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Most patients adjust to the therapy within the first 3 months. 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 was told the damaged nerve can regenerate at one mm per month. Electrodiagnostic testing is repeated throughout the procedure to objectively assess for immediate improvement. Answer a few short questions to see if you may be a candidate. These problems lead to fatigue, insomnia, headaches, blue lips and fingers, and overall difficulty breathing. The incidence of transient phrenic nerve palsy is virtually 100% after landmark- and paresthesia-guided interscalene block techniques that use a large-volume injection of 20 ml or greater.13,14. Point of care diaphragmatic ultrasonography made easy. My right phrenic nerve was damaged (paralyzed) during surgery to remove a Thymic tumor. Carter was forced to stop painting, a hobby he loved, due to the unbearable pain. On a chest X-ray, the diaphragm will appear elevated. One of our patient coordinators will use this time to discover more about your condition, such as when you were diagnosed, what caused the damage, symptoms, previous tests, and more. Contact Avery Biomedical Devices to learn more about the Avery Diaphragm Pacing System and its cost-saving benefits compared to traditional mechanical ventilation. This video demonstrates surgical repair of the phrenic nerve in a patient diagnosed with right diaphragm paralysis resulting from a prior neck surgery. Dr. Kaufman has seen a great. Effect of hemidiaphragmatic paresis caused by interscalene brachial plexus block on breathing pattern, chest wall mechanics, and arterial blood gases. Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment. Research and Clinical Trials The Center for Peripheral Nerve Surgery utilizes a multi-faceted research approach ranging from basic/translational research to clinical trials to clinical outcomes research. Implanting the diaphragm pacing technology is an outpatient laparoscopic procedure. If your doctor determines that you have central sleep apnea you should discuss with your physician if the remed System is right for you. This site is not optimized for Internet Explorer 8 (or older). Phrenic nerve reconstruction Developed by The Institute for Advanced Reconstruction physician Dr. Matthew Kaufman, this procedure is a world-class treatment for phrenic nerve injury to reverse diaphragm paralysis. Ultrasound standard of peripheral nerve block for shoulder arthroscopy: A single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. The interposition nerve graft will require several months to regrow and would not be expected to contribute to clinical improvements for up to 10 months. Brian Louie. Contemporary studies in healthy patients with unilateral phrenic nerve palsy suggest that oxygen saturations may remain unchanged40 or decrease by less than 7%.16,43,44 The limited extent of this change correlates with a reduction in Pao2 of 6 to 7 mmHg and an increase in Paco2 of only 3 mmHg.28 In contrast, hypoxemia may be more significant after interscalene block in patients with multiple comorbidities and who receive higher volumes and/or concentrations of local anesthetic.33,34,45 In one study of patients with chronic renal failure undergoing arteriovenous fistula surgery, 10% had oxygen saturations less than 85% on room air after a high-volume (30 ml) interscalene block.45 In another study, brief episodes of oxygen saturations less than 85% after interscalene block with 20 to 28 ml bupivacaine, 0.75%, were seen in 4 of 10 patients, three of whom were obese.33, Pulmonary function tests using bedside spirometry to assess diaphragmatic function should be performed with the patient in the semirecumbent position, with the head up at 45. Phrenic nerve reconstruction may involve neurolysis, interposition nerve grafting, and/or neurotization, depending on the extent of the injury. To learn more about our services, call 310-825-5510. Patient concerns: An 88-year-old man presented himself to the emergency geriatric unit with intermittent painless abdominal contraction due to phrenic nerve stimulation.He has a history of transcatheter aortic valve . Recovery of diaphragmatic function also was faster in the patients who received the C7 root injection. In order to expedite your inquiry,please have the following information ready: Reinnervation of the Paralyzed Diaphragm Kaufman, MRet al. A significant reduction in costs for the long-term care of ventilator-dependent patients is one of the advantages of the Avery Diaphragm Pacing System over a mechanical ventilator. Incidence of phrenic nerve block after interscalene brachial plexus block. It allows a patient to maintain normal speech and breathing. The presentation of phrenic nerve injury is non-specific, and the diagnosis may easily be missed. Matthew Kaufman, MD This specialization includes repair of . To provide the best experiences, we use technologies like cookies to store and/or access device information. It has been almost 6 months since my ablation and still having to sleep on the recliner due to doctor injuring my phrenic nerve during surgery. By. Some of the procedures are done at West Pavilion building. In addition, other operating costs associated with mechanical ventilation are either reduced substantially or eliminated altogether. The diaphragm is the main breathing muscle and contraction of the diaphragm is vital for ventilation so any disease that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction. Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina. As a plastic and reconstructive, and head and neck surgeon he understood how to reconstruct facial nerves and treat peripheral nerve injuries. 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. Reza Jarrahy, MD (left) and Matthew Kaufman, MD (right), Diaphragm Paralysis Caused by Transverse Cervical Artery Compression of the Phrenic Nerve: The Red Cross Syndrome. 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%. For example, Drugstore.com charges about $10-$12 for a one-month supply of a generic tricyclic antidepressant such as nortriptyline [ 1] or amitripyline, which have been shown to relieve nerve pain in some patients. Ultrasound has been instrumental in the development of these modifications: the increased accuracy of local anesthetic deposition allows the use of lower doses, and direct visualization increases the range of available sites for injection. Indeed, the patient no longer needs to reside in an ICU hospital setting. Interscalene brachial plexus block with bupivacaine and ropivacaine in patients with chronic renal failure: Diaphragmatic excursion and pulmonary function changes. A double crush syndrome26 due to previous cervical spine stenosis along with nerve trauma also may contribute to persistent phrenic nerve palsy.18 Finally, a triple crush mechanism that includes pressure ischemia resulting from high volumes of local anesthetic injected within the tight confines of the interscalene sheath also has been postulated.27 It must be noted that these causes of persistent phrenic nerve palsy differ from those implicated in transient phrenic nerve palsy, and thus it cannot be assumed that strategies to reduce the risk of the latter will also reduce the risk of the former. According to a study published in the journal Spinal Cord [1], diaphragm pacing costs about 90% less than the comparable costs for keeping a patient on a positive-pressure ventilator (PPV). Reza Jarrahy, MD The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle. You may stay in the hospital overnight, which will depend on your health, how well you tolerate the procedure and how fast you recover. Kaufman, MRet al. In: Kaufman MR, Elkwood AI, Aboharb F, et al. Phrenic nerve breathing pacemaker surgeryIn this procedure, surgeons implant a breathing pacemaker to control the diaphragm muscle. (surgery, post-surgical recovery and phrenic conditioning) typically takes 12 weeks. Instead, a small incision is made in the nerve sheath and each end of the nerve graft is sutured in place. A new nerve block procedure for the suprascapular nerve based on a cadaveric study. It winds through C3-C5 and makes its way down towards the diaphragm. This process is repeated before and after the chosen regional anesthetic technique with the patient in the same position. Once the phrenic nerve is injured, the diaphragm will become paralyzed. With any surgery there are risks, but the alternative of not having your nerve damage addressed has far more downsides. 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. Hypoxemia secondary to unilateral phrenic nerve palsy after regional anesthesia has a low diagnostic sensitivity due to the mechanics of respiratory compensation. Kaufman M, Bauer T, Massery M, Cece J. Phrenic nerve reconstruction for diaphragmatic paralysis and ventilator dependency. It is the only source of motor innervation to the diaphragm and therefore plays a crucial role in breathing. The use of intravenous dexamethasone or perineural local anesthetic adjuvants that prolong the duration of sensory-motor blockade and analgesia8890 are a promising way to address this issue and should be specifically studied in this context. Just like any other muscle in your body, you can strengthen it with exercises. Your diaphragm is a muscle. Ultrasonographic evaluation of diaphragmatic motion. Contraction of the diaphragm muscle permits expansion of the chest cavity and inhalation of air into the lungs. Comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery: A prospective, randomized, parallel study. 