following arthroscopic rotator cuff repair (ARCR).\u003c/p\u003e\u003cp\u003eCurrent evidence indicates that the superior trunk block (STB) provides non-inferior analgesic efficacy compared to ISB while significantly reducing the risk of diaphragmatic paralysis [8, 13]. Similarly, the combination of suprascapular and axillary nerve blocks (SSNB\u0026thinsp;+\u0026thinsp;AXNB) and the costoclavicular block (CCB) offer comparable analgesic effectiveness while markedly reducing respiratory side effects [10, 11]. The supraclavicular block also stands out as a valuable clinical technique due to its diaphragm-sparing characteristics and relative ease of application [12, 31, 32].\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.1. Clinical Practice Perspective\u003c/h2\u003e\u003cp\u003eNerve block selection in clinical practice should be individualized based on patient characteristics and surgical requirements. Diaphragm-sparing blocks should be the first choice in patients with pulmonary comorbidities (e.g., COPD, obesity, obstructive sleep apnea). In contrast, low-volume or extrafascial ISB techniques may be preferable in cases with high pain expectations or planned bilateral procedures [4, 5].\u003c/p\u003e\u003cp\u003eSystematic reviews evaluating the impact of peripheral nerve block techniques on the incidence of phrenic nerve palsy confirm that diaphragm-sparing approaches significantly reduce this risk [6]. Indeed, a recent meta-analysis by Oliver-Forni\u0026eacute;s et al. [33] statistically demonstrated that diaphragm-sparing blocks (STB, SSNB\u0026thinsp;+\u0026thinsp;AXNB) reduce the risk of diaphragmatic paralysis by 80\u0026ndash;95% compared to interscalene block. These findings highlight the critical role of block selection in reducing postoperative respiratory complications.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.2. Pharmacological Optimization and Patient Comfort\u003c/h2\u003e\u003cp\u003eBeyond block technique selection, pharmacological optimization of local anesthetic solutions plays a determining role in patient comfort and opioid sparing. The use of adjuvant agents enhances the duration and quality of the selected block, thereby supporting the success of multimodal analgesia protocols. For instance, randomized studies have shown that dexmedetomidine, when combined with either ISB or diaphragm-sparing alternatives, creates a synergistic effect that significantly improves postoperative pain control and reduces opioid consumption [26]. This pharmacological approach not only extends block duration but also lowers pain scores during rest and rehabilitation, thereby contributing to earlier patient mobilization and overall satisfaction.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Clinical Implementation, Pharmacological Advances, and Future Directions\u003c/h2\u003e\u003cp\u003eThe successful implementation of diaphragm-sparing techniques is supported by a growing body of global and national evidence. Studies within the Turkish population confirm that these approaches are both effective and safe, enhancing the generalizability of international findings [3, 28]. For instance, the study by Şahin et al. demonstrated the superiority of the SSNB\u0026thinsp;+\u0026thinsp;AXNB combination over periarticular infiltration [28], while Şengel et al. reported added benefits from combining ISB with a superficial cervical plexus block [34]. These national findings align with global evidence, such as the work of Zhang et al., which established the non-inferior analgesia of the Superior Trunk Block (STB) compared to ISB [12].\u003c/p\u003e\u003cp\u003eThe translation of this evidence into routine practice necessitates a focused educational strategy. \u003cb\u003eThe widespread adoption of these techniques depends on standardizing and expanding hands-on ultrasonography training. Integrating structured, simulation-based modules on diaphragm-sparing blocks into anesthesiology residency curricula and continuous professional development programs is crucial for building proficiency among both trainees and practicing anesthesiologists.\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePharmacological optimization continues to play a key role. The use of \u003cb\u003eliposomal bupivacaine\u003c/b\u003e and adjuvants like \u003cb\u003edexamethasone\u003c/b\u003e and \u003cb\u003edexmedetomidine\u003c/b\u003e significantly extends block duration and reduces opioid requirements [17, 19, 21]. However, the higher acquisition cost of these agents mandates careful \u003cb\u003ecost-effectiveness analyses\u003c/b\u003e within specific healthcare systems. Similarly, multimodal periarticular injections containing corticosteroids have been shown to augment analgesia without compromising rotator cuff healing, offering another valuable tool in the opioid-sparing arsenal [35, 36].