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Interscalene Brachial Plexus Block: Technique
Transducer position
- Place the transducer in a transverse orientation over the neck, approximately 2-3 cm superior to the clavicle and over the external jugular vein when visible.
Scanning
Different scanning techniques can be used:
A. Identify the carotid artery deep to the sternocleidomastoid muscle, and move the transducer posteriorly to visualize the anterior and middle scalene muscles. The brachial plexus is typically visualized at a depth of 1–3 cm.
B. Traceback technique:
1. Start scanning at the supraclavicular fossa.
2. Identify the brachial plexus.
3.Trace the supraclavicular brachial plexus to the level of the interscalene space.
Depending on the depth of the field selected and the level at which scanning is performed, the first rib and/or the apex of the lung may be seen.
Fig. SCM, sternocleidomastoid; ASM, anterior scalene muscle; LCa, longus capitis muscle; VA, vertebral artery; MSM, middle scalene muscle; LS, levator scapulae; C7-TP, transverse process of C7.
Needle insertion
- Insert the needle in-plane towards the brachial plexus in a lateral-to-medial direction. The exit of the needle from the middle scalene muscle into the interscalene space is often accompanied by a perceptible click.
- Aspirate to rule out intravascular needle placement and inject 1-2 mL of local anesthetic to verify proper needle position.
- A proper spread, inside the sheath, will result in the displacement of the brachial plexus by the local anesthetic.
- Complete the block with 10-15 mL.
- Scan proximally and distally along the neck to verify spread within the interscalene space covering the brachial plexus roots.
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