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. The rest is a long story you can check my history. To expedite the process, we ask that you come prepared with a confirmed diagnosis for a paralyzed diaphragm. Kaufman MR, Bauer TL, Brown DP. Contact us today to learn more about diaphragm pacing and the Avery Diaphragm Pacemaker, and how it may be able to help you, a patient, or loved one! Linear array transducer ultrasound image of the pleura in the right midaxillary line at the level of the seventh and eighth ribs in (A) early inspiration; (B) mid-inspiration; and (C) end-inspiration. Possible causes include injury or a system-wide problem such as diabetes or HIV infection. MT = middle trunk; ST = superior trunk. Patients should understand that there isnt an unlimited time that you can wait to fix the nerves. Floh and colleagues defined early plication as being performed at median of 6 days (2-21 days after diagnosis). A right robotic thymectomy is described for the treatment of myasthenia gravis and thymoma. It tells the diaphragm when to contract, allowing the chest cavity to expand and triggering the inhalation of air into the lungs. Our very own Dr. Matthew Kaufman has helped patients from around the world suffering from A unique area of our practice is our Phrenic Nerve surgery program. Specific conditions we treat include: Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery. He has completed over 500 successful diaphragm paralysis reversal surgeries, pioneering a new era of phrenic nerve injury treatment. Dr. Kaufman embarked on his surgical training at one of the nation's top training programs for Otolaryngology - Head and Neck Surgery at The Mount Sinai Hospital in Manhattan. Phrenic nerve injury that results in diaphragm paralysis can significantly decrease quality of life. In addition, scar tissue can form in the neck and compress the nerve. Contact your doctor with questions regarding the use of MRI and theremed System. Paralyzed diaphragm caused by neurological disorders, spinal cord disorders and trauma to the phrenic nerve from surgery, radiation or a tumor. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Lower risk of respiratory infection Diaphragm pacing patients are at much lower risk of upper airway infections due to the reduction in suctioning and potential elimination of external humidifier, ventilator circuits, and tracheostomy tube. Less equipment = less money. In view of the trade-off in analgesic efficacy, suprascapular and axillary nerve blocks are probably best reserved for patients with preexisting respiratory dysfunction or who have other comorbidities (e.g., obesity) that are likely to lead to clinically significant dyspnea and hypoxemia in the presence of unilateral phrenic nerve palsy. The Institute for Advanced Reconstruction is one of the only places worldwide that performs diaphragm pacemaker implantation in select patients with unilateral or bilateral diaphragm paralysis due to phrenic nerve injury. In the presence of diaphragmatic paresis, inspiration is achieved largely by contraction of intercostal and accessory muscles and expansion of the rib cage.28 Pleural pressure is reduced, which leads to air intake and expansion of intrathoracic volume.29 However, this reduction in pleural pressure during inspiration also causes the paralyzed diaphragm to move cephalad and the abdominal muscles inward. (A) Preblock sniff test assessment for phrenic nerve palsy. His entire focus is peripheral nerve surgery. Regardless of the specific type of diaphragm paralysis, the symptoms are generally the same, including: Causes of phrenic nerve injury can vary from accidents and trauma to infections and diseases. The lateral border o The sternocleidomastoid muscle was then grasped by fingers and pulled away from the neck. From the Department of Anaesthesia, Guys and St. Thomas National Health Service Foundation Trust, London, United Kingdom (K.E.-B. Cadaveric (left) and corresponding sonographic images (right) demonstrating the course of the right phrenic nerve as it emerges beneath the lateral margin of the sternocleidomastoid muscle (SCM), between the middle scalene muscle (MSM) and the anterior scalene muscle (ASM). Your doctor will need to determine the type and severity of sleep apnea based on your sleep study. 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. In 3-4 years the diaphragm pacing system can pay for itself with the cost savings! However, randomized controlled trials generally exclude patients with pulmonary disease, obesity, or obstructive sleep apnea, and this therefore hinders the generalizability of the results reported in the literature. Phrenic nerve injury, such as may occur from cardiothoracic surgery, can lead to diaphragmatic paralysi Phrenic Nerve Injury Book Thoracic outlet syndrome (TOS) involves upper extremity symptoms due to compression of the neurovascular bundle at the superior thoracic outlet by any of various structures in the area just above the first rib and behind the clavicle. Untreated phrenic nerve paralysis will likely end with the patient being required to use a mechanical ventilator to breathe, and no one likes the thought of that. Kaufman MR, Elkwood AI, Rose MI, et al. Try looking up a doctor, a clinic location, or information about a condition/treatment. That's a savings of up to $20,000 per year. Your nerve sends signals that cause your diaphragm to contract (become thicker and flatter). It is also very common during surgery for congenital heart disease in infants. Diaphragmatic paralysis was diagnosed in 2.5% of patients, and plication of the diaphragm was performed in 19% of those patients. 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. The phrenic nerve provides both sensory and motor nerves to the diaphragm, and sensory fibers to parts of the pleura and peritoneum. 