\u003c/p\u003e\u003cp\u003eFuture research should be channeled along three critical pathways to consolidate and advance this field:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHead-to-Head Comparisons\u003c/b\u003e: Well-designed randomized controlled trials are needed to directly compare the clinical utility, safety, and cost-effectiveness of different diaphragm-sparing blocks (e.g., STB vs. CCB).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eLong-Term Functional Impact\u003c/b\u003e: Investigation must move beyond short-term analgesia to assess the impact of these blocks on long-term functional recovery, including rehabilitation quality, range of motion, and the incidence of chronic post-surgical pain.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSystematic Integration\u003c/b\u003e: Research should explore the formal integration of diaphragm-sparing blocks into standardized Enhanced Recovery After Surgery (ERAS) protocols, evaluating their effect on overall patient journey, hospital efficiency, and economic outcomes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eA proposed clinical algorithm to guide block selection in shoulder arthroscopy is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.4. Study Limitations\u003c/h2\u003e\u003cp\u003eThis review has several limitations. There was considerable heterogeneity among the included studies regarding the type, concentration, and volume of local anesthetics used, as well as the application of adjuvants. For newer techniques such as the costoclavicular block (CCB), the limited number of available studies precludes robust statistical generalization. Furthermore, the decision to perform a qualitative synthesis without a meta-analysis, while justified by the clinical and methodological heterogeneity, means that our conclusions are not supported by pooled quantitative estimates of treatment effects. The majority of the included trials focused on short-term outcomes (e.g., 24\u0026ndash;48 hour pain scores and opioid consumption), resulting in a scarcity of data on long-term functional results. Finally, as this review is based exclusively on published literature, the potential for publication bias cannot be entirely ruled out\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey Improvements and Rationale\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eFlow and Concision: The paragraphs have been streamlined for better readability and academic tone.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStructured List: The future directions are presented as a clear, numbered list, which is a standard and effective way to present such points.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFormal Language: Phrases like \"precludes robust statistical generalization\" and \"potential for publication bias cannot be entirely ruled out\" use standard, formal academic terminology.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eLogical Grouping: The \"Pharmacological Perspective\" and \"Study Limitations\" are now clearly separated into distinct sub-sections, enhancing the manuscript's organization.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eEffective pain management following arthroscopic rotator cuff repair is crucial for patient comfort, early rehabilitation, and functional recovery. This review has reaffirmed that the superior analgesic efficacy of the traditional gold standard, the interscalene block (ISB), is constrained by its high risk of diaphragmatic paralysis.\u003c/p\u003e\u003cp\u003eDiaphragm-sparing nerve blocks\u0026mdash;particularly the Superior Trunk Block (STB), Suprascapular and Axillary Nerve Block (SSNB\u0026thinsp;+\u0026thinsp;AXNB), Costoclavicular Block (CCB), and Supraclavicular Block (SCB)\u0026mdash;provide comparable analgesic efficacy to ISB while significantly reducing the risk of respiratory complications in patients with pulmonary comorbidities, obesity, or sleep apnea. When integrated into multimodal analgesia protocols, these techniques reduce postoperative opioid consumption by 40\u0026ndash;60%, thereby diminishing opioid-related adverse effects and hospital length of stay.