Safety and acceptability of suprascapular nerve block in rheumatology patients. My right phrenic nerve was damaged (paralyzed) during surgery to remove a Thymic tumor. The diaphragm, the fundamental muscle of respiration, is innervated by the phrenic nerve which originates from the cervical ventral horn of C3-C5 roots, and it is supplied mainly by C4 [].Injury to the phrenic nerve and/or one of its roots may lead to diaphragmatic paralysis (DP) and dysfunction [].The spinal level mostly affected in cervical spondylosis is C5-C6, C6-C7, and C4-C5. All the terminal nerves supplying the shoulder arise distal to the origin of the superior trunk and hence analgesic efficacy is not compromised. Early results are comparable to sternotomy and VATS approaches. The diaphragm (white circle) is seen to move caudally, toward the probe, in M-mode. Costanzo MR, Ponikowski P, Javaheri S, et al. He is certified by the American Board of Plastic Surgery and has exceptional expertise and experience with nerve transfers and bypass grafting. The phrenic nerve regularly stimulates it to contract. In 3-4 years the diaphragm pacing system can pay for itself with the cost savings! Each end of the transected sural nerve is then sewn into a nerve conduit or nerve allograft to promote regeneration and hopefully avoid permanent sequelae of sural nerve sacrifice. Specific conditions we treat include: Unilateral phrenic nerve injury not related to regional anesthesia reduces the total lung capacity (by 14 to 29%), forced vital capacity (by 23 to 27%), and inspiratory capacity (by 10 to 20%) compared with baseline or predicted parameters.4649 Unilateral phrenic nerve palsy after interscalene block reduces the forced expiratory volume in 1 s (FEV1) by 16 to 40%,17,50 the forced vital capacity by 13 to 40%,36,50 and the peak expiratory flow rates by 15 to 43% (tables 1 and 2).36,40, Characteristics of Relevant Studies of Regional Anesthesia Techniques for Shoulder Surgery, Incidence and Magnitude of Phrenic Nerve Palsy and Analgesic Outcomes of Relevant Studies of Regional Anesthesia Techniques for Shoulder Surgery, The assessment of phrenic nerve palsy using ultrasound relies on visualizing the diaphragm and quantifying the magnitude and direction of its movement with respiration. Hernia repair. Patients work with physical therapists on strengthening their diaphragm and using their rib (intercostal) muscles and neck (scalene) muscles to help with breathing. Pulmonary function changes after interscalene brachial plexus anesthesia with 0.5% and 0.75% ropivacaine: A double-blinded comparison with 2% mepivacaine. A comparison of combined suprascapular and axillary nerve blocks to interscalene nerve block for analgesia in arthroscopic shoulder surgery: An equivalence study. On October 6, 2017, the FDA approved the Remede System for adult patients who have been diagnosed with moderate-to-severe CSA. Board certified thoracic surgeons evaluate and treat diaphragm conditions in conjunction with pulmonologists at the Brigham and Women's Hospital Lung Center. Pulmonary function changes during interscalene brachial plexus block: Effects of decreasing local anesthetic injection volume. Once a view of the curved, hyperechoic diaphragmatic line has been obtained, M-mode sonography is used to quantify the extent of diaphragmatic excursion. A Google search on Phrenic Nerve Treatment, lead him to find Dr. Matthew Ka. However, conventional interscalene block is associated with several complications, the most common of which is phrenic nerve palsy with ensuing hemidiaphragmatic paresis, and this has driven the development of modifications to the interscalene block as well as alternative techniques that target the peripheral sensory supply to the shoulder at sites distal to the C5 and C6 roots. The most common causes of phrenic nerve injury are surgical complications and trauma. Neurostimulation of the phrenic nerve is a new technology that has demonstrated improvement. What side(s) of your diaphragm is paralyzed? We also review the various techniques that seek to provide adequate regional anesthesia of the shoulder while minimizing the risk of phrenic nerve palsy, as well as methods for assessing their impact on diaphragmatic function, and thus provide a comprehensive narrative of their value in achieving these two objectives. 