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. However, isolated testing after block performance may be compared with predicted values based on patient demographics, although this is less accurate than a comparison with baseline values. In the upper image, the phrenic nerve (yellow arrow) can be seen above (superficial to) the ASM in close proximity to the C5 nerve root. Partial early recovery can sometimes occur and reveals itself by an increase in lung aeration by one to two rib spaces, suggestive of increased tone in the diaphragm. Patients work with physical therapists on strengthening their diaphragm and using their rib (intercostal) muscles and neck (scalene) muscles to help with breathing. In a subsequent study, the same authors reported that the minimum effective anesthetic volume to achieve complete sensory block of C5 and C6 dermatomes within 30 min in 50% of patients using this technique was 2.9 ml ropivacaine 0.75%. Patients endured chronic shortness of breath, sleep disturbances, and lower energy levels. In arthroscopic shoulder surgery, suprascapular nerve block alone or combined with an axillary nerve block has been shown to provide superior analgesia compared with placebo or subacromial local anesthetic infiltration7981 but is less effective compared with interscalene block.78,79 Because this peripheral nerve block technique primarily targets the capsular innervation of the shoulder, it also may be less useful in open or extensive shoulder surgery.82 Nevertheless, this technique has a good safety record in chronic pain practice83 and has not been associated with any reported episodes of phrenic nerve palsy to date. Intraoperative chest fluoroscopy is performed to confirm the diagnosis and assess for immediate results following phrenic nerve reconstruction. The techniques used are derived from the procedures commonly used to treat arm or leg paralysis, which have allowed surgeons to restore function to previously paralyzed muscle groups. Long-term follow-up after phrenic nerve reconstruction for diaphragmatic paralysis: a review of 180 patients [published correction appears in. The surgical approach begins with an incision in the area of the supraclavicular fossa. Surgery can cost $20,000-$90,000 or more, depending on the facility and the type of surgery. 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). 3). Check out sunburn treatment options. 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. Search terms included (1) regional anesthesia; (2) local anesthesia; (3) shoulder; (4) surgery; (5) phrenic; (6) nerve; (7) diaphragm; and (8) diaphragmatic. We report a case report that describes this complication and how it can be resolved. The phrenic nerve can also be injured by epidural injections, interscalene nerve blocks, and even chiropractic manipulation of the neck. 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. Phrenic nerve reconstruction may involve neurolysis, interposition nerve grafting, and/or neurotization, depending on the extent of the injury. Your doctor will need to evaluate your condition to determine if the remed system is right for you. Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: A randomized, triple-arm, double-blind, placebo-controlled trial. Shoulder pain: Diagnosis and management in primary care. In these cases, we recommend diaphragm muscle replacement surgery. Cervical variations of the phrenic nerve. There is hope for healing with phrenic nerve damage treatments pioneered by our physicians. Furthermore, one anatomical study indicate, that the phrenic nerve on the right side supply the liver capsule with thin sensory nerves. Treatment for neuropathy typically is covered by insurance. No equipment is neededat home. Quantified sonography of the diaphragm is more sensitive to changes in unilateral diaphragmatic dysfunction than pulmonary function tests and oxygen saturation because the latter two variables assess bilateral pulmonary function simultaneously, including the use of accessory muscles and contralateral diaphragmatic activity. https://www.uptodate.com/contents/surgical-treatment-of-phrenic-nerve-injury. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. good afternoon everyone. Introduction: Phrenic nerve lesion is a known complication of thoracic surgical intervention, but it is rarely described following thymectomy and lung surgery. A case of persistent hemidiaphragmatic paralysis following interscalene brachial plexus block. Anesthesiology 2017; 127:173191 doi: https://doi.org/10.1097/ALN.0000000000001668. It is made to last a lifetime. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. It causes problems with breathing, which is thoroughly uncomfortable on its own. 11, pp. Severe Right Atrial and Ventricular Compression From a Massive Morgagni Hernia and Paralyzed Right Hemidiaphragm, Robotic-Assisted Resection of a Large Solitary Fibrous Tumor Followed by Repair of Iatrogenic Diaphragmatic Hernia, Watch the SCTS 2019 "Take on the Experts" Video Competition, Pulmonary Re-Expansion After Diaphragmatic Plication. When an injury to the phrenic nerve occurs, this results in a condition known as diaphragm paralysis. Neuromuscular ultrasound for evaluation of the diaphragm. Once the therapy is adjusted for you, you will need check-up visits every 3-6 months. 