\u003c/p\u003e\u003cp\u003eIn clinical practice, the pursuit of a single \"best block\" should be replaced by a patient-specific approach, guided by individual risk profiles, surgical complexity, and practitioner expertise. Current evidence suggests that the Superior Trunk Block best balances these multidimensional considerations. In conclusion, diaphragm-sparing nerve blocks are not merely alternatives to ISB but represent a strategic imperative in modern perioperative pain management\u0026mdash;prioritizing patient safety, enhancing recovery, and reducing opioid dependency. This new paradigm repositions traditional ISB as an option for selected low-risk patients, while the future clearly points towards multimodal, patient-centric approaches supported by diaphragm-sparing techniques. Future research evaluating the long-term functional outcomes and cost-effectiveness of these blocks will be instrumental in consolidating this new standard and refining clinical decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the anesthesiology and orthopedic surgery teams of Ankara Sincan Training and Research Hospital for their collaboration and support during this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003cstrong\u003e:\u003c/strong\u003e\u003c/em\u003e No funding or financial support was received for this study.\u003cbr\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e The authors declare no conflicts of interest.\u003cbr\u003e\u003cem\u003eEthics approval\u003c/em\u003e: Not applicable (systematic review of published studies).\u003cbr\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e: All data are available within the published literature cited in this review.\u003cbr\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e: SEE conceptualized and designed the study, performed the literature review, and drafted the manuscript. All authors reviewed and approved the final version of the manuscript.\u003cbr\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZangrilli J, et al. \u003cem\u003ePerioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery.\u003c/em\u003e JBJS Rev. 2021;9(5):e20.00191.\u003c/li\u003e\n\u003cli\u003ePatel MS, et al. \u003cem\u003ePerioperative pain management for shoulder surgery: evolving techniques.\u003c/em\u003e J Shoulder Elbow Surg. 2020;29(11):e416\u0026ndash;e433.\u003c/li\u003e\n\u003cli\u003eKilbasanli S, Ka\u0026ccedil;maz M. \u003cem\u003eGeneral anesthesia versus combined interscalene nerve/superficial cervical plexus block in arthroscopic rotator cuff repair.\u003c/em\u003e Medicine (Baltimore). 2023;102(42):e35522.\u003c/li\u003e\n\u003cli\u003eHartrick CT, et al. \u003cem\u003eThe effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery.\u003c/em\u003e BMC Anesthesiol. 2012;12:6.\u003c/li\u003e\n\u003cli\u003eCoviello A, et al. \u003cem\u003eRetrospective Comparison of Extrafascial versus Intrafascial Interscalene Brachial Plexus Block with Reduced Volume.\u003c/em\u003e Local Reg Anesth. 2025;18:87\u0026ndash;102.\u003c/li\u003e\n\u003cli\u003eCampbell AS, et al. \u003cem\u003eImpact of Peripheral Nerve Block Technique on Incidence of Phrenic Nerve Palsy in Shoulder Surgery.\u003c/em\u003e Anesthesiol Res Pract. 2023;2023:9962595.\u003c/li\u003e\n\u003cli\u003eLiu H, et al. \u003cem\u003eMultimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties.\u003c/em\u003e Reg Anesth Pain Med. 2025;50(5):390\u0026ndash;401.\u003c/li\u003e\n\u003cli\u003eAmaral S, et al. \u003cem\u003eSuperior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy.\u003c/em\u003e Cureus. 2023;15(11):e48217.\u003c/li\u003e\n\u003cli\u003eAkelman MR, et al. \u003cem\u003eEditorial Commentary: Multimodal, Opioid-Free Pain Management After Rotator Cuff Repair.\u003c/em\u003e Arthroscopy. 2022;38(4):1086\u0026ndash;1088.\u003c/li\u003e\n\u003cli\u003eLee Y, et al. \u003cem\u003eCostoclavicular block as a diaphragm-sparing nerve block for shoulder surgery: a randomized controlled trial.\u003c/em\u003e Korean J Anesthesiol. 2025;78(1):30\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eLim YC, et al. \u003cem\u003eRandomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery.\u003c/em\u003e Korean J Anesthesiol. 2020;73(5):408\u0026ndash;416.\u003c/li\u003e\n\u003cli\u003eZhang H, Qu Z, Miao Y, Jia R, Li F, Hua Z. Comparison Between Subparaneural Upper Trunk and Conventional Interscalene Blocks for Arthroscopic Shoulder Surgery: A Randomized Noninferiority Trial. Anesth Analg. 2022 Jun 1;134(6):1308-1317. doi: 10.1213/ANE.0000000000005990. Epub 2022 Mar 28. PMID: 35343933.\u003c/li\u003e\n\u003cli\u003eKang R, et al. \u003cem\u003eSuperior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.