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Brachial Plexus Block


Brachial Plexus Block Above the Clavicle Edited by Dr. M Dorgham Under supervision of Proff Dr. Amr Abdelfattah Ultrasound guided Infraclavicular Brachial Plexus ... – PowerPoint PPT presentation

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Title: Brachial Plexus Block

Brachial Plexus Block Above the Clavicle
Edited by Dr. M Dorgham Under supervision of
Proff Dr. Amr Abdelfattah
Review the Anatomy of brachial plexus
Neurostimulation guided approaches
Sonoanatomy and Ultrasound guidance
Complications Advantages of ultrasound guidance
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.

Anatomy of Brachial Plexus
The brachial plexus is divided into
  • 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
  • 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
  • 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)

Anatomy of Brachial Plexus
Anatomy of Brachial Plexus
Anatomy of Brachial Plexus
Anatomy of Brachial Plexus
Anatomy of Brachial Plexus
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Anatomy of Brachial Plexus
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Superficial anatomy
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
Deep anatomy
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.
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Surface anatomy 1 Phrenic nerve 2 Brachial
plexus 3 Dorsal scapular nerve (to rhomboid
muscles) 4 Nerve to levator scapulae
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.
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  • 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
  • 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.

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.
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).
  • 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

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
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.
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.
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.
  • Horners 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
  • 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.

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.
Ultrasound guided Interscalene Brachial plexus
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.
The ultrasound probe (10-12MHz) is applied in the
axial oblique plane closer to the midline and
angled to first visualize the carotid artery
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.
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
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
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
0.5-1.5 cm) before inserting the needle. The
needle should never be inserted deeper than the
depth indicated on the ultrasound image.
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 (lt20 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).
Supraclavicular Brachial Plexus Block
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.
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Classic Kulenkampff technique
In 1988 Brown described the plumb-bob technique
Ultrasound guided Supraclavicular Brachial Plexus
POSITIONING The patient is placed supine The
patients 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
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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.
Pre injection
Post injection
  • 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

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.

  • 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 50-100 after interscalene brachial plexus
  • 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.

  • 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 Horners syndrome.
  • with20 to 90 incidence
  • Recurrent Laryngeal Nerve.
  • Hoarseness may transpire after interscalene block
    or after 1.3 of supraclavicular blocks

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

Thank You
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.
Anatomic structures of importance. Pectoralis
muscle (shown cut to expose brachial
plexus) clavicle (removed) coracoid
process humerus brachial plexus subclavian/axillar
y 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.
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
  • 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

The needle insertion site is marked approximately
3cm caudal to the midpoint of the line connecting
points 1 and 2.
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
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
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
Ultrasound guided Infraclavicular Brachial
Plexus Block
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