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Science, Technology and Medicine open access publisher.Publish, read and share novel research. Ultrasound-Guided Peripheral Nerve Block Anesthesia with Emphasis on the Interscalene Approach to Brachial Plexus BlockadeJames C.
1Typical ultrasound probe selection for the performance of interscalene block includes a straight, linear array probe due to its higher operating frequencies (5 - 13 MHz), providing increased resolution at the expense of decreased penetration. 2Typical block needle selection may include a 22 gauge, beveled needle 5 cm or greater in length. Typical ultrasound probe placement on a patient’s neck while performing the interscalene block. Ultrasound view of the interscalene region demonstrating hypoechoic nerve cross sections of the brachial plexus (N), lying between the middle scalene (MS) and anterior scalene (AS) muscle bellies.
Ultrasound view demonstrating typical lateral approach of a peripheral nerve block needle within the interscale groove. Ultrasound view of areas of local anesthetic (LA) volume deposition surrounding the brachial plexus at the level of the interscalene groove.
Changes in anesthesia-related factors in ambulatory knee and shoulder surgery: United States 1996-2006. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries.
For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials.
Regional anesthesia procedures for shoulder and upper arm surgery upper extremity update--2005 to present. The role of a preprocedure systematic sonographic survey in ultrasound-guided regional anesthesia. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization.
Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve.
Characterizing novice behavior associated with learning ultrasound-guided peripheral regional anesthesia.
Ultrasound-guided interscalene blocks: understanding where to inject the local anaesthetic. Correlation between ultrasound imaging, cross-sectional anatomy, and histology of the brachial plexus: a review.
The 5 most common ultrasound artifacts encountered during ultrasound-guided regional anesthesia. Is circumferential injection advantageous for ultrasound-guided popliteal sciatic nerve block?: A proof-of-concept study. Echotexture of peripheral nerves: correlation between US and histologic findings and criteria to differentiate tendons.
A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block.
Anatomy of the normal brachial plexus revealed by sonography and the role of sonographic guidance in anesthesia of the brachial plexus.
Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function. Brachial plexus examination and localization using ultrasound and electrical stimulation: a volunteer study. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis.
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Note positioning of the patient’s head to the contralateral side of the intended nerve block may facilitate ultrasound probe placement and visualization of brachial plexus anatomy. Note the circumferential enhancement of the brachial plexus nerves (N) after local anesthetic deposition. Orebaugh1[1] Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA1.
Verify probe anatomical orientation on patient matches orientation displayed on ultrasound screen13. Levy’s philosophy is practiced by thousands of people across the country and has helped transform the lives of many. Levy lives in Chicago, where he enjoys spending time with his wife Anne and their two dogs, Lucy and Ricky.
The peripheral block needle is seen here as a hyperechoic linear structure positioned above the brachial plexus.Table 1. IntroductionEpidemiologic data has revealed a progressive rise in the aggregate number of patient surgical visits with an increasing number occurring within the ambulatory setting [1]. Accompanying this rise has been a growing need for adequate, efficient patient anesthesia and analgesia [2].
With a significant proportion of procedures involving focal orthopedic interventions of the knee and shoulder, peripheral nerve blockade has become an increasing trend in anesthetic practice while neuraxial blockade use has decreased [2]. The popularity of peripheral nerve blockade may stem from its demonstrated effectiveness with studies showing improved analgesia and recovery during the postoperative period versus opioids [3] or general anesthetic [4]. Scan with probe to interscalene groove in order to identify optimal local anesthetic injection site (consider ultrasound Doppler function to scan for vessels at chosen injection site)17. In this chapter, we will review ultrasonography and its application to a commonly employed peripheral nerve block, namely, the interscalene block.2. The peripheral block needle is seen here as a hyperechoic linear structure positioned above the brachial plexus.The block needle may be equipped with a PNS for further confirmation of appropriate plexus proximity before deposition of local anesthetic [38]. A brief historyThe first published account of ultrasound use with peripheral nerve blockade occurred in 1978 when Doppler sonography assisted blood flow detection during supraclavicular brachial plexus block [5].
