Ultrasound-Guided Interscalene Brachial Plexus Block

INTERSCALENE BRACHIAL PLEXUS BLOCK AT A GLANCE

  • Indications: shoulder and upper arm surgery, surgery of the clavicle (combined with cervical plexus block)
  • Transducer position: transverse on neck, 3–4 cm superior to clavicle, over external jugular vein (Figure 32B–1)
  • Goal: local anesthetic spread around superior and middle trunks of brachial plexus, between the anterior and middle scalene muscles
  • Local anesthetic: 7–15 mL

GENERAL CONSIDERATIONS

US guidance allows for visualization of the spread of the LA and additional injections around the brachial plexus if needed to ensure adequate spread of local anesthetic, improving block success. The ability to visualize local anesthetic spread and to inject multiple aliquots also allows for a reduction in the volume of local anesthetic required to accomplish the block.1,2

ULTRASOUND ANATOMY

The brachial plexus at the interscalene level is seen lateral to the carotid artery and internal jugular vein, between the anterior and middle scalene muscles (Figures 32B–2 and 32B–3). The prevertebral fascia, superficial cervical plexus, and sternocleidomastoid muscle are seen superficial to the plexus. The transducer is moved in the proximal-distal direction until two or more of the brachial plexus elements are seen in the space between the scalene muscles. Depending on the depth of field selected and the level at which scanning is performed, the first rib and/or the apex of the lung may be seen. The brachial plexus is typically visualized at a depth of 1–3 cm.

BLOCKADE DISTRIBUTION

The interscalene approach to brachial plexus blockade results in reliable anesthesia of the shoulder and upper arm (Figure 32B–4). The supraclavicular branches of the cervical plexus, supplying the skin over the acromion and clavicle, are also blocked due to the proximal and superficial spread of local anesthetic. The inferior trunk (C8-T1) is usually spared, unless the injection occurs at a more distal level of the brachial plexus.

EQUIPMENT

The equipment needed for an interscalene brachial plexus block includes the following:
• Ultrasound machine with linear transducer (8–14 MHz), sterile sleeve, and gel
• Standard nerve block tray
• A 20-mL syringe containing local anesthetic
• A 5-cm, 22-gauge, short-bevel, insulated stimulating needle
• Peripheral nerve stimulator
• Opening injection pressure monitoring system
• Sterile gloves

LANDMARKS AND PATIENT POSITIONING

Any position that allows for comfortable placement of the ultrasound transducer and needle advancement is appropriate. The block is typically performed with the patient in a supine, beach

FIGURE 32B–1. Ultrasound-guided interscalene brachial plexus block: transducer and needle position to obtain the desired ultrasound image for an in-plane approach. The knowledge of external landmarks substantially facilitates and shortens the time to obtain the view necessary for block performance. The transducer is positioned behind the clavicular head of the sternocleidomastoid muscle (SCM) and over the external jugular vein (not seen). The patient is in a semi-sitting position. Tilting the transducer in the caudad direction can facilitate recognition of the brachial plexus (arrow).

chair, or semilateral decubitus position, with the patient’s head facing away from the side to be blocked. The latter position may prove more ergonomic, especially during an in-plane approach from the lateral side, in which the needle enters the skin at the posterolateral aspect of the neck. A slight elevation of the head of the bed is often more comfortable for the patient and allows for

FIGURE 32B–2. Relevant anatomy for interscalene brachial block and transducer position to obtain the desired views. The brachial plexus (BP) is seen between middle scalene muscle (MSM) laterally and the anterior scalene muscle (ASM) medially. The ultrasound image often includes a partial view of the lateral border of the sternocleidomastoid muscle (SCM) as well as the internal jugular vein (IJV) and carotid artery (CA). The transverse process of one of the cervical vertebrae is also often seen.

better drainage and less prominence of the neck veins. The patient should be asked to reach for the ipsilateral knee in order to lower the shoulder and provide more space for the block performance.
Knowledge of the underlying anatomy and the position of the brachial plexus is important to facilitate recognition of the ultrasound anatomy. Scanning usually begins just below the level of the cricoid cartilage and medial to the sternocleidomastoid muscle with the goal of identifying the carotid artery.

