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Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence

To the Editor We thank Dr Tsui and colleagues for their interest in our reply[1][1] to Nair et al .[2][2] To reiterate our position, we are not opposed to the concept of diaphragm-sparing erector spinae plane block (ESPB), but remain highly skeptical of Nair et al ’s dogmatic advocacy since these

We thank Drs Diwan and Nair for their interest in our recent Daring Discourse pertaining to diaphragm-sparing nerve blocks for shoulder surgery.[1][1] In their letter to the editor, Diwan and Nair opine that, based on their data, a T2-T3 erector spinae plane block constitutes “another diaphragm

To the Editor Aside from notable exceptions,[1][1] most randomized trials have investigated diaphragm-sparing nerve blocks for shoulder surgery in the setting of postoperative analgesia and not surgical anesthesia.[2][2] However, the care of patients with pulmonary compromise undergoing shoulder