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Brachial Plexus Block Above the Clavicle Edited by Dr. M Dorgham

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1 Brachial Plexus Block Above the Clavicle Edited by Dr. M Dorgham
Under supervision of Proff Dr. Amr Abdelfattah

2 Objectives Review the Anatomy of brachial plexus
Neurostimulation guided approaches Sonoanatomy and Ultrasound guidance Complications Advantages of ultrasound guidance

3 Anatomy of Brachial Plexus
The brachial plexus is a network of nerve fibers , running from the spine, formed by the ventral rami of the lower four cervical and first thoracic nerve roots (C5-T1). It proceeds through the neck, the axilla (armpit region), and into the arm. The brachial plexus is responsible for cutaneous and muscular innervation of the entire upper limb, with two exceptions: The trapezius muscle innervated by the spinal accessory nerve (CN XI) and An area of skin near the axilla innervated by the intercostobrachial nerve.

4 Anatomy of Brachial Plexus
The brachial plexus is divided into Roots Trunks Devisions Cords Branches

5 The brachial plexus is divided into
Roots, Trunks, Divisions, Cords, and Branches. There are five "terminal" branches and numerous other "pre-terminal" or "collateral" branches that leave the plexus at various points along its length. The five roots are the Anterior rami of the spinal nerves (C5 T1), after they have given off their segmental supply to the muscles of the neck. These roots merge to form three trunks: "superior" or "upper" (C5-C6) "middle" (C7) "inferior" or "lower" (C8-T1) Each trunk then splits in two, to form six divisions: anterior divisions of the upper, middle, and lower trunks posterior divisions of the upper, middle, and lower trunks These six divisions will regroup to become the three cords. The cords are named by their position with respect to the axillary artery. The posterior cord is formed from the three posterior divisions of the trunks (C5-T1) The lateral cord is the anterior divisions from the upper and middle trunks (C5-C7) The medial cord is simply a continuation of the anterior division of the lower trunk (C8-T1)

6 Anatomy of Brachial Plexus
Nerve Roots Muscles Cutaneous Dorsal scapular nerve C5 Rhomboid Levator scapulae Long thoracic nerve C5 C6 C7 Serratus anterior

7 Anatomy of Brachial Plexus
Nerve Roots Muscles Cutaneous Upper Trunk Nerve to subclavius C5 C6 Subclavious Suprascapular nerve Supraspinatous Infraspinatous

8 Anatomy of Brachial Plexus
Nerve Roots Muscles Cutaneous Lateral cord Lateral pectoral nerve C5 C6 C7 Pectoralis Major By communication with Medial Pectoral Nerve Musculocutaneous nerve Coracobrachialis Brachialis Biceps brachii Become the Lateral cutaneous nerve of forearm Lateral root of median nerve Fibres of Median nerve

9 Anatomy of Brachial Plexus
Nerve Roots Muscles Cutaneous Medial cord Medial pectoral Nr C8 T1 Pectoralis major Pectoralis minor Medial root of median Nr. Fibres to median nerve portions of hand not served by ulnar or radial Medial cord Medial cutaneous nerve of arm front and medial skin of the arm Medial cutaneous nerve of forearm medial skin of the forearm

10 Anatomy of Brachial Plexus
Medial cord Ulnar Nr. C8 T1 Flexor carpi ulnaris the medial two bellies of flexor digitorum profundus, the intrinsic hand muscles except the thenar muscles. the two most medial lumbricals the skin of the medial side of the hand medial one and a half fingers on the palmar side medial two and a half fingers on the dorsal side

11 Nerve Roots Muscles Cutaneous Post cord Upper subscapular nerve C5 C6 Sub scapilaris (upper part) Thoracodorsal Nr (Middle subscapular) C6 C7 C8 Latismus Dorsi Post cord Lower scapular Nr Subscapularis (lower part) Teres major Axillary Nr. Ant Br: Deltoid & small area of overlying skin Post Br: Teres minor & Deltoid ms Post Branch continues as upper Lateral cutaneous Nr of arm Radial Nr. C5 C6 C7 C8 T1 Triceps brachii Supinator Anconeus Brachioradialis Extensors of forearm Posterior cutaneous nerve of arm

