Brachial Plexus BlockAbove the Clavicle

Edited by Dr. M Dorgham

Under supervision of Proff Dr. Amr Abdelfattah

Objectives

Review the Anatomy of brachial plexus

Neurostimulation guided approaches

Sonoanatomy and Ultrasound guidance

Complications Advantages of ultrasound guidance

•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.

Anatomy of Brachial Plexus

•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) andAn area of skin near the axilla innervated by the intercostobrachial nerve.

Anatomy of Brachial PlexusThe brachial plexus is divided into

Trunks

Cords

Devisions

Branches

Roots

Anatomy of Brachial PlexusNerve Roots Muscles Cutaneous

Roots Dorsal scapular nerve

C5 RhomboidLevator scapulae

Roots Long thoracic nerve C5 C6 C7 Serratus anterior

Anatomy of Brachial PlexusNerve Roots Muscles Cutaneous

UpperTrunk

Nerve to subclavius C5 C6 Subclavious

Upper Trunk

Suprascapular nerve

C5 C6 SupraspinatousInfraspinatous

Anatomy of Brachial PlexusNerve Roots Muscles Cutaneous

Lateral cord

Lateral pectoral nerve

C5 C6 C7 Pectoralis Major By communication with Medial Pectoral Nerve

Lateral cord

Musculocutaneous nerve

C5 C6 C7 CoracobrachialisBrachialis

Biceps brachii

Become the Lateral cutaneous nerve of forearm

Lateral cord

Lateral root of median nerve

C5 C6 C7 Fibres of Median nerve

Nerve Roots Muscles Cutaneous

Medial cord

Medial pectoral Nr C8 T1 Pectoralis majorPectoralis minor

Medialcord

Medial root of median Nr.

C8 T1 Fibres to median nerve

portions of hand not served by ulnar or radial

Medial cord

Medial cutaneous nerve of arm

C8 T1 front and medial skin of the arm

Medial cord

Medial cutaneous nerve of forearm

C8 T1 medial skin of the forearm

Anatomy of Brachial Plexus

Medial cord

Ulnar Nr. C8 T1 1.Flexor carpi ulnaris

2.the medial two bellies of flexor digitorum profundus,

3.the intrinsic hand muscles except the thenar muscles.

4.the two most medial lumbricals

the skin of the medial side of the hand

medial one and a half fingers on the palmar side

medial two and a half fingers on the dorsal side

Anatomy of Brachial Plexus

Nerve Roots Muscles Cutaneous

Post cord

Upper subscapular nerve

C5 C6 Sub scapilaris(upper part)

Post cord

Thoracodorsal Nr(Middle subscapular)

C6 C7 C8 Latismus Dorsi

Post cord

Lower scapular Nr C5 C6 Subscapularis(lower part)Teres major

Post cord

Axillary Nr. C5 C6 Ant Br: Deltoid & small area of overlying skinPost Br: Teres minor & Deltoid ms

Post Branch continues as upper Lateral cutaneous Nr of arm

Post cord

Radial Nr. C5 C6 C7C8 T1

Triceps brachiiSupinatorAnconeusBrachioradialisExtensors of forearm

Posterior cutaneous nerve of arm

INTERSCALENE BLOCKANTERIOR APPROACH

Superficial anatomy

Superficial anatomyThe sternal head of the sternocleidomastoid muscle (1) is anterior to its

clavicular head (2), which forms the anterior borderof 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 floorof the posterior triangle of the neck and gives rise to the

supraclavicular nerves (6). The superficial cervical plexus originatesfrom 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 (8).

Deep anatomy

Deeper anatomyA 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 thethoracic 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. Thesuprascapular nerve (14) and the dorsal scapular nerve (15) (which innervates the rhomboid muscles) branches from thebrachial plexus. Note that the subclavian