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484 August 2013 U NILATERAL diaphragm paralysis after interscalene nerve block can result in respiratory disturbances that may have a substantial impact on quality of life and increased prevalence of respiratory infections.1,2 Several reports have estimated the incidence of transient diaphragm paralysis after routine interscalene blocks for shoulder surgery to be 100%,3 however, with modified local anesthetic dosing and ultrasound-guided needle placement, more recent data suggest this rate to be lower.4,5 Of greater concern is permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. There are isolated reports in the literature regarding long-standing postprocedural diaphragm paralysis,6,7 yet the underlying causative mechanism has not been previously sought. Peripheral nerve injury may occur from a variety of mechanical causes, including: transection, piercing, stretching, thermal injury, and compression. Alternatively, a nonmechanical injury can result from the toxic or ischemic effects of pharmacologic agents, such as local anesthetics, epinephrine, or chemotherapeutic agents. Phrenic nerve injury from many of these causes may be repaired using nerve-reconstruction techniques. We report our experience with 14 patients suffering permanent diaphragm paralysis after interscalene nerve blocks evaluated and treated between 2009 and 2012 at a tertiary referral center for peripheral nerve injuries with a catchment area that includes the entire United States. Parameters for review included: results of comprehensive evaluation, intraoperative findings during phrenic nerve surgery, and outcomes of surgical intervention (using our previously reported surgical treatment algorithm and outcomes study8). Successful treatment of the paralyzed diaphragm was based on improvements on: sniff testing, spirometry, nerve conduction testing, electromyography, and patient reporting.

Surgical Treatment of Permanent Diaphragm Paralysis after Interscalene Nerve Block for Shoulder Surgery