- Anesthesia for surgery of the shoulder and arm
- Analgesia for the shoulder and arm
- Post-surgical
- Post-traumatic
- Frozen shoulder
- Complex regional pain syndrome
- Post-amputation pain
- Vascular disease (ischemic limb pain)
- Tumor-related pain
- Vasodilation for some upper extremity procedures
- Vascular flaps
- Reimplantation of forearm, hand, digits
- Post-thoracotomy shoulder pain
- Absolute contraindications
- Patient refusal
- Allergy to local anesthetics
- Local infection at or near the needle insertion site
- Relative contraindications
- Non-cooperative patient
- Severe respiratory compromise
- The need for bilateral upper extremity anesthesia (and risk for bilateral phrenic nerve blockade or pneumothoraces)
- Coagulopathy or medical anticoagulation
- Traumatic nerve injury in the upper extremity or neck
- Preexisting neurodeficits in the distribution of the block
- Previous surgery in the neck that may distort brachial plexus anatomy
- Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
- Local anesthetic, typically:
- 1% to 1.5% lidocaine
- 1% to 1.5% mepivacaine
- 0.25% to 0.5% bupivacaine
- 2% chloroprocaine
- Sterile gloves and mask
- Sterile fenestrated drape or sterile towels for draping
- Sterile prep solution
- Two 20-mL syringes
- A 5-mL sterile syringe and small gauge (25- or 30-gauge) needle for local anesthetic infiltration of the skin
- IV extension tubing
- 3-way stopcock
- Peripheral nerve stimulator and ECG electrode
- 1- to 1.5-inch, 25-gauge, short-bevel, insulated nerve stimulating needle
- The plexus is formed from the anterior rami of C5-8 and most of T1. Contributions to the plexus also come from C4 and T2, and occasionally the plexus is mainly derived from C4-8 (“pre-fixed” plexus), or from C6-T2 (“post-fixed” plexus).
- The five roots of the plexus emerge from the intervertebral foramina, and all five roots are then sandwiched between the anterior and middle scalene muscles. The roots mingle and unite to form three trunks: the upper trunk (C5 and C6), the middle trunk (C7), and the lower trunk (C8 and T1).
- The three trunks emerge from between the scalene muscles and pass downward and laterally across the first rib. Behind the clavicle, each trunk then divides into an anterior and posterior division. These six divisions stream into the axilla, where they unite into three cords—the lateral, medial, and posterior cords—named for their relationship to the axillary artery. The lateral cord gives rise to the lateral pectoral nerve, the musculocutaneous nerve, and the lateral head of the median nerve. The medial cord gives rise to the medial pectoral nerve, the medial cutaneous nerve of the arm, the medial cutaneous nerve of the forearm, the medial head of the median nerve, and the ulnar nerve. The posterior cord gives rise to the upper and lower subscapular nerves, the thoracodorsal nerve, the axillary nerve, and the radial nerve. These nerves exit into the axilla in close relation to the axillary artery, with the median nerve lying anteriorly, the ulnar nerve posteriorly, and the radial nerve posterolaterally.
- In the neck the nerves of the brachial plexus pass laterally in a deep groove or “gutter” in the superior surface of the transverse process of the cervical vertebrae. The gutter runs laterally and slightly forward and at about a 45-degree angle downward.
- The interscalene groove can be identified by palpating the posterior border of the sternocleidomastoid muscle at the level of the transverse process of C6 (the level of the cricoid cartilage). The fingers are then rolled back from the sternocleidomastoid muscle to palpate the belly of the anterior scalene muscle. The interscalene groove lies directly posterior to the anterior scalene muscle. In thin patients, deep palpation in this area can often elicit an uncomfortable paresthesia due to pressure on the brachial plexus. Often the external jugular vein lies close to the point of needle insertion.
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Figure 1
:
Basic materials required for interscalene brachial block. Sterile prep, nerve stimulator, connector and ECG electrode, two 20-mL syringes containing local anesthetic and connected to a three-way stopcock, and a 5-mL syringe containing local anesthetic with a 30-gauge needle for skin infiltration.
Figure 2
:
Nerve-stimulating needle with extension tubing and electrode connection.
Figure 3
:
Brachial plexus. From Drake R, Vogl AW, Mitchell AWM, et al. Gray’s Atlas of Anatomy. Philadelphia: Churchill Livingstone/Elsevier, 2008, p. 369.
Figure 4
:
Relationship of the brachial plexus to the anterior and middle scalene muscles and the phrenic nerve. From Drake R, Vogl AW, Mitchell AWM, et al. Gray’s Atlas of Anatomy. Philadelphia: Churchill Livingstone/Elsevier, 2008, p. 495.
Figure 5
:
Trunks, divisions, cords, and nerves of the brachial plexus. From Drake R, Vogl AW, Mitchell AWM, et al. Gray’s Atlas of Anatomy. Philadelphia: Churchill Livingstone/Elsevier, 2008, p. 369.
Figure 5
:
Trunks, divisions, cords, and nerves of the brachial plexus. From Drake R, Vogl AW, Mitchell AWM, et al. Gray’s Atlas of Anatomy. Philadelphia: Churchill Livingstone/Elsevier, 2008, p. 369.
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