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Background and Aims Arthroscopic-assisted lower trapezius tendon (LTT) transfer, performed for irreparable posterosuperior rotator cuff tears, involves surgical incisions that extend beyond the dermatomes typically covered by brachial plexus blocks. This often results in inadequate postoperative analgesia. We implemented a novel regional anaesthesia strategy combining thoracic paravertebral block (PVB), 1 interscalene block (ISB),2 and graft-site-specific peripheral nerve blocks to optimise pain control and recovery.Methods We report on 10 patients who underwent LTT transfer using this multimodal technique: single-shot T4/5 thoracic PVB, low-volume ISB (<10 ml), and additional adductor canal and medial genicular blocks based on graft harvest location. This approach provided improved perioperative analgesia (pain scores <3/10), stable intraoperative hemodynamics, and enabled same-day discharge. No block-related complications were reported. The block strategy has since been adopted into our enhanced recovery pathway.Conclusions This is the first case series describing the combined use of brachial plexus and thoracic paravertebral blocks for complex shoulder procedures. The multimodal approach effectively addresses analgesic gaps from ISB alone, especially in surgeries with multisite incisions. Success depended on multidisciplinary collaboration and operator skill in ultrasound-guided thoracic PVB. Limitations include small sample size and lack of a control group. Further studies are warranted to validate these findings. A figure is included to illustrate incision sites and corresponding sensory coverage areas.Abstract EP154 Figure 1Nerve supply from the brachial plexus and thoracic dermatomal coverage relevant to the surgical site. Figure 2 Site of incision for lower trapezius tendon transfer (showing location outside brachial plexusReferences Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001;95(3):771–780.Fredrickson MJ, et al. Interscalene block for shoulder surgery. Anesth Analg. 2009;109(1):265–274.