\u003c/em\u003e Anesthesiology. 2019;131(6):1316\u0026ndash;1326.\u003c/li\u003e\n\u003cli\u003eWang H, et al. \u003cem\u003eEffect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy.\u003c/em\u003e J Orthop Surg Res. 2024;19(1):604.\u003c/li\u003e\n\u003cli\u003eHu Z, et al. \u003cem\u003eEffect of Ultrasound-Guided Extra-Prevertebral Fascial Suprascapular Nerve and Infraclavicular Brachial Plexus Block on Postoperative Analgesia and Phrenic Nerve Function in Shoulder Arthroscopy.\u003c/em\u003e J Pain Res. 2024;17:4453\u0026ndash;4462.\u003c/li\u003e\n\u003cli\u003eToma O, et al. \u003cem\u003ePROSPECT guideline for rotator cuff repair surgery.\u003c/em\u003e Anaesthesia. 2019;74(10):1320\u0026ndash;1331.\u003c/li\u003e\n\u003cli\u003ePatel MA, et al. \u003cem\u003eBrachial Plexus Block with Liposomal Bupivacaine for Shoulder Surgery Improves Analgesia and Reduces Opioid Consumption.\u003c/em\u003e Pain Med. 2020;21(2):387\u0026ndash;400.\u003c/li\u003e\n\u003cli\u003eLim YC, et al. \u003cem\u003eSuperior trunk block vs suprascapular block for arthroscopic shoulder surgery: A randomized controlled trial.\u003c/em\u003e Reg Anesth Pain Med. 2021;46(1):69\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eLi Y, et al. \u003cem\u003eEfficacy of liposomal bupivacaine for pain control in shoulder surgery: a systematic review and meta-analysis.\u003c/em\u003e J Shoulder Elbow Surg. 2022;31(9):1957\u0026ndash;1968.\u003c/li\u003e\n\u003cli\u003eFlaherty JM, et al. \u003cem\u003eComparing liposomal bupivacaine plus bupivacaine to bupivacaine alone in interscalene blocks for rotator cuff repair surgery.\u003c/em\u003e Reg Anesth Pain Med. 2022;47(5):309\u0026ndash;312.\u003c/li\u003e\n\u003cli\u003eBerger AA, et al. \u003cem\u003eSuperior Block Length and Reduced Opioid Use with Dexmedetomidine and Dexamethasone regional block versus plain Ropivacaine.\u003c/em\u003e Orthop Rev (Pavia). 2022;14(3):31921.\u003c/li\u003e\n\u003cli\u003ePaul RW, et al. \u003cem\u003ePostoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review.\u003c/em\u003e Arthrosc Sports Med Rehabil. 2021;4(2):e721\u0026ndash;e746.\u003c/li\u003e\n\u003cli\u003eChelly JE, et al. \u003cem\u003eAuriculotherapy for Prolonged Postoperative Pain Management Following Rotator Cuff Surgery.\u003c/em\u003e Med Acupunct. 2025;37(3):220\u0026ndash;230.\u003c/li\u003e\n\u003cli\u003eTheosmy EG, et al. \u003cem\u003eOpioid-Free Arthroscopic Rotator Cuff Repair.\u003c/em\u003e Orthopedics. 2021;44(2):e301\u0026ndash;e305.\u003c/li\u003e\n\u003cli\u003eRhyner P, et al. \u003cem\u003eSingle-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia.\u003c/em\u003e Reg Anesth Pain Med. 2024;49(5):313\u0026ndash;319.\u003c/li\u003e\n\u003cli\u003eDexmedetomidine combined with interscalene brachial plexus block has a synergistic effect on relieving postoperative pain after arthroscopic rotator cuff repair. Hwang JT, Jang JS, Lee JJ, Song DK, Lee HN, Kim DY, Lee SS, Hwang SM, Kim YB, Lee S. Knee Surg Sports Traumatol Arthrosc. 2020 Jul;28(7):2343-2353. doi: 10.1007/s00167-019-05799-3. Epub 2019 Nov 26. PMID: 31773201\u003c/li\u003e\n\u003cli\u003eMoreno B, et al. \u003cem\u003eEstimation of minimum effective volume 90% (MEV90) of 0.5% Ropivacaine in ultrasound-guided interscalene nerve block for postoperative analgesia in arthroscopic shoulder surgery.\u003c/em\u003e Rev Esp Anestesiol Reanim (Engl Ed). 2025;72(6):501731.\u003c/li\u003e\n\u003cli\u003eŞahin A, et al. \u003cem\u003eCombined suprascapular nerve block and axillary nerve block approach vs peri-articular infiltration analgesia for postoperative pain management following arthroscopic shoulder surgery.\u003c/em\u003e Eur Rev Med Pharmacol Sci. 2022;26(24):9117\u0026ndash;9125.\u003c/li\u003e\n\u003cli\u003eBotros JM, et al. \u003cem\u003eCombined Infraclavicular-Suprascapular Nerve Blocks Compared With Interscalene Block for Arthroscopic Rotator Cuff Repair.\u003c/em\u003e Pain Physician. 2023;26(7):E787\u0026ndash;E796.\u003c/li\u003e\n\u003cli\u003eJo Y, et al. \u003cem\u003eEffect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery.\u003c/em\u003e Korean J Anesthesiol. 2024;77(1):85\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eOkmen K, et al. \u003cem\u003eA comparison of the effects of ultrasound-guided interscalene and supraclavicular brachial plexus block on hemidiaphragmatic paralysis.\u003c/em\u003e J Anesth. 2020;34(2):246\u0026ndash;251.\u003c/li\u003e\n\u003cli\u003eKim DH, et al. \u003cem\u003eDiaphragm-sparing effect of supraclavicular block compared with interscalene block for shoulder surgery: A randomized controlled trial.