2). Transient phrenic nerve palsy is caused by local anesthetic spreading directly to the phrenic nerve and its contributing nerves (including the accessory phrenic nerve) or proximally to the roots of the phrenic nerve. That's a savings of up to $20,000 per year. It is more cost effective. Persistent phrenic nerve paresis following interscalene brachial plexus block. Theremed System should not be placed if an active infection is present. Treatment for neuropathy typically is covered by insurance. Lidocaine infusion for continuous interscalene nerve block: Is there evidence for local and systemic benefits? It is indicated for patients with diaphragmatic dysfunction owing to a C3 or higher spinal cord injury (such that the lower motor neuron formed from the C3-C5 nerve roots is uninjured), polio, amyotrophic lateral sclerosis, central sleep apnea . The remed System, remed EL System, and remed EL-X System have received FDA approval. (surgery, post-surgical recovery and phrenic conditioning) typically takes 12 weeks. The high incidence of phrenic nerve palsy associated with the conventional technique of interscalene block have led some to propose that the safest option to avoid phrenic nerve block would be to avoid performing an interscalene block altogether.3 However, the evidence indicates first that temporary phrenic nerve palsy is inconsequential in the vast majority of healthy patients and, second, that relatively simple modifications such as minimizing local anesthetic doses and injection volumes (to less than 10 ml), as well as performing injection further distal to the C5C6 nerve roots (e.g., at the level of the superior trunk or supraclavicular brachial plexus), will significantly reduce the incidence of phrenic nerve palsy. Less disposable equipment A patient utilizing the Avery Diaphragm Pacing System with a plugged or omitted tracheostoma does not need respiratory tubes, filters, or suction catheters. Patients endured chronic shortness of breath, sleep disturbances, and lower energy levels. Phrenic nerve injury, such as may occur from cardiothoracic surgery, can lead to diaphragmatic paralysi Phrenic Nerve Injury Book The segment isolated will permit bypass of the injured segment of the phrenic nerve in the neck. Please consult with your doctor for additional information. Call (212) 305-3408 for existing patients, (212) 304-7535 for new patients to make an appointment with an expert from the Diaphragm Center at Columbia. It makes eating and drinking easier. Effect of local anesthetic concentration (0.2% vs 0.1% ropivacaine) on pulmonary function, and analgesia after ultrasound-guided interscalene brachial plexus block: A randomized controlled study. Knee replacement. Pain relief after arthroscopic shoulder surgery: A comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. The phrenic nerve is formed from C3, C4, and C5 nerve fibres and descends along the anterior surface of the scalenus anterior muscle before entering the thorax to supply motor and sensory input to the diaphragm. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: A systematic review and meta-analysis. Phrenic nerve damage may occur after a major operation such as neck dissection for head and neck cancer, lung surgery, coronary bypass surgery, heart valve or other vascular surgery and thymus gland surgery. They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes. Now, Dr. Kaufman and his team have found a way to offer it to both children and adults who experience diaphragm paralysis. In addition, other operating costs associated with mechanical ventilation are either reduced substantially or eliminated altogether. Once we determine you are an ideal candidate, we may perform additional diagnostic testing to determine the cause, if possible, and to decide which procedure would be best for you. The majority of these events are resolved either on their own or by adjusting the therapy settings. Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: A randomized, controlled, double-blind trial. We read with interest the case series "Surgical Treatment of Permanent Diaphragm Paralysis after Interscalene Nerve Block for Shoulder Surgery." 1 We agree with the conclusion made by authors that the current practice of regional anesthetic blocks should continue to focus on technical accuracy, including use of ultrasound guidance. Are you planning a Labor Day picnic? The phrenic nerve can also be injured by epidural injections, interscalene nerve blocks, and even chiropractic manipulation of the neck. Support was provided solely from institutional and/or departmental sources. Pain lasting more than 3 months following: Prior surgery. The suprascapular nerve provides sensory fibers to approximately 70% of the shoulder joint capsule, and blocking this peripheral nerve can be performed with either a landmark-guided7173 or ultrasound-guided technique.4,74,75 The suprascapular nerve can either be blocked in the suprascapular fossa or in the root of the neck distal to where it arises from the superior trunk of the brachial plexus.76 However, large volumes of injection in the latter approach may still potentially lead to local anesthetic spread to the phrenic nerve and its roots. Illustration demonstrating the course of the phrenic nerve from the root of the neck, through the thorax, and terminating at the diaphragm. The remaining procedures are done at Scurlock Tower. Prolonged hemidiaphragmatic paralysis following interscalene brachial plexus block. They were often told by their physicians that they would simply have to live with it. For additional information on Phrenic Nerve Paralysis and Paralyzed Diaphragm treatment in Los Angeles, CA, call our office at (310) 423-2129 to schedule a consultation today! I am on oxygen 24/7. Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. If rib (intercostal) nerves are used as nerve transfers, patients may be admitted overnight in the Intensive Care Unit as a precaution to monitor their breathing and then stay for 3-4 days before being discharged to home. (C) The osteotomal supply of the shoulder. These signals stimulate breathing in the same way that the brain signals breathing. This condition can mimic that of comorbid conditions like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The impact of phrenic nerve palsy on respiratory function may be quantified by several bedside methods, including pulse oximetry, pulmonary function tests, and sonographic evaluation of the diaphragm. The. The surgical approach begins with an incision in the area of the supraclavicular fossa. Kariem El-Boghdadly, Ki Jinn Chin, Vincent W. S. Chan; Phrenic Nerve Palsy and Regional Anesthesia for Shoulder Surgery: Anatomical, Physiologic, and Clinical Considerations. The transducer is then moved in both caudal and cephalad directions to visualize the end-inspiratory and end-expiratory levels of the pleural line, respectively, which are then marked on the patients skin. The lateral border o The sternocleidomastoid muscle was then grasped by fingers and pulled away from the neck. Your doctor will need to determine the type and severity of sleep apnea based on your sleep study. The nerve is important for breathing because it provides exclusive motor control of the diaphragm, the primary muscle of respiration. A comprehensive microscopic neurolysis of the phrenic nerve and upper cervical roots is performed. Images adapted with permission from Maria Fernanda Rojas Gomez and reproduced with permission from Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). He travels abroad on an annual basis to assist in the care of craniofacial patients in Brazil and Guatemala. Telehealth Services. In the first few months after the therapy begins, you may be aware of the movements of your diaphragm at night. Key landmarks to identify proximity to the phrenic nerve include the posterior border of the sternocleidomastoid muscle medially, the brachial plexus laterally, and the anterior scalene muscle, upon which the phrenic nerve courses. Diaphragm pacing. The authors thank Maria Fernanda Rojas Gomez, M.D., Staff Anesthesiologist, Sociedad Especializada de Anestesiologia SEA S.A. Fundacion Oftalmologica de Santander, Clinica Carlos Ardila Lulle, Floridablanca, Santander, Colombia, and Danilo Jankovic, M.D., Chief of Staff, Pain Management Center, St. Elisabeth University Hospital, Cologne, Germany, for their invaluable assistance in the production of the illustrations. The pleural line (yellow circle) can be seen progressively descending with inspiration. The phrenic nerve is among the most important nerves in the body due to its role in respiration. Studies were supplemented qualitatively with an informal literature search for relevant articles describing anatomical, physiologic, clinical, and diagnostic concepts so as to provide a comprehensive insight into the subject. So, while there are risks of further nerve damage, along with all of the risks inherent in any surgery, such as excessive bleeding, reaction to anesthesia, and the like, in these surgeries the rewards far outweigh the potential risks. Alexander Farivar. Its application to the study of lung function in normal man. Liposomal bupivacaine for pain control after anterior cruciate ligament reconstruction: A prospective, double-blinded, randomized, positive-controlled trial. This traditionally has been achieved by performing an interscalene block, which targets the C5 and C6 roots of the brachial plexus in the interscalene region. Implanting the diaphragm pacing technology is an outpatient laparoscopic procedure. This nerve wrap acts to promote regrowth and to prevent recurrence of scar tissue and adhesions. The Remede System is an implantable device that stimulates the phrenic nerve to stimulate breathing. You can return to most of your