Upper extremity nerve blocks: Techniques
- Christina L Jeng, MD
Christina L Jeng, MD
- Assistant Professor of Anesthesiology and Orthopaedics
- Icahn School of Medicine at Mount Sinai
- Meg A Rosenblatt, MD
Meg A Rosenblatt, MD
- Professor of Anesthesiology and Orthopaedics
- Icahn School of Medicine at Mount Sinai
Peripheral nerve blocks of the upper extremity are used for operative anesthesia and/or postoperative analgesia for a variety of upper extremity surgeries.
This topic will discuss the innervation of the upper extremity, techniques and drugs used for upper extremity nerve blocks, and complications specific to these blocks. Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment, and complications common to all nerve blocks are discussed separately. (See "Overview of peripheral nerve blocks".)
INNERVATION: UPPER EXTREMITY
The brachial plexus is formed by the ventral rami of the lower cervical and upper thoracic nerve roots (figure 1 and figure 2). It supplies cutaneous and muscular innervation to the upper extremity, with the exception of the trapezius muscle, the cape of the shoulder, and a small area of skin near the axilla (figure 3). The cervical plexus supplies cutaneous innervation above the clavicle, the shoulder tip, and the first two anterior intercostal spaces through the superficial cervical plexus and the supraclavicular nerves (C3 and C4).
The nerve roots emerge in the neck from the transverse processes of the cervical vertebrae posterior to the vertebral artery. The trunks of the brachial plexus (superior [C5,C6], middle [C7], inferior [C8,T1]) pass between the anterior and middle scalene muscles. At this point, the phrenic nerve is located anterior to the anterior scalene muscle. The trunks divide into the anterior and posterior divisions, corresponding to the ventral and dorsal upper extremities, respectively (figure 2).
Passing over the first rib and continuing beneath the clavicle, the cords of the brachial plexus form and are named according to their position relative to the axillary artery (ie, lateral, posterior, and medial). The cords give rise to the five major nerves of the upper extremity:
- Sinha SK, Abrams JH, Weller RS. Ultrasound-guided interscalene needle placement produces successful anesthesia regardless of motor stimulation above or below 0.5 mA. Anesth Analg 2007; 105:848.
- Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991; 72:498.
- Sanchez M, Malhotra N, Lin L. End-stage pulmonary disease and brachial plexus regional anesthesia: their implications on perioperative pulmonary function. Semin Cardiothorac Vasc Anesth 2012; 16:59.
- Riazi S, Carmichael N, Awad I, et al. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2008; 101:549.
- Stundner O, Meissnitzer M, Brummett CM, et al. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial. Br J Anaesth 2016; 116:405.
- Vester-Andersen T, Christiansen C, Hansen A, et al. Interscalene brachial plexus block: area of analgesia, complications and blood concentrations of local anesthetics. Acta Anaesthesiol Scand 1981; 25:81.
- Kumar A, Battit GE, Froese AB, Long MC. Bilateral cervical and thoracic epidural blockade complicating interscalene brachial plexus block: report of two cases. Anesthesiology 1971; 35:650.
- Dutton RP, Eckhardt WF 3rd, Sunder N. Total spinal anesthesia after interscalene blockade of the brachial plexus. Anesthesiology 1994; 80:939.
- Moore DC. Complications of regional anesthesia. Clin Anesth 1969; 2:218.
- Brand L, Papper EM. A comparison of supraclavicular and axillary techniques for brachial plexus blocks. Anesthesiology 1961; 22:226.
- Soffer RJ, Rosenblatt MA. Teaching ultrasound-guided interscalene blocks: description of a simple and effective technique. J Clin Anesth 2007; 19:241.
- Soares LG, Brull R, Lai J, Chan VW. Eight ball, corner pocket: the optimal needle position for ultrasound-guided supraclavicular block. Reg Anesth Pain Med 2007; 32:94.
- Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 2003; 97:1518.
- Perlas A, Lobo G, Lo N, et al. Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med 2009; 34:171.
- Pham-Dang C, Gunst JP, Gouin F, et al. A novel supraclavicular approach to brachial plexus block. Anesth Analg 1997; 85:111.
- Koyyalamudi VB, Arulkumar S, Yost BR, et al. Supraclavicular and paravertebral blocks: Are we underutilizing these regional techniques in perioperative analgesia? Best Pract Res Clin Anaesthesiol 2014; 28:127.
- Knoblanche GE. The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesth Intensive Care 1979; 7:346.
- Neal JM, Moore JM, Kopacz DJ, et al. Quantitative analysis of respiratory, motor, and sensory function after supraclavicular block. Anesth Analg 1998; 86:1239.
- Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Cochrane Database Syst Rev 2010; :CD005487.
- Sauter AR, Smith HJ, Stubhaug A, et al. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesth Analg 2006; 103:1574.