Visualize block needle tip prior to advancing to desired position within interscalene groove20.
These responses indicate adequate proximity to the brachial plexus prior to local anesthetic delivery, if consistent with appropriate deposition of local anesthetic solution in the interscalene groove as visualized with real-time ultrasound imaging [41].Physical examination is used to evaluate for brachial plexus block success.
Although the initial technology did not allow for direct nerve visualization, this was later rectified in 1994, when advancements in technology allowed the first documented use of ultrasound to visually facilitate supraclavicular brachial plexus block [5].

Instruct assistant to provide negative-pressure syringe aspiration to rule out intravascular needle placement21.
Just as Winnie noted maximal anesthetic effect within 15 min of landmark ISB technique [28], physical examination to assess for appropriate motor and sensory block after ultrasound-guided ISB should be conducted after this timeframe. Since this time, ultrasound use for regional anesthesia has shown increasing popularity, and ultrasound technology has mirrored practitioner demand with machines possessing greater portability, simplicity, and image resolution [5]. Warn patient of possible discomfort and instruct assistant to inject local anesthetic in small (3 – 5 ml) increments (aspirate prior to injecting each aliquot)22. Literature regarding the utility of ultrasound for a variety of peripheral nerve blocks continues to emerge. Assess local anesthetic spread on ultrasound screen for adequacy and reposition block needle if necessary23. Efficacy of ultrasound guidance for interscalene blockThe successful implementation of ultrasonography for interscalene block has been well-documented with a variety of studies citing its efficacy [6]. Regarding imaging sensitivity, Muhly et al compared ultrasound imaging with cadaveric dissections of ISB anatomy and found that ultrasound was successfully able to detect vasculature branching as well as its course closely bordering nerves of the brachial plexus [42].
AdvantagesThe rising popularity of ultrasound guidance for peripheral nerve blockade (PNB) stems from numerous described advantages supporting its use [6], [7], [5]. Due to individual variation in the neurovasculature surrounding the brachial plexus, one may appreciate the utility of directly visualizing such discrepancies from typical anatomy that might otherwise remain undetected using prior forms of PNB guidance [42].Several studies have examined the effect of ultrasound with respect to quality of ISB anesthesia. Perhaps the principal benefit of ultrasound resides in the technology’s inherent ability to directly visualize peripheral nerves and tissue planes in real-time, allowing for optimal injectate or catheter placement with the ultimate goal of optimizing neural blockade [7].
Kapral et al compared performance of ISB using ultrasound versus peripheral nerve stimulation in a randomized trial, finding a significantly greater motor, sensory, and extent of brachial plexus blockade while using ultrasound [30].
Today’s ultrasound machines are equipped with high-frequency probes capable of imaging the majority of nerves necessary for a wide array of regional blocks, and also their oblique course as they traverse the body [7]. Similarly, a randomized study by Liu et al, examining ultrasound versus nerve stimulator for ISB in randomized patients, revealed increased motor blockade assessed after five minutes as well as a decreased number of needle attempts for the ultrasound group [25]. This imaging modality permits the identification of relatively diminutive 2 mm diameter digital nerves [7], as well as differentiation of complex neurovascular nuances as found within the brachial plexus [8]. McNaught et al also noted decreased needle attempts using ultrasound for ISB, while showing a significant decrease in the minimum effective analgesic volume (MEAV) of local anesthetic, and decreased pain 30 min postoperatively when compared to a nerve stimulator group [27]. Additional benefit is conveyed in the ability to reposition one’s needle in assessing for adequate local anesthetic spread, fascial plane movement, or lack thereof with intravascular injection [7]. When examining ultrasound placement versus nerve stimulator placement of ISB catheters in randomized patients, Fredrickson et al demonstrated greater effectiveness in the ultrasound group, requiring less local anesthetic boluses and tramadol use in addition to fewer needle attempts [43].