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. Similarly, our group has demonstrated that hemidiaphragmatic paresis resulted in a decrease in forced vital capacity and FEV1 to 75 and 78% of baseline, respectively.36 However, these patients remain asymptomatic and require no treatment. Copyright 2022 ZOLL Medical Corporation. We would like to point out that in 3 of the 14 patients . A randomised controlled trial comparing continuous supraclavicular and interscalene brachial plexus blockade for open rotator cuff surgery. Please review our full disclaimer page here. There are several known causes that can lead to diaphragm paralysis: Birth defects such as congenital central hypoventilation syndrome. Learn more about the Avery Diaphragm Pacing System System, Published Article: Diaphragm Pacing Using the Minimally Invasive Cervical Approach. The Phrenic Nerve Program is a collaboration between Reza Jarrahy, MD at the UCLA Division of Plastic & Reconstructive Surgery and Matthew Kaufman, MD at The Institute for Advanced Reconstruction. 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. Dr. Onders and his team discovered implanting electrodes into the muscle near the phrenic nerve, which controls the diaphragm, and stimulating the electrodes with a small battery-powered external pulse generator causes the diaphragm to contract. He travels abroad on an annual basis to assist in the care of craniofacial patients in Brazil and Guatemala. However, there may be some correlation between these parameters. Dr. Seruya is a peripheral nerve surgery specialist. The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular. Occipital nerve block for occipital neuralgia Botox injection for chronic migraine, hemifacial spasm and focal spasticity A physician referral is needed to obtain testing. For further information, please visit remede.zoll.com, call+1-952-540-4470 or email info@remede.zoll.com. Pruning trees before the storm season can help ensure dead branches won't imperil your home. In situations where the diagnosis is unclear, a nerve conduction and muscle study can be ordered to obtain more information on the health of the right and left phrenic nerves and the diaphragm muscle. Advice Media. Curved array transducer ultrasound image of the right diaphragm using the liver as an acoustic window in two-dimensional B-mode and M-mode. My lungs were seriously damaged from the intense radiation I had following surgery. Diaphragm muscle replacement surgeryFor some patients, phrenic nerve surgery and diaphragm pacemakers are not the right solutions, especially when the condition has been present for many years, or if the individual has previously undergone diaphragm plication. Transvenous Phrenic Nerve Stimulation for Treatment of Central Sleep Apnea: Five-Year Safety and Efficacy Outcomes. In addition, its system of using small implanted radiofrequency receivers rather than electrode wires that pass directly through the skin may decrease a patients risk of infection and ongoing wound care management issues. 105 The nerve then passes from the neck posterior to the subclavian vein to enter the thorax, innervate the ipsilateral diaphragm . For most nerve procedures, patients may only need an overnight hospital stay and are discharged home the following morning. Then 3 weeks after surgery, I went to the ER by ambulance for chest pains which went across my back. The clinical aim of regional anesthesia or analgesia is to deliver local anesthetic to some or all of these key nerves that contribute to pain after shoulder surgery. Surgery is recommended when it is believed that the chances of achieving further recovery are better with nerve reconstruction than waiting for the nerve to heal on its own. The device is an implantable system which uses stimulation of a nerve in the chest (phrenic nerve) to send signals to the large muscle between the chest and abdomen (the diaphragm). Advances in nerve decompression and transplant allow reconstructive plastic surgeons to reverse diaphragm paralysis. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: A meta-analysis of randomized trials. 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. You will not be able to have an MRI or diathermy (special heat therapies) if you have the remed system implanted. Early results are comparable to sternotomy and VATS approaches. Otherwise, the first step is physical therapy to strengthen the diaphragm, rib, and neck muscles. Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. The diaphragm (white circle) is seen to move caudally, toward the probe, in M-mode. Many patients with phrenic nerve injuries have been told that they must simply learn to live with this deficit. In men, the normal displacement of an unaffected diaphragm is 1.8 0.3, 7.0 0.6, and 2.9 0.6 cm in quiet breathing, deep breathing, and sniffing, respectively, and 1.6 0.3, 5.7 1.0, and 2.6 0.5 cm in women.60 Once again, it is ideal to obtain baseline measures of diaphragmatic excursion before block performance. Suprascapular nerve block. Over the first three months of therapy, you will work with your doctor to ensure that the therapy is set up for your individual needs.