FIGURE 32B–3. Ultrasound image of the brachial plexus at the interscalene groove. The BP is seen positioned between the anterior scalene muscle (ASM) and the middle scalene muscle (MSM). In this particular image, the vertebral artery (VA), carotid artery (CA), and the transverse process of C7 (TP-C7) are also seen.
FIGURE 32B–4. Sensory distribution of the interscalene brachial plexus block (in red). Ulnar nerve distribution area (C8-T1) can also be accomplished by using larger volume (e.g. 15-20 ml) and using low interscalene block where the injection occurs between the ISB and supraclavicular block.

GOAL

The goal of this block is to place the needle in the tissue space between the anterior and middle scalene muscles and inject local anesthetic until the spread around the brachial plexus is documented by ultrasound. The volume of the local anesthetic and number of needle insertions are determined during the procedure and depend on the adequacy of the observed spread of local anesthetic.

TECHNIQUE

With the patient in the proper position, the skin is disinfected and the transducer is positioned in the transverse plane to identify the carotid artery (Figure 32B–5). Once the artery has been identified, the transducer is moved slightly laterally across the neck. The goal is to identify the anterior and middle scalene muscles and the elements of the brachial plexus that is located between them.

Clinical Pearl

• When visualization of the brachial plexus between the scalene muscles proves difficult, a “traceback” technique can be used.3 The transducer is lowered to the supraclavicular fossa. At this position, the brachial plexus is identified posterior and superficial to the subclavian artery (Figure 32B–6). From here, the brachial plexus is traced cranially to the desired level.


It is recommended to use the color Doppler to identify vascular structures and avoid them. The needle is then inserted in plane toward the brachial plexus, typically in a lateral-to-medial direction (Figure 32B–7), although a medial-to-lateral needle orientation can also be used if there is no room for the former. The needle should always be aimed in between the roots instead of directly at them in order to minimize the risk of accidental nerve injury.
As the needle passes through the prevertebral fascia, a certain “pop” is often appreciated. When nerve stimulation is used (0.5 mA, 0.1 msec), the entrance of the needle in the interscalene groove is often associated with a motor response of the shoulder, arm, or forearm as another confirmation of proper needle placement. After careful aspiration to rule out intravascular needle placement, 1–2 mL of local anesthetic is injected to verify proper needle placement (Figure 32B–8a). It is necessary to ensure that high resistance to injection is absent to decrease the risk of intrafascicular injection. Injection of several milliliters of local anesthetic often displaces the brachial plexus away from the needle. An additional advancement of the needle 1–2 mm toward the brachial plexus may be beneficial to ensure proper spread of the local anesthetic (Figure 32B–8b). When injection of the local anesthetic does not appear to result in a spread around the brachial plexus, additional needle repositioning and injections may be necessary.

FIGURE 32B–5. Ultrasound image just below the level of the cricoid cartilage and medial to the sternocleidomastoid muscle (SCM). ASM, anterior scalene muscle; CA, carotid artery; IJV, internal jugular vein; SCM, sternocleidomastoid muscle; Th, thyroid gland.
FIGURE 32B–6. View of the brachial plexus (BP) at the supraclavicular fossa. When identification of the brachial plexus at the interscalene level proves difficult, the transducer is positioned at the supraclavicular fossa to identify the BP superficial and posterior to the subclavian artery (SA). The transducer is then slowly moved cephalad while continuously visualizing the brachial plexus until the desired level is reached.
FIGURE 32B–7. (A) Transducer placement and needle insertion. (B) Position of the needle (1) for the interscalene brachial plexus block using an in-plane approach. The needle tip is seen in contact with the elements of the brachial plexus (yellow arrows); this always results in high injection pressure (> 15 psi)—indicating that the needle should be withdrawn slightly away from the trunk.
FIGURE 32B–8. (A) A small volume of local anesthetic (blue-shaded area) is injected through the needle to confirm proper needle placement. A properly placed needle tip will result in distribution of local anesthetic between and/or alongside roots of the brachial plexus (BP). (B) An actual needle (white arrowhead) placement in the interscalene groove, with dispersion of local anesthetic (LA) (blue-shaded area or arrows) surrounding the BP.