12 Anatomy of Brachial Plexus





17 Superficial anatomy

18 Superficial anatomy The sternal head of the sternocleidomastoid muscle (1) is anterior to its clavicular head (2), which forms the anterior border of the posterior triangle of the neck. The accessory nerve (3) is superficial to the fascial floor of the posterior triangle of the neck and originates close to the lesser occipital nerve (4). The superficial cervical plexus (5) is superficial to the fascial floor of the posterior triangle of the neck and gives rise to the supraclavicular nerves (6). The superficial cervical plexus originates from C2 and supplies the ipsilateral skin of the neck, shoulder and occipital area with sensory fibers. The trapezius muscle (7) is innervated by the accessory nerve (3), and the nerve to levator scapulae innervates the levator scapulae muscle (8).

19 Deep anatomy

20 Deeper anatomy A view of the anatomy with the sternocleidomastoid muscle removed shows the position of the internal jugular vein (1) (cut off here). Deep to the internal jugular vein is the thoracic duct (2) on the left side of the neck and adjacent to that the Anterior scalene muscle (3). Posterior to that is the middle scalene muscle (4) and more posterior, the posterior scalene muscle (5). Posterior to the posterior scalene muscle is the levator scapulae muscle (6) with the nerve to the levator scapulae muscle (7). The accessory nerve (8) as well as the trapezius muscle (9) can be seen. Also note the vagus nerve (10), which is situated in close relationship to the carotid artery (11), and the phrenic nerve (12), which is situated on the belly of the anterior scalene muscle (3). The brachial plexus (13) is situated between the anterior and middle scalene muscles. The suprascapular nerve (14) and the dorsal scapular nerve (15) (which innervates the rhomboid muscles) branches from the brachial plexus. Note that the subclavian artery (16) lies anterior to the brachial plexus.


22 Surface anatomy 1 = Phrenic nerve 2 = Brachial plexus 3 = Dorsal scapular nerve (to rhomboid muscles) 4 = Nerve to levator scapulae

23 “NERVE MAPPING” To facilitate proper anatomical orientation, the relative positions of the motor nerves in the posterior triangle of the neck can be identified before the skin is penetrated “Nerve Mapping” Five nerves can be identified in the posterior triangle of the neck by percutaneous stimulation with 5 – 10 mA. Stimulating the phrenic nerve (1), just posterior to the clavicular head of the sternocleidomastoid muscle on the level of the cricoid cartilage (C6) causes unmistakable twitches of the diaphragm. Moving the needle one centimeter posteriorly will stimulate the brachial plexus (2). This causes twitching of the biceps, triceps, major pectoral and/or the deltoid muscles. Posterior to the brachial plexus and posterior to the middle scalene muscle is the dorsal scapular nerve (3), which innervates the rhomboid muscles. Stimulation of this nerve causes the scapula and shoulder to move when the rhomboid muscles contract. This often causes confusion when stimulated and is a common cause of failed interscalene nerve blocks. levator scapulae muscle (4). Stimulating this nerve percutaneously will elevate the scapula and cause movements of the shoulder. More cephalad and higher up in the posterior triangle of the neck is the Accessory nerve (5), which innervates the trapezius muscle.


CONTINUOUS INTERSCALENE BLOCK NEEDLE PLACEMENT • The patient is placed in the supine position with the neck slightly flexed (to prevent the sternocleidomastoid muscle from covering the interscalene groove) and the head is slightly turned to the opposite side. The operator stands at the head of the bed, which is raised slightly to facilitate venous drainage so that venous congestion and accidental venous puncture are minimized. Feel for the interscalene groove with the middle and index fingers of the non-dominant hand (Figure 5) Split the fingers and apply light pressure with the middle finger. This causes the external jugular vein to become visible. The index finger applies traction to the skin for easy penetration by the needle. After appropriate skin infiltration with local anesthetic agent, the sheathed Tuohy needle (Arrow International, Reading, PA, USA) enters the skin halfway between the clavicle and the mastoid process just posterior to the posterior border on the sternocleidomastoid muscle.