- Dhir S, Ganapathy S. Comparative evaluation of ultrasound-guided continuous infraclavicular brachial plexus block with stimulating catheter and traditional technique: a prospective-randomized trial. Acta Anaesthesiol Scand 2008; 52:1158.
- Tsui, BC, Chan, VW, Bhargava, R. Infraclavicular Block. In: Atlas of Ultrasound and Nerve Stimulation-Guided Regional Anesthesia, Springer, 2007. p.87.
- Borene SC, Edwards JN, Boezaart AP. At the cords, the pinkie towards: Interpreting infraclavicular motor responses to neurostimulation. Reg Anesth Pain Med 2004; 29:125.
- Lecamwasam H, Mayfield J, Rosow L, et al. Stimulation of the posterior cord predicts successful infraclavicular block. Anesth Analg 2006; 102:1564.
- Sharma D, Srivastava N, Pawar S, et al. Infraclavicular brachial plexus block: Comparison of posterior cord stimulation with lateral or medial cord stimulation, a prospective double blinded study. Saudi J Anaesth 2013; 7:134.
- Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001; 93:436.
- Lo N, Brull R, Perlas A, et al. Evolution of ultrasound guided axillary brachial plexus blockade: retrospective analysis of 662 blocks. Can J Anaesth 2008; 55:408.
- Youssef MS, Desgrand DA. Comparison of two methods of axillary brachial plexus anaesthesia. Br J Anaesth 1988; 60:841.
- Koscielniak-Nielsen ZJ, Hesselbjerg L, Fejlberg V. Comparison of transarterial and multiple nerve stimulation techniques for an initial axillary block by 45 mL of mepivacaine 1% with adrenaline. Acta Anaesthesiol Scand 1998; 42:570.
- Rodríguez J, Taboada M, Del Río S, et al. A comparison of four stimulation patterns in axillary block. Reg Anesth Pain Med 2005; 30:324.
- Lavoie J, Martin R, Tétrault JP, et al. Axillary plexus block using a peripheral nerve stimulator: single or multiple injections. Can J Anaesth 1992; 39:583.
- Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Lippert FK. Readiness for surgery after axillary block: single or multiple injection techniques. Eur J Anaesthesiol 1997; 14:164.
- Inberg P, Annila I, Annila P. Double-injection method using peripheral nerve stimulator is superior to single injection in axillary plexus block. Reg Anesth Pain Med 1999; 24:509.
- Sukhani R, Garcia CJ, Munhall RJ, et al. Lidocaine disposition following intravenous regional anesthesia with different tourniquet deflation technics. Anesth Analg 1989; 68:633.
- Davies JA, Walford AJ. Intravenous regional anaesthesia for foot surgery. Acta Anaesthesiol Scand 1986; 30:145.
- Kim DD, Shuman C, Sadr B. Intravenous regional anesthesia for outpatient foot and ankle surgery: a prospective study. Orthopedics 1993; 16:1109.
- Dunbar RW, Mazze RI. Intravenous regional anesthesia: experience with 779 cases. Anesth Analg 1967; 46:806.
- Brown EM, McGriff JT, Malinowski RW. Intravenous regional anaesthesia (Bier block): review of 20 years' experience. Can J Anaesth 1989; 36:307.
- Guay J. Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications. J Clin Anesth 2009; 21:585.
- Davies JA, Hall ID, Wilkey AD, et al. Intravenous regional analgesia. The danger of the congested arm and the value of occlusion pressure. Anaesthesia 1984; 39:416.
- INNERVATION: UPPER EXTREMITY
- BRACHIAL PLEXUS BLOCKS
- Interscalene block
- - Positioning
- - Ultrasound-guided interscalene block
- - Nerve stimulator-guided interscalene block
- - Perineural catheter interscalene block
- - Side effects and complications of interscalene block
- Supraclavicular block
- - Positioning
- - Ultrasound-guided supraclavicular block
- - Nerve stimulator-guided supraclavicular block
- - Perineural catheter supraclavicular block
- - Side effects and complications of supraclavicular block
- Infraclavicular block
- - Positioning
- - Ultrasound-guided infraclavicular block
- - Nerve stimulator-guided infraclavicular block
- - Perineural catheter infraclavicular block
- - Side effects and complications of infraclavicular block
- Axillary block
- - Positioning
- - Ultrasound-guided axillary block
- - Transarterial axillary block
- - Nerve stimulator-guided axillary block
- - Side effects and complications of axillary block
- INTERCOSTOBRACHIAL NERVE BLOCK
- WRIST BLOCKS
- Radial nerve block
- Median nerve block
- Ulnar nerve block
- DIGITAL NERVE BLOCK (FINGER)
- DRUG CHOICES
- INTRAVENOUS REGIONAL ANESTHESIA (BIER BLOCK)
- IV regional anesthesia technique
- Side effects and complications of IV regional
- SUMMARY AND RECOMMENDATIONS