TIPS

• It is not necessary to elicit a motor response to nerve stimulation; however, when it occurs at intensities < 0.5 mA, the needle should be slightly withdrawn before injecting as it may be intraneural.
• The neck is a highly vascular area, and care must be exercised to avoid needle placement or injection into the vascular structures. Of particular importance is to avoid the vertebral artery and branches of the thyrocervical trunk: the inferior thyroid artery, suprascapular artery, and transverse cervical artery. Use color Doppler imaging at least once before inserting the needle to locate any vessel that might be in the path of the needle. Anatomical variations are common.4
• Never inject against high resistance because such resistance may indicate needle–nerve contact or an intrafascicular injection. A high opening injection pressure (> 15 psi) is always present with needle–root contact.5 Thus, a seemingly extraneural injection may in fact be subepineural.6 An intraneural injection may spread proximally into the spinal canal.7
• One useful maneuver to ensure injection into the proper compartment, after injecting 5–7 mL, is to trace the plexus down to the supraclavicular fossa (while keeping the needle steady to avoid injury). If the injection is performed insede the brachial plexus “sheath,” the correct spread can be seen very clearly (Figure 33B–9). The probe can then be moved back until the needle is visualized in order to complete the injection. If the brachial plexus appears unchanged in the supraclavicular area, one must question whether the injection was done outside the correct compartment (see Figure 32B–9).
• The lateral-to-medial insertion is often chosen to prevent injury to the phrenic nerve, which is typically located anteriorly to the anterior scalene, although one should be aware that the dorsal scapular nerve and the long thoracic nerve usually course through the middle scalene and could potentially be injured as well (Figure 32B–10).8–10
• It is common for C6 and C7 to split proximally. It is prudent to avoid injecting between the nerves coming from a single root, as this may result in an intraneural injection. Instead, it is safer to inject between C5 and C6, superficial to C5, or deep to C6 (Figure 32B–11).11
• Another relatively common anatomical variation involves the C5 root travelling through the anterior scalene for part of its course (Figure 32B–12). To block this anatomical variant, the root should be traced distally until it enters the interscalene groove.
• Multiple injections are best avoided as they are not usually needed to successfully block the brachial plexus and may carry higher risk of nerve injury.
• In an adult patient, 7–15 mL of local anesthetic is usually adequate for a successful and rapid onset of blockade. Smaller volumes of local anesthetic may also be effective;12,13 however, the rate of success of smaller volumes

FIGURE 32B–9. Diffusion of local anesthetic solution to the supraclavicular area during interscalene block performance. (A) Before injection. (B) After injection of 10 mL at the interscalene level. The nerves lateral to the subclavian artery are surrounded by local anesthetic and appear deeper. This confirms that the injection was performed in the correct space.
FIGURE 32B–10. Dorsal scapular nerve (DSN) and long thoracic nerve (LTN) visible in the middle scalene muscle (MS).

in everyday clinical practice may be inferior to those reported in meticulously conducted clinical trials.

