One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Interscalene brachial plexus anesthesia for shoulder surgery routinely includes sensory anesthesia of the fourth and fifth cervical nerves. The authors reasoned that some degree of diaphragm paralysis should result from interscalene blocks that produce surgical C3-C5 sensory anesthesia. In this investigation, ultrasonography was used to study the incidence of ipsilateral hemidiaphragmatic paresis during routine interscalene block, as it is a practical, sensitive, and low-risk method for diagnosing hemidiaphragmatic function without radiation exposure. Thirteen healthy patients received interscalene blocks using a paresthesia technique with 34-52 mL 1.5% mepivacaine with added epinephrine and bicarbonate. All developed cervical sensory anesthesia. Data were collected before and 2, 5, and 10 min after injection, and, when possible (11 of 13 patients), at hourly intervals after surgery. Changes from normal to paradoxical motion of the ipsilateral hemidiaphragm were seen in all 13 patients during sniff and Mueller maneuvers within 5 min (in 11 of 13 patients at 2 min). Diaphragmatic motion returned to normal in 10 of 11 patients between 3 and 4 h after injection and in the remaining patient by the fifth hour after injection. Diaphragmatic paresis appears to be an inevitable consequence of interscalene brachial plexus block when providing anesthesia sufficient for shoulder surgery. 