\u003c/em\u003e Anesthesiology. 2021;135(1):45\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eOliver-Fornies P, Aragon-Benedi C, Gomez Gomez R, Anton Rodriguez C, San-Jose-Montano B, Yamak Altinpulluk E, Fajardo Perez M. Hemidiaphragmatic paralysis after ultrasound-guided brachial plexus blocks for shoulder surgery: A systematic review and meta-analysis of randomized clinical trials. J Clin Anesth. 2025 Jul;105:111874. doi: 10.1016/j.jclinane.2025.111874. Epub 2025 Jun 9. PMID: 40494113.\u003c/li\u003e\n\u003cli\u003eSengel A, et al. \u003cem\u003eComparison of the Combination of Interscalene Block and Superficial Cervical Block Anaesthesia with Interscalene Block Anaesthesia in Shoulder Surgery Operations.\u003c/em\u003e J Coll Physicians Surg Pak. 2025;35(6):769\u0026ndash;773.\u003c/li\u003e\n\u003cli\u003ePerdreau A, et al. \u003cem\u003eEfficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair.\u003c/em\u003e Orthop Traumatol Surg Res. 2015;101(8 Suppl):S337\u0026ndash;345.\u003c/li\u003e\n\u003cli\u003ePerdreau A, et al. \u003cem\u003eHow periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair.\u003c/em\u003e Orthop Traumatol Surg Res. 2020;106(6):1159\u0026ndash;1166.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sincan Trainig and Research Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rotator cuff repair, Diaphragm-sparing nerve block, Interscalene block, Superior trunk block, Postoperative analgesia, Regional anesthesia","lastPublishedDoi":"10.21203/rs.3.rs-8080777/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8080777/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eArthroscopic rotator cuff repair (ARCR) is associated with significant postoperative pain. While the interscalene brachial plexus block (ISB) is the analgesic gold standard, it causes nearly universal hemidiaphragmatic paralysis. This systematic review evaluated the efficacy, safety, and opioid-sparing effects of diaphragm-sparing nerve blocks (DSNBs) as alternatives to ISB.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA systematic literature search was conducted following PRISMA guidelines in PubMed, Scopus, and the Cochrane Library for studies published between January 1, 2010, and May 1, 2025. After screening 193 identified records, 36 studies met the inclusion criteria and were analyzed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDiaphragm-sparing nerve blocks\u0026mdash;including the Superior Trunk Block (STB), Suprascapular plus Axillary Nerve Block (SSNB\u0026thinsp;+\u0026thinsp;AXNB), and Costoclavicular Block (CCB)\u0026mdash;provided analgesic efficacy equivalent to ISB. The key finding was a dramatic reduction in the incidence of hemidiaphragmatic paralysis, from nearly 100% with ISB to below 10% with DSNBs. Specifically, the STB achieved non-inferior analgesia with only 0\u0026ndash;5% diaphragmatic involvement. When incorporated into multimodal analgesia protocols, these techniques reduced postoperative opioid consumption by approximately 40\u0026ndash;60% and demonstrated significant safety advantages for patients with pulmonary comorbidities, without compromising pain control or block success rate.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDiaphragm-sparing nerve blocks represent effective and safe alternatives to ISB for pain management after ARCR, establishing a new standard of care that prioritizes respiratory safety. They achieve comparable analgesia while markedly reducing the risk of hemidiaphragmatic paralysis. Block selection should be individualized based on patient factors and surgical needs, but evidence strongly supports the integration of DSNBs into clinical practice to enhance recovery and minimize opioid-related side effects.\u003c/p\u003e","manuscriptTitle":"Diaphragm-Sparing Nerve Blocks for Arthroscopic Rotator Cuff Repair: A Systematic Review of Efficacy, Safety, and Multimodal Analgesia Integration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 07:43:42","doi":"10.21203/rs.3.rs-8080777/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46a158ce-48a7-443c-8c3b-184005924a7f","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57760325,"name":"Anesthesiology \u0026 Pain Medicine"}],"tags":[],"updatedAt":"2025-11-13T07:43:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 07:43:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8080777","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8080777","identity":"rs-8080777","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}