26 needle approaches the brachial plexus and the nerve stimulator is set to 1 mA. Reduce the output of the nerve stimulator and look for brisk muscle twitches at approximately 0.5 mA (200 – 300 μs), which indicates penetration of the fascial sheath surrounding the brachial plexus

The continuous cervical paravertebral block is ideal for relief of postoperative pain following shoulder surgery, especially arthroscopic shoulder surgery. This approach sometimes does not involve the nerves of the superficial cervical plexus and the skin around the shoulder area will therefore not be anesthetized. Although not yet evaluated by formal research, the experience of this author is that loss of resistance to air as well as nerve stimulation may be used for the placement in this block. If proven successful, this should make this block ideally suited for postoperative use, and when severely painful conditions such as fractures of the shoulder are present where nerve stimulation is not advisable or impractical.

28 Anatomy The brachial plexus (1) is situated between the anterior (2) andmiddle (3) scalene muscles, while the vertebral artery (4) is guarded by the bony structures of the vertebrae. The posterior approach for ISB is antero-lateral to the trapezius muscle (5) and postero-medial to the levator scapulae muscle (6).

29 TECHNIQUE • The patient can be in the sitting or lateral decubitis position. After liberal skin and subcutaneous tissue injection of local anesthetic agent, the needle enters at the apex of the “V” formed by the trapezius and levator scapulae muscles. • Attach the nerve stimulator and loss of resistance to air device to the needle and set the current output to 2 – 3 mA. Because the roots of the plexus have to a large extent split into motor (anterior) and sensory (posterior) fibers here, more current is required to elicit a motor response. The needle is aimed medially and approximately 30 degrees caudate towards the suprasternal notch and advanced until the short transverse process of C6 is encountered. The needle is “walked off” this bony structure and there is a distinct change of resistance to air, which occurs simultaneously with muscle twitches in the arm when the cervical paravertebral space is entered

30 Anatomy The point of needle entry is in the apex of the “V” formed by the trapezius muscle posterior and the levator scapulae muscle anterior – the “B”-spot

31 Surface anatomy Needle entry should be at the level of C6 and just antero-lateral to the trapezius muscle and postero-medial to the levator scapulae muscle in the apex of the “V” formed by these two muscles.

32 Needle placement The nerve stimulator is clipped to the needle and a loss-of-resistance to air device is placed on the needle. The needle is directed , anteriorly and caudad, aiming for the suprasternal notch. The needle is carefully “walked off” the transverse process of C6 and loss of resistance to air and muscle twitches of the shoulder girdle appear simultaneously.

33 Practical points The anterior approach to the interscalene space is probably best suited for “open” shoulder surgery, while the posterior approach is ideal for arthroscopic surgery. The posterior approach provides less motor block than the anterior approach, but does not usually provide anesthesia of the skin around the shoulder joint. Horner’s syndrome almost always accompanies the posterior approach, The loss of resistance to air technique for placement of the cervical paravertebral block (posterior approach to ISB) may makes it ideally suited for postoperative placement or other instances where nerve stimulation is undesirable or painful. Protect the ulnar nerve (at the elbow) and radial nerve (mid-humeral area) while the arm is insensitive. Prevent traction injury to the brachial plexus by proper positioning on the operating table during surgery and by using a properly fitted sling in the ambulatory patient.

34 Inadvertent epidural or subarachnoid injection is a potentially serious complication resulting from incorrect needle placement. Vertebral artery injection, this can result in convulsions and loss of consciousness. Phrenic nerve block is frequently produced, this complication precludes bilateral use of this technique. Recurrent laryngeal, vagus, and cervical sympathetic nerves are sometimes blocked. Pneumothorax is rare but can happen with deep placement of the needle and in unskilled hands.

35 Interscalene Brachial plexus block
Ultrasound guided Interscalene Brachial plexus block

36 The patient is in semi-sitting supine position with the head facing away from the side to be anesthetized. The premedication of an adult, average size patient typically consists of 2-4 mg of midazolam; 250mcg -500mcg of alfentanyl administered just before insertion of the needle TIP: Visualization of the brachial plexus in the interscalene grove can be challenging in patients who are tense, moving or exhibit guarding. Proper sedation can go a long way toward obtaining quality images.

37 The ultrasound probe (10-12MHz) is applied in the axial oblique plane closer to the midline and angled to first visualize the carotid artery

38 Note the position of the internal jugular vein (IJ) as the pressure on the ultrasound probe is lightened. The internal jugular vein is positioned slightly superficially and lateral to the carotid artery. Changing the pressure on the probe causes the IJ to open and close.