PHRENIC NERVE BLOCKADE

Phrenic nerve blockade is common following ISB and may compromise respiratory function in patients with pre-existing pulmonary pathology. Four main strategies14 can be used in such patients to provide analgesia after shoulder surgery while avoiding phrenic blockade: (1) decreasing local anesthetic volume; (2) performing the ISB more caudad in the neck, around C7; (3) using a supraclavicular block;15 and (4) using a suprascapular nerve block (possibly in association with an axillary nerve block).
The phrenic nerve lies just superficially to the interscalene groove at the level of the cricoid cartilage and courses caudad and anteriorly and distally along the superficial aspect of the anterior scalene muscle along the neck.16
The use of a low volume of local anesthetic (eg, 5 mL) reduces the incidence of phrenic nerve blockade17–19 but may also reduce the duration of analgesia20 and possibly decreases the success rate. Higher volumes (10 mL) injected at the level of the cricoid would cause phrenic nerve blockade.21

FIGURE 32B–11. Split C6 and C7 roots in the interscalene groove.
FIGURE 32B–12. Anatomic variation showing the C5 root located in the anterior scalene muscle. To block this anatomical variant, the root should be traced distally until it enters the interscalene groove.

The function of the phrenic nerve can be assessed using ultrasound in M-mode22 during which a low-frequency curvilinear probe is positioned under the rib cage on the anterior axillary line to evaluate the hemidiaphragm motion (Figure 32B–13).
Of note, some authors have recommended using a combination of suprascapular nerve and axillary nerve blockade to provide postoperative analgesia with minimal motor blockade distal to the shoulder with a lower risk of phrenic nerve blockade and other complications of interscalene block.23–27 The targeted nerves are small, and may prove difficult to find in obese patient. Moreover, these blocks will not provide surgical anesthesia.
Another issue that must be considered is persistent phrenic nerve palsy. There is little agreement as to what causes persistent phrenic nerve palsy, but it seems to be at least in part related to inflammation and nerve entrapment rather than direct needle trauma.28 A contribution of cervical spine disease has been suggested.29 Other factors may be involved, as most patients in published series have been male, overweight or obese, and middle-aged.30

FIGURE 32B–13. Imaging of the right hemidiaphragm under the ribcage on the anterior line. (A) Before interscalene block. (B) After interscalene block with phrenic nerve block.

CONTINUOUS ULTRASOUND-GUIDED INTERSCALENE BLOCK

The goal of the continuous interscalene block is to place the catheter in the vicinity of the elements of the brachial plexus between the scalene muscles. The procedure consists of: (1) needle placement; (2) LA injection to assure the proper needle tip position and “open up the space” for catheter (3) catheter advancement; (4) Injection through the catheter while monitoring on US to verify its therapeutic position and (5) securing the catheter. For the first two phases of the procedure, ultrasound can be used to ensure accuracy. The needle is typically inserted in plane from the lateral-to-medial direction and underneath the prevertebral fascia to enter the interscalene space (Figure 32B–14), although other needle orientations, such as out-of-plane or aiming caudad, may also be used.
Proper needle placement can also be confirmed by obtaining a motor response of the deltoid muscle, arm, or forearm (0.5 mA, 0.1 msec), at which point 4–5 mL of local anesthetic can be injected. This small dose of local anesthetic serves to ensure adequate distribution of local anesthetic as well as to make the advancement of the catheter more comfortable to the patient. This first phase of the procedure does not significantly differ from the single-injection technique. The second phase of the procedure involves maintaining the needle in the proper position and inserting the catheter 2–3 cm into the interscalene space within the vicinity of the brachial plexus (Figure 32B–15). Catheter insertion can be accomplished by a single operator or with an assistant. Proper catheter location can be confirmed either by visualizing the course of the catheter or by an injection of local anesthetic through the catheter. When this proves difficult, an alternative is to inject a small amount of air (1 mL) to confirm the catheter tip location.
The catheter is secured either by taping to the skin with or without tunneling. Some clinicians prefer one over the other. However, the decision about which method to use can be based on patient age, duration of catheter therapy, and/or anatomy.