normal routine within a week. The device is an implantable system TheremedSystem implant is typically an outpatient procedure that is performed under light sedation. Subjectively, dyspnea is the cardinal symptom of phrenic nerve palsy after interscalene block. Eligible trials included randomized or quasirandomized controlled trials, controlled trials, case series, or pertinent correspondence that were deemed relevant or providing new knowledge on the subject in question. The phrenic nerve is a bilateral nerve, and its left and right counterparts have some important differences in terms of course and relations with surrounding structures. Intact phrenic nerves are required for successful stimulation. Or, the American Academy of Neurology offers a neurologist locator[. 6) in a two-dimensional B-mode. They are readily available and a relatively low cost . However, just as phrenic nerve palsy does not always result in dyspnea, dyspnea may also be experienced in the absence of phrenic nerve palsy.3138 Although up to 40% of patients complain of dyspnea after interscalene block or supraclavicular block,14,17,39 only one third40 to three quarters41 of these patients have objective evidence of phrenic nerve palsy. Once again, this suggests that the dose and volume of local anesthetic and the caudocephalad level at which it is injected are the most significant factors affecting incidence of phrenic nerve palsy. Image adapted with permission from Danilo Jankovic and reproduced with permission from Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). The reduction in local anesthetic concentration and dose decreased duration of sensory blockade by 34% and increased postoperative opioid requirements by up to 50%.43,44 Zhai et al.56 demonstrated that there is no significant difference in the incidence of phrenic nerve palsy with a fixed 50-mg dose of ropivacaine for ultrasound-guided interscalene block using concentrations of 0.25, 0.5, or 0.75%, with minimal effect on analgesic outcomes. We're Here For You Our Office 5.0 stars from over 20 Google Reviews Cedars-Sinai Medical Center 8635 West 3rd St#770W Los Angeles, CA 90048 However, recent advances in medicine have done away with this myth. We encourage practitioners to use the principles and methods outlined in this article to refine and tailor their regional anesthetic strategy to each patient in their care, taking into account all the medical and surgical considerations pertinent to that individual. https://www.uptodate.com/contents/surgical-treatment-of-phrenic-nerve-injury. Kaufman MR, Elkwood AI, Rose MI, et al. Each patients recovery is different. Make a payment to The Plastic Surgery Center, Make a pagment to The Center for Outpatient Surgery, Inability to perform tasks without feeling winded, A surgical injury, from procedures such as lung surgery, heart valve surgery, aorta surgery, thymus gland surgery, carotid-subclavian bypass surgery, or thoracic outlet syndrome surgery, An anesthetic injury, such as injury from epidural injections or interscalene nerve blocks, Trauma, such as falling from a horse, car accidents, or sports accidents, MRI, if we suspect chronic peripheral nerve compression, Additional diagnostic testing to rule out the possibility of a viral cause or a generalized neurological disorder. Cutaneous innervation is provided by the axillary (C5C6), suprascapular nerve (C5C6), and supraclavicular nerves of the cervical plexus (C3C4). Leg, ankle or foot operations. For more information, please call 713.363.7310 . It causes problems with breathing, which is thoroughly uncomfortable on its own. Read full indications for use. Your doctor will need to determine your type and severity of sleep apnea. For further information, please visit remede.zoll.com, call+1-952-540-4470 or email [email protected]. Phrenic Nerve Paralysis can involve injury of the right, left, or both phrenic nerves. Just like any other muscle in your body, you can strengthen it with exercises. Kaufman MR, Elkwood AI, Brown D, et al. Theremed System cannot be used with Magnetic Resonance Imaging (MRI). Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. Prior tests can be particularly helpful, such as EMG/NCV, diagnostic nerve blocks, and 3T MRIs. I was told the damaged nerve can regenerate at one mm per month. Advice Media. The Remed System comprises a battery pack surgically placed under the skin in the upper chest area and small, thin wires that are inserted into the blood vessels in the chest near the nerve (phrenic) that stimulates breathing. Kaufman M, Bauer T, Massery M, Cece J. Phrenic nerve reconstruction for diaphragmatic paralysis and ventilator dependency. Chest fluoroscopy is an even more detailed X-ray and can show the right and left side of the diaphragm in motion as the patient breathes in and out. Your diaphragm is a muscle. Are you interested in learning more about phrenic nerve damage treatment and diaphragm paralysis? On deep inspiration, caudal descent of the liver or spleen precedes descent of the bright pleural line (fig. Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. The phrenic nerve is a bilateral, mixed nerve that originates from the cervical nerves in the neck and descends through the thorax to innervate the diaphragm. Respicardia andremed are registered trademarks of ZOLL Respicardia, Inc. in the United States and/or other countries. The anatomy of the phrenic nerve is key to understanding the basis for the strategies to reduce the risk of phrenic nerve palsy. It tells the diaphragm when to contract, allowing the chest cavity to expand and triggering the inhalation of air into the lungs. Inspire is a sleep apnea treatment. Phrenic Nerve Paralysis Treatment in Los Angeles, CA, Surgical trauma during a heart or neck procedure, Injury during chiropractic manipulation of the neck, Birth trauma that injures the phrenic nerve in newborns and infants, Neurological diseases, such as amyotrophic lateral sclerosis (ALS), multiple sclerosis, muscular dystrophy, Guillain-Barre syndrome, Cancer in the lung or lymph nodes that compresses the phrenic nerve, Chest surgery where the phrenic nerve is cut or removed to remove a tumor, Chronic pneumonia, bronchitis, or cardiac arrhythmias, Neuropathic disease, including thyroid disease and autoimmune disease. The most common method involves placing a 3- to 5-MHz curved array transducer inferior to the costal margin and in a longitudinal parasagittal orientation in the anterior axillary line on the left or in the midclavicular line on the right (fig. Occipital nerve block for occipital neuralgia Botox injection for chronic migraine, hemifacial spasm and focal spasticity A physician referral is needed to obtain testing. MRI imaging is a non-invasive test that doctors may use to diagnose various conditions such as strokes, cancer, and joint problems. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting. This may include one or more of the following: 1) removing scar tissue from around the nerve to allow the electrical signals to travel more easily across the nerve (nerve decompression/neurolysis); 2) cutting out the scar tissue that is filling the nerve gap and bridging it with a sensory nerve (nerve graft); 3) selecting a motor nerve from a healthy but less important muscle group (spinal accessory nerve or intercostal nerves) and transferring it to the injured phrenic nerve (nerve transfer). This site is not optimized for Internet Explorer 8 (or older). Among his nerve surgery expertise which he performs together with his partners at the Institute for Advanced Reconstruction in Shrewsbury, NJ, Dr. Kaufman is the only known surgeon to perform specialized phrenic nerve surgery. Sensory contributions to the muscles of the shoulder comprise the following: the ventral rami of the third and fourth cervical nerves to the trapezius muscle, the pectoral nerves (C5C7) to the pectoral muscles, the dorsal scapular nerve (C5) to the levator scapulae and rhomboid muscles, and the axillary nerve (C5C6) to the deltoid muscle. When was your most recent Pulmonary Function Test completed? Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Phrenic nerve breathing pacemaker surgeryIn this procedure, surgeons implant a breathing pacemaker to control the diaphragm muscle. Check out sunburn treatment options. It allows a patient to maintain normal speech and breathing. (D) An index of color coding of dermatomes, nerves, and osteotomes. No equipment is neededat home. After the phrenic nerve is identified, intraoperative nerve threshold testing is used to evaluate any remaining electrical activity prior to intervention. The duration of phrenic nerve palsy is determined by the duration of local anesthetic effect, which in turn is related primarily to the type and mass of local anesthetic administered. During this bypass, the phrenic nerve is rarely transected. Surgical treatment focuses on healing the injured nerve(s). Anterior (left) and posterior (right) innervation of the shoulder. The suprascapular nerve provides up to 70% of the innervation to the glenohumeral joint,4 with the axillary nerve supplying the majority of the remaining joint capsule. Our goal is to maximize function, minimize suffering, and help patients realize . Asymptomatic profound oxyhemoglobin desaturation following interscalene block in a geriatric patient. As with any surgically implanted device, there are risks related to the implant procedure