39 The ultrasound probe is then moved slightly laterally to visualize the brachial plexus in the interscalene grove between anterior and middle scalene muscles. The roots/trunks (N) of the brachial plexus are seen stacked between the scalene muscles usually as round, hypoechoic structures

40 Sliding or angling the ultrasound probe slightly more inferior allows visualization in the low-interscalene position in which the brachial plexus is positioned in proximity to the subclavian artery

41 After the brachial plexus is identified on the image, a 50 mm (max) stimulating needle is inserted perpendicular to the long axis of the ultrasound probe. The needle is inserted at the point on the probe that corresponds to the location of the brachial plexus on the screen The needle insertion results in shadowing of the ultrasound image which indicates the path of the needle TIP: Make sure to estimate the exact depth of the brachial plexus (typically cm) before inserting the needle. The needle should never be inserted deeper than the depth indicated on the ultrasound image.

42 Injection of local anesthetic is made with monitoring of the dispersion of the injectate. If the injectate does not appear to fill the lower compartment of the interscalene space, the needle is slightly advanced (0.5-1cm) and additional injection is made at a slightly greater depth (0.5-1cm deeper). Local anesthetic is injected slowly and with frequent aspirations, while avoiding excessive injection pressures (<20 psi). Thirty to forty ml of local anesthetic is more than adequate for reliable blockade of the brachial plexus. Typical indications for this block are surgery on the shoulder, lateral clavicle, acromioclavicular joint, proximal humerus and elbow (with low interscalene block).

43 Supraclavicular Brachial Plexus Block

44 The trunks divide behind
the clavicle into anterior and posterior divisions, which separate the innervation of the ventral and dorsal halves of the upper limb.


46 Classic Kulenkampff technique

47 In 1988 Brown described the plumb-bob technique

48 Supraclavicular Brachial Plexus Block
Ultrasound guided Supraclavicular Brachial Plexus Block

49 POSITIONING • The patient is placed supine • The patient’s head is turned toward the contralateral side • The operator is positioned on the ipsilateral side • The ultrasound machine should be placed on the contralateral side SONOANATOMY. The subclavian artery appears hypoechoic and pulsatile and the individual nerves as hypoechoic small circles. It is very important to identify the pleura while performing this block so as to avoid pneumothorax. The first rib acts as a backstop to prevent pleural puncture, which means that the needle tip is in the same plane


51 the "chimney" effect as local anesthetic is forced to spread up between the anterior and middle scalene muscles, unable to go down because the first rib is in the way.

52 Pre injection Post injection

53 The major advantage of the supraclavicular approach is that the nerves are very tightly packed, so that the onset is fast and the blockade deep, leading to this technique being nicknamed “the spinal of the arm”. Ultrasound guidance, the pleura can be visualized, and as long as proper technique is used, i.e. if the needle, and especially the needle tip, is visualized at all times, pneumothorax should not occur. Typical Indication : For surgeries below the mid-humerus level. It will not diffuse to the lower roots of the cervical plexus, and thus will not block the upper aspect of the shoulder. Twenty to Forty mls local anaesthetic is adequate for reliable block

54 Possible Complications
Peripheral Nerve Injury Most nerve injury presents as residual paresthesia, hand or forearm hypoesthesia, and rarely as permanent Paresis The overall incidence of long-term nerve injury ranges between 0.02% and 0.4% Vascular Injury The risk of hematoma immediately after brachial plexus techniques is small (0.001 to 0.02%) Muscle Injury Myonecrosis from local anesthetics at concentrations typically achieved at the site of injection is well proven and characteristic of all local anesthetics, with bupivacaine producing the most intense effect. Because damage is dose related, continuous local anesthetic administration may worsen injury.

55 Hemidiaphramatic Paresis
The proximity of the phrenic nerve to the interscalene groove frequently leads to unintended local anesthetic block and resultant diaphragmatic dysfunction. The incidence of hemidiaphragmatic paresis (HDP) is % after interscalene brachial plexus block Pneumothorax The reported incidence of pneumothorax after supraclavicular block is 0.5% to 6.1% Intravascular Injection local anesthetic injected directly into the vertebral or carotid artery, or retrograde flow of local anesthetic via the subclavian artery, may proceed directly to the brain.