FIGURE 32B–14. Continuous brachial plexus block. The needle is inserted in the interscalene space using an in-plane approach. Note that for didactic purposes, neither sterile drapes nor ultrasound transducer cover are used in this figure.
FIGURE 32B–15. An ultrasound image demonstrating needle and catheter (white arrowhead) inserted in the interscalene space between the anterior (ASM) and middle (MSM) scalene muscles. BP, brachial plexus.

Tunneling may be preferred in older patients with obesity or sagging skin over the neck or when a longer duration of catheter infusion is expected. Two main disadvantages of tunneling are the risk of catheter dislodgement during tunneling and the potential for scar formation. A number of catheter-securing devices are available to help stabilize the catheter.

TIPS

• Both stimulating and nonstimulating catheters can be used. Because motor response on catheter stimulation may be absent even with ideal catheter placement, the use of stimulating catheters may lead to unnecessary needle and catheter manipulation to obtain evoked motor responses.31
• The catheter-over-needle technique has recently been reintroduced as an alternative to accomplishing continuous interscalene blockade.32

SUGGESTED READINGS

Single-Injection Ultrasound-Guided Interscalene Block

Albrecht E, Kirkham KR, Taffé P, et al: The maximum effective needle-to-nerve distance for ultrasound-guided interscalene block: an exploratory study. Reg Anesth Pain Med 2014;39:56–60.
Avellanet M, Sala-Blanch X, Rodrigo L, Gonzalez-Viejo MA: Permanent upper trunk plexopathy after interscalene brachial plexus block. J Clin Monit Comput 2016;30:51–54.
Burckett-St Laurent D, Chan V, Chin KJ: Refining the ultrasound-guided interscalene brachial plexus block: the superior trunk approach. Can J Anaesth 2014;61:1098–1102.
Errando CL, Muñoz-Devesa L, Soldado MA: Bloqueo interescalénico guiado por ecografía en un paciente con alteraciones anatómicas de la region supraclavicular secundarias a radioterapia y cirugía [Ultrasound-guided interscalene block in a patient with supraclavicular anatomical abnormalities due to radiotherapy and surgery]. Rev Esp Anestesiol Reanim 2011;58:312–314.
Falcão LF, Perez MV, de Castro I, Yamashita AM, Tardelli MA, Amaral JL: Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2013;110:450–455.
Fredrickson MJ, Kilfoyle DH: Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study. Anaesthesia 2009;64:836–844.
Fritsch G, Hudelmaier M, Danninger T, Brummett C, Bock M, McCoy M: Bilateral loss of neural function after interscalene plexus blockade may be caused by epidural spread of local anesthetics: a cadaveric study. Reg Anesth Pain Med 2013;38:64–68.
Gadsden J, Hadzic A, Gandhi K, et al: The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene block. Anesth Analg 2011;112: 471–476.
Ihnatsenka B, Boezaart AP: Applied sonoanatomy of the posterior triangle of the neck. Int J Shoulder Surg 2010;4:63–74.
Koff MD, Cohen JA, McIntyre JJ, Carr CF, Sites BD: Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis. Anesthesiology 2008;108:325–328.
Lang RS, Kentor ML, Vallejo M, Bigeleisen P, Wisniewski SR, Orebaugh SL:The impact of local anesthetic distribution on block onset in ultrasoundguided interscalene block. Acta Anaesthesiol Scand 2012;56:1146–1151.
Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, Yadeau JT: A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg 2010;111:617–623.
Liu SS, YaDeau JT, Shaw PM, Wilfred S, Shetty T, Gordon M: Incidence of unintentional intraneural injection and post-operative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia 2011;66:168–174.
Lu IC, Hsu HT, Soo LY, et al: Ultrasound examination for the optimal head position for interscalene brachial plexus block. Acta Anaesthesiol Taiwan 2007;45:73–78.
Madison SJ, Humsi J, Loland VJ, et al: Ultrasound-guided root/trunk (interscalene) block for hand and forearm anesthesia. Reg Anesth Pain Med 2013;38:226–232.
Marhofer P, Harrop-Griffiths W, Willschke H, Kirchmair L: Fifteen years of ultrasound guidance in regional anaesthesia: part 2—recent developments in block techniques. Br J Anaesth 2010;104:673–683.
McNaught A, McHardy P, Awad IT: Posterior interscalene block: an ultrasoundguided case series and overview of history, anatomy and techniques. Pain Res Manag 2010;15:219–223.
McNaught A, Shastri U, Carmichael N, et al: Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block. Br J Anaesth 2011;106:124–30.
Natsis K, Totlis T, Didagelos M, Tsakotos G, Vlassis K, Skandalakis P: Scalenus minimus muscle: overestimated or not? An anatomical study. Am Surg 2013;79:372–374.
Orebaugh SL, McFadden K, Skorupan H, Bigeleisen PE: Subepineurial injection in ultrasound-guided interscalene needle tip placement. Reg Anesth Pain Med 2010;35:450–454.
Plante T, Rontes O, Bloc S, Delbos A: Spread of local anesthetic during an ultrasound-guided interscalene block: does the injection site influence diffusion? Acta Anaesthesiol Scand 2011;55:664–669.
Renes SH, van Geffen GJ, Rettig HC, Gielen MJ, Scheffer GJ: Minimum effective volume of local anesthetic for shoulder analgesia by ultrasoundguided block at root C7 with assessment of pulmonary function. Reg Anesth Pain Med 2010;35:529–534.
Roessel T, Wiessner D, Heller AR, Zimmermann T, Koch T, Litz RJ: Highresolution
ultrasound-guided high interscalene plexus block for carotid endarterectomy. Reg Anesth Pain Med 2007;32:247–253.
Soeding P, Eizenberg N: Review article: anatomical considerations for ultrasound guidance for regional anesthesia of the neck and upper limb. Can J Anaesth 2009;56:518–533.
Spence BC, Beach ML, Gallagher JD, Sites BD: Ultrasound-guided interscalene blocks: understanding where to inject the local anaesthetic. Anaesthesia 2011;66:509–514.