The idea of preemptively scanning patient anatomy for neurovascular variations or abnormalities has been suggested as a means of improving patient safety by preventing block complication [9].A number of objective evaluations have supported the efficacy of ultrasound guidance during PNB. When compared with performance via peripheral nerve stimulation (PNS), PNB executed using ultrasound guidance has been shown to require less time to perform, possesses more rapid onset and longer duration of anesthesia, and is more likely to be successful (less block failure) [6].
Revelations with ultrasound and interscalene blockUnexpected findings have been revealed when utilizing ultrasound guidance for interscalene block since the technique’s initial application.
The use of ultrasound rather than PNS has also been shown to decrease the risk of vascular puncture [6], [10], and demonstrate improved quality of sensory block [11].
The use of ultrasonography does not exclude the use of PNS for PNB, and the combination for brachial plexus block was shown to have decreased risk of central nervous system toxicity secondary to local anesthetic versus a PNS-landmark technique [12]. Plante et al carried out a study comparing ultrasound-guided ISB performed at the C5 versus C6 anatomical level in randomized patients undergoing shoulder surgery [39].
Another study demonstrated high rates of success with axillary brachial plexus block using sonography regardless of concurrent PNS use [13]. This study revealed ISB performed at both levels possessing similar efficacy, however the C6 level resulted in significantly greater block success of the distal brachial plexus, including the ulnar, radial, and medial nerves [39].Needle proximity and neuronal tissue microanatomy with regard to ISB have also been examined. Compared with PNS for femoral nerve block, ultrasound guidance also provides a reduction in the minimum effective anesthetic volume (MEAV50) [14], and has allowed reduced dosing for many blocks, with a potential impact on local anesthetic systemic toxicity and therefore patient safety [15]. Spence et al sought to determine the ideal location of local anesthetic deposition for ISB [18]. When comparing needle tip and injection superficial to the brachial plexus sheath versus penetration deep to this plexus covering in randomized patients, both positions showed comparable times to block onset, yet the deeper injection resulted in longer mean block duration [18].
DisadvantagesDespite many reported advantages to ultrasound guidance during PNB, several barriers to implementation and training have been described. In examining ultrasound-guided needle tip placement relative to the nerve roots of the brachial plexus epineurium in the interscalene groove, using india ink staining in a cadaveric study, it was demonstrated that subepineural injection occurred more often than anticipated despite ultrasound guidance [45].Although the middle scalene muscle itself was largely thought devoid of neuronal structures, the continued use of ultrasound guidance in performance of the interscalene block has indeed proven useful in both identifying and localizing brachial plexus nerves within this area.
One such limitation arises from peripheral nerve anatomical variation leading to difficulty in regional pattern recognition [16]. Difficulty to trainees may arise from the necessary knowledge of cross-sectional anatomy, terminology, appropriate local anesthetic spread, as well as an understanding of novel probe operating mechanics and regular needle tip visualization [7], [17], [18].
These nerves were found to occur at a depth approximating the C6 nerve root level and less than 1 cm posterior to the larger brachial plexus with the dorsal scapular nerve identified more commonly than the long thoracic nerve (77% versus 23%, respectively) [46]Local anesthetic volume and concentration necessary for successful ISB have also been studied. As a result, images may appear ambiguous to the novice operator [19], and identifying the intricate neurovascular anatomy of a common PNB structure as the brachial plexus may prove formidable [20]. Riazi et al compared the use of 5 ml versus 20 ml ropivicaine 0.5% with ultrasound-guided ISB for randomized patients receiving shoulder surgery [26]. Inexperience leading to inability to recognize common on-screen artifacts stemming from image processing may also skew interpretation [21]. The lower volume group was shown to provide equivalent analgesia to the 20 ml group while resulting in a significant decrease in respiratory complications, including diaphragmatic or phrenic nerve paralysis, declines in oxygen saturation, and reduced function on spirometry testing [26]. In contrast to a definitive motor response end-point elicited with nerve stimulator, the optimal pattern of local anesthetic deposition and distribution continues to be investigated [22], [18].Ultrasonography may also prove challenging as a result of current technological limitations.