56 Subarachnoid or Epidural Injection.
Interscalene brachial plexus block has been linked to unintended subarachnoid block and to cervical or thoracic epidural block. Cervical Sympathetic Chain. Excessive local anesthetic spread can also affect the cervical sympathetic chain, causing the patient to manifest Horner’s syndrome. with20% to 90% incidence Recurrent Laryngeal Nerve. Hoarseness may transpire after interscalene block or after 1.3% of supraclavicular blocks

57 Advantages of Ultrasound Guidance
Ultrasound guidance with real-time needle visualization in relation to anatomic structures and target nerves makes regional anesthesia safer and more successful. With ultrasound guidance in experienced hands, brachial plexus blockade can lead to Decreased block performance and onset time, Increased success rate and Decreased rate of complications. These advantages result in increased operating room efficiency, as well as increased patient satisfaction.

58 Thank You

59 The infraclavicular block is a blockade of the brachial plexus below the level of the clavicle and in the proximity of the coracoid process. This block is uniquely well-suited for hand, wrist, elbow, and distal arm surgery. It also provides excellent analgesia for an arm tourniquet. As opposed to a supraclavicular block, an infraclavicular block is not a good choice for shoulder surgery.

60 Anatomic structures of importance
Anatomic structures of importance. Pectoralis muscle (shown cut to expose brachial plexus) clavicle (removed) coracoid process humerus brachial plexus subclavian/axillary artery and vein The boundaries of the infraclavicular fossa are the pectoralis minor and major muscles anteriorly, ribs medially, clavicle and the coracoid process superiorly, and humerus laterally. At this location, the brachial plexus is composed of cords. The sheath surrounding the plexus is delicate. It contains the subclavian/axillary artery and vein. Axillary and musculocutanous nerves leave the sheath at or before the coracoid process in 50% of patients. Consequently, the deltoid and biceps twitches should not be accepted as reliable signs of brachial plexus identification.

61 The patient is in the supine position with the head facing away from the side to be blocked.
The anesthesiologist also stands opposite to the side to be blocked to assume an ergonomic position during the block performance. It is best to keep the arm abducted and flexed in the elbow to keep the relationship of the landmarks to the brachial plexus constant. Attention should be paid when the arm is supported at the wrist to allow clear unobstructed detection of the twitches of the hand

62 Surface Landmarks The following surface anatomy landmarks are useful in identifying the estimated site for an infraclavicular block: Sternoclavicular joint Medial end of the clavicle Coracoid process Acromioclavicular joint Head of the humerus Anatomic Landmarks Landmarks for the infraclavicular block include: Coracoid Process Medial clavicular head Midpoint of line connecting 1 and 2 and 3cm caudal The needle insertion site is marked approximately 3cm caudal to the midpoint of the line connecting points 1 and 2.

63 TIP: Palpation of the bony prominence just medial to the shoulder, while the arm is elevated and lowered, identifies the coracoid process. As the arm is lowered, the coracoid process meets the fingers of the palpating hand. This maneuver should be used to identify the coracoid process in each patient planned for an infraclavicular block

64 Needle insertion A 10-cm long, 22-gauge insulated needle, attached to a nerve stimulator, is Inserted at a 45-degree angle to the skin and Advanced parallel to the line connecting the medial clavicular head with the coracoid process. The nerve stimulator is initially set to deliver 1.5 mA. A local twitch of the pectoralis muscle is typically elicited as the needle is advanced beyond the subcutanous tissue. Once the pectoralis twitches disappear, the needle advancement should be slow and methodical while looking for the twitch of the brachial plexus

65 TIPS: When the pectoralis twitch is absent despite appropriately deep needle insertion, the landmarks should be checked as the needle is most likely inserted too cranially (underneath the clavicle). The bevel of the needle should be facing down to facilitate nerve stimulation and reduce the risk of vascular puncture (subclavian or axillary artery and vein). Brachial plexus stimulation is typically obtained at a depth of 5 to 8 cm. Twitches from the biceps or deltoid muscles should not be accepted, since the musculocutaneous and axillary nerve, respectively, may depart the brachial sheath before the caracoid process

66 Infraclavicular Brachial Plexus Block
Ultrasound guided Infraclavicular Brachial Plexus Block


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