Continuous Ultrasound-Guided Interscalene Block

Antonakakis JG, Sites BD, Shiffrin J: Ultrasound-guided posterior approach for the placement of a continuous interscalene catheter. Reg Anesth Pain Med 2009;34:64–68.
Fredrickson MJ, Ball CM, Dalgleish AJ: Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Reg Anesth Pain Med 2010;35:28–33.
Fredrickson MJ, Price DJ: Analgesic effectiveness of ropivacaine 0.2% vs 0.4%
via an ultrasound-guided C5–6 root/superior trunk perineural ambulatory catheter. Br J Anaesth 2009;103:434–439.
Fredrickson MJ, Ball CM, Dalgleish AJ: Posterior versus anterolateral approach interscalene catheter placement: a prospective randomized trial. Reg Anesth Pain Med 2011;36:125–133.
Fredrickson MJ, Ball CM, Dalgleish AJ, Stewart AW, Short TG: A prospective randomized comparison of ultrasound and neurostimulation as needle end points for interscalene catheter placement. Anesth Analg 2009;108:1695–1700.
Mariano ER, Afra R, Loland VJ, et al: Continuous interscalene brachial plexus block via an ultrasound-guided posterior approach: a randomized, triplemasked, placebo-controlled study. Anesth Analg 2009;108:1688–1694.
Mariano ER, Loland VJ, Ilfeld BM: Interscalene perineural catheter placement using an ultrasound-guided posterior approach. Reg Anesth Pain Med 2009;34:60–63.
Shin HJ, Ahn JH, Jung HI, et al: Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery. Korean J Anesthesiol 2011;61:475–481.

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Philippe E. Gautier, Catherine Vandepitte, and Jeff Gadsden



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