which may include, but are not limited to, pain, swelling and infection. A case of persistent hemidiaphragmatic paralysis following interscalene brachial plexus block. High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines quality of block and incidence of complications. Be sure to talk with your doctor so that you thoroughly understand all of the risks and benefits associated with the implantation of theremed System. Try looking up a doctor, a clinic location, or information about a condition/treatment. With any surgery there are risks, but the alternative of not having your nerve damage addressed has far more downsides. We would like to point out that in 3 of the 14 patients . The incidence of respiratory compromise was not reported in this study, so it is unclear whether there are further reductions in the incidence of phrenic nerve palsy at volumes less than 5 ml. My invasive tumor was involved with both phrenic nerves, and as my surgeon tried to free the right nerve it was damaged; he opted to not attempt to disentangle the left phrenic nerve to avoid putting me on a ventilator for life. Reza Jarrahy, MD Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty. Innervation of the cutaneous, muscular, bony, and capsular components of the shoulder is complex. Several studies have shown that reducing local anesthetic concentration independent of volume, thus reducing the dose of drug delivered, also produces a significant decrease in the incidence of phrenic nerve palsy and an improvement in pulmonary function after landmark- or ultrasound-guided interscalene block.36,43,44 With a nerve stimulator-guided interscalene block, halving the concentration of a 30-ml mixture of 0.5% bupivacaine and 2% lidocaine but doubling the volume led to a reduction in phrenic nerve palsy from 27% to 0%.55 Halving the concentration of bupivacaine from 0.5% to 0.25% reduced the incidence of phrenic nerve palsy from 100% to 17% when 10 ml was administered via a landmark approach36 and from 78% to 21% when 20 ml was administered with nerve-stimulator localization.44 Similarly, the incidence of phrenic nerve palsy was reduced from 71% to 42% by halving the concentration of 20 ml ropivacaine from 0.2% to 0.1% in an ultrasound-guided interscalene block.43 Unfortunately, this reduction in phrenic nerve palsy generally appears to come at the expense of reduced analgesic efficacy. Regional and total lung function studies in patients with hemidiaphragmatic paralysis. 5). Find a provider Our locations Innovative new surgery repairs phrenic nerve injury, restores breathing function Phrenic nerve function after interscalene block revisited: Now, the long view. You may stay in the hospital overnight, which will depend on your health, how well you tolerate the procedure and how fast you recover. He completed his general surgery training at New York University and University of California, San Diego, and completed his plastic surgery residency at the David Geffen School of Medicine at UCLA. MT = middle trunk; ST = superior trunk. Contact us today and let us guide you toward a solution for your condition. Insurance Reimbursment Avery Diaphragm Pacing Systems are approved by the Center for Medicare & Medicaid Services for Medicare reimbursement and by most private and government insurance plans throughout the world. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. Journal of Reconstructive Microsurgery , 2016; DOI: 10.1055/s-0036-1588018 Cite This . Dr. Seruya is a peripheral nerve surgery specialist. The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. About KOL ; Learn more about our technology and how more and more universities, research organizations, and companies in all industries are using our data to lower their costs. Answer a few short questions to see if you may be a candidate. 12400 Whitewater Dr., Suite 150 Strategies that have been proposed to reduce phrenic nerve palsy while preserving analgesic efficacy include limiting infusion rates to 2 ml/h.85 In a letter to the editor, Tsui and Dillane86 reported that using an intermittent bolus regimen reduces phrenic nerve palsy; however, this has yet to be confirmed in a formal clinical trial. The diaphragm is the most important inspiratory muscle, accounting for 75% of the increase in lung volume during quiet inspiration; intercostal, scalene, and sternocleidomastoid muscles contribute the remaining 25%. My lungs were seriously damaged from the intense radiation I had following surgery. It therefore falls to the individual anesthesiologist to assess the likely impact of phrenic nerve palsy in any given patient undergoing shoulder surgery and to select the appropriate regional anesthetic technique accordingly.