A later study by Renes et al examined the minimum effective volume (MEV) of ropivicaine 0.75% necessary to provide successful analgesia for elective shoulder surgery when deposited at the C7 level via ultrasonography [31]. For example, discriminating neuronal tissue and its epineurium from that of connective tissue or tendons may prove difficult due to the similar hyperechoicity, or echotexture [7], [20]. Furthermore, ultrasound imaging has been shown to underrepresent the total number of neuronal fascicles as compared to light microscopy, and the possibility of intraneural injection (a topic of controversy with respect to morbidity) exists [23], [20].3.
Fredrickson et al compared varying ISB bolus ropivicaine concentrations and volumes for preoperative PNB in randomized patients undergoing shoulder surgery and also receiving postoperative 0.2% ropivicaine infusions [47]. Block descriptionUpper extremity peripheral nerve blocks account for the majority of performed regional anesthesia techniques in most anesthesia practices [24]. Of note, local anesthetic concentration was shown to be the principle determinant of motor blockade [47].Goebel et al conducted a randomized trial examining the use of ultrasound-placed ISB catheters in managing postoperative pain for major shoulder surgery [48].
Of the upper extremity PNBs, the interscalene block (ISB) is the most commonly applied block for patients undergoing shoulder surgery [25], [26], [8], imparting both anesthesia and analgesia with adequate coverage of the shoulder, lateral arm, and lateral forearm [27]. The ISB was first described in 1970 by Winnie, who noted based on anatomic and radiographic imaging that the interscalene space allowed for a novel, percutaneous approach to anesthetizing the proximal brachial plexus [28]. Adverse effects with interscalene blockWith the performance of interscalene block over the past four decades, notable adverse effects have been established.
This approach allowed for brachial plexus anesthesia of similar quality to that of thoracic epidural anesthesia [28]. Perhaps most notable, phrenic nerve (C3-5) paralysis occurs in nearly all patients receiving ISB that may lead to significant decline respiratory function, particularly in patients with underlying pulmonary disease [26], [31]. Compared to the previously described axillary and subclavian approaches prior to this time, the ISB was quickly favored for its ease of execution due to readily palpable landmarks in patients with large body habitus, no requirement for unique upper extremity positioning, and ability to readily repeat the block during protracted surgical procedures [28].
One ultrasound study found the anatomical separation between the brachial plexus and phrenic nerve lateral to the cricoid cartilage to be as little as 2 mm [49]. Other undesirable effects of regional anesthesia at this site may include blockade of the recurrent laryngeal nerve causing hoarseness, stellate ganglion causing Horner’s syndrome, and increased local anesthetic spread rarely causing elements of epidural or spinal quality anesthesia [27].
AnatomyWith the exception of the supraclavicular nerves, the brachial plexus is responsible for all motor and sensory innervation to the shoulder area [8].

Inadvertent needle placement during ISB performance may lead to vasculature puncture and direct nerve injury, including reported cases of spinal cord injury [50]. The brachial plexus is an intricate neuronal network originating as ventral rami from cervical nerve roots, C5-8, and initial thoracic nerve root, T1 [24]. As with other forms of regional anesthesia, systemic local anesthetic toxicity as well as block failure may occur [51]. Together, these roots within the neck further subdivide into trunks, divisions, cords, and, ultimately, peripheral branches traveling distally into the upper arm [29]. Failure to anesthetize the distribution of the ulnar nerve is of particular propensity with ISB, as the lower trunk is often spared [24]. After exiting the vertebral column, the roots become trunks as they traverse through the apposition of the anterior and middle scalene muscles, or interscalene groove [24]. Impact of ultrasound on adverse effectsWith the inclusion of ultrasound guidance for interscalene block, several studies have demonstrated an impact on previously reported adverse effects.
At the distal clavicle and latter portion of the axillary artery, the divisions combine to form cords, which further subdivide into terminal branches at the level of the humerus [24].Winnie described three anatomical spaces comprising the fascial sheath-enveloped area, cradling the neurovasculature of the brachial plexus along its course from the proximal, cervical vertebral bodies distally toward the axilla [28]. Renes et al conducted a randomized trial in patients undergoing shoulder surgery, comparing general anesthesia combined with ISB performed with 10 ml ropivacaine deposited via ultrasound versus peripheral nerve stimulator technique [35]. The ultrasound group showed a significantly decreased incidence of diaphragmatic hemiparesis [35].
The interscalene space describes the contiguous area enveloped posteriorly by the fascial sheath covering of the middle scalene muscle and anteriorly by that of the anterior scalene fascia [28]. In addition, the use of ultrasound technique has allowed ISB studies that have revealed decreased incidence of phrenic nerve blockade and respiratory complications based on level of block performance (C7) and reduced volume of local anesthetic [27], [26]. The interscalene space was noted to be continuous with both the axillary and subclavian spaces, thereby allowing appropriate peripheral nerve blockade introduction at this site [28].In order to provide effective analgesia for shoulder surgery, one must anesthetize the nerves supplying all of the muscle, ligamentous, and osseous tissues of the shoulder joint and surrounding area [8]. Abrahams et al conducted a systematic review and meta-analysis of randomized trials for a variety of peripheral nerve blocks [6]. Properly performed interscalene blockade provides anesthesia to the superior and middle trunks of the brachial plexus with C5-7 coverage, while also blocking the supraclavicular nerves arising from C3-4 [26]. When comparing ultrasound guidance versus peripheral nerve stimulation, ultrasound guided blocks were shown to have significantly less risk of vascular puncture [6]. Despite direct visualization when using ultrasound-guidance for PNB, no significant difference in the incidence of neuronal injury or neurologic symptoms postoperatively has been shown [25], [24].
IndicationsSince its initial description, the interscalene block has been met with widespread acceptance, demonstrating effective [30], [31], [26], [8] and reliable perioperative analgesia for shoulder surgery [27], [26]. With regard to failure to anesthetize the brachial plexus inferior trunk with ISB, Kapral et al demonstrated improved ulnar nerve and median nerve blockade 30 min post-block when compared to PNS guidance [30].Perhaps the most important impact of ultrasound guidance during performance of peripheral nerve blockade to date has been related to an increase in patient safety via a decrease in local anesthetic systemic toxicity (LAST). The interscalene block is suitable for a wide array of surgical procedures involving the shoulder with coverage including the shoulder joint, proximal humerus, as well as distal clavicle [8]. Over a hundred cases of severe toxicity have been described in the medical literature, including some that have resulted in fatality, though the incidence of actual cases are likely much more numerous [15]. Most such cases involve toxicity to the central nervous system, including loss of consciousness, agitation, or, most commonly, seizure. ISB may be used as an adjuvant to general anesthesia or as solitary anesthetic technique for shoulder surgery [8].
Fifty percent of reported cases showed some evidence of cardiovascular toxicity, for which resuscitation may prove quite challenging [15]. As a primary anesthetic, ISB may thereby reduce the risk of adverse events associated with general anesthesia, including time to ambulation secondary to impaired motor function, postoperative nausea and vomiting, and prolonged length of stay [4]. Several studies have recently been published which strongly support the idea that ultrasound imaging has reduced the incidence of serious LAST.
ISB also allows for a reduction in opioid analgesics and their consequential ill-effects [27], [8]. In another large database report from a single site summarizing experience at a single teaching institution, Orebaugh, et al, reported a significant reduction in LAST episodes over a six-year period as the practice transitioned from nerve stimulator to ultrasound guidance-there were no such complications in over 9000 cases in which ultrasound was utilized [53].
Landmark and nerve stimulator techniquesPrior to the advent of ultrasound imaging guidance, the primary methods for performing brachial plexus blockade included landmark and peripheral nerve stimulator (PNS) techniques [32], [33]. Both methods of nerve localization involve non-visualization of internal structures, and instead rely on either paresthesias or muscle twitch responses for landmark and PNS, respectively [32].
ConclusionsPeripheral nerve blockade has become an ever-increasing tool in providing analgesia for patients undergoing focal surgical interventions. Specifically, a contraction of the biceps or triceps may be appreciated, corresponding to cervical nerve stimulation at levels C5-6 and C6-8, respectively, at which point local anesthetic is deposited [35].
Advancements in ultrasound guidance for performance of these peripheral nerve blocks have allowed a parallel increase in this technology’s utilization.
Of note, PNS may hold limited effectiveness in diabetic patients complicated by neuropathy, as motor response may not be elicited despite application of a standard stimulus [36].
The interscalene approach to brachial plexus blockade is a commonly employed peripheral nerve block that has demonstrated effectiveness in providing perioperative analgesia for patients undergoing shoulder surgery.
Despite a theoretical advantage in determining needle tip proximity to neuronal tissue with greater precision using PNS as compared to paresthesia elicitation, both techniques have shown similar efficacy for peripheral nerve blockade [24]. The use of ultrasound guidance in performing the interscalene block has been shown to be effective in providing postoperative analgesia while decreasing specific respiratory side-effects [26], [27], [35], vascular puncture [6], and local anesthetic toxicity [53] as compared to non-ultrasongraphic, blind techniques. These benefits likely stem from the direct visualization of anatomical structures afforded by ultrasound implementation during block performance. Ultrasonography for interscalene blockIn contrast to prior methods of nerve localization, ultrasound guidance provides visualization of the block needle, neurovascular structures and their anatomical course, and the spread of local anesthetic injectate in real-time [38], [7], [5], [24], [39], [8].
Ultrasound guidance has been implemented both with and without concomitant nerve stimulator for the performance of regional anesthesia [10], although no added benefit has been proven with the addition of PNS [24], [40].Typical sonoanatomy seen while performing the interscalene block has been described. Application of an ultrasound probe in the vicinity of interscalene groove allows for direct visualization of the C5-7 nerve roots exiting their corresponding intervertebral foramina and subsequently passing between the anterior and middle scalene muscles [20].
One may reliably differentiate the seventh cervical nerve root, as the C7 transverse process possesses no anterior tubercle [24]. Elements of the brachial plexus appear characteristically as a cluster of hypoechoic, or comparably dark, bodies on ultrasound imaging, while surrounding fascial layers appear hyperechoic, or comparably white [20]. Of note, numerous variations of the brachial plexus have been characterized, and these subtle deviations may be appreciated with ultrasonography [24].Reliable brachial plexus blockade via ISB and ultrasonography has been described using a consistent method [38], [41] (Table 1). Patients undergoing ISB should have routine monitoring and supplemental oxygen in place prior to beginning the PNB, with low dose anxiolytic premedication administered when appropriate. Head positioning away from the intended block site may facilitate probe placement (Figure 1). Antiseptic technique including cleansing solution, drape, transducer dressing, gel, and standard practitioner barriers should be implemented.
In order to assist avoidance of initial vascular trauma or injection, the subclavian artery is first visualized in cross-sectional view within the supraclavicular region.
Color Doppler mode may assist in identifying additional vasculature surrounding the plexus [9]; [42].
Translation of the transducer probe medially reveals the characteristic hypoechoic cluster of brachial plexus fascicles located between the anterior and middle scalene muscle bellies [38] (Figure 2).1.
Position ultrasound machine with screen readily visible and probe accessible to practitioner4. Position patient head away from intended block site to facilitate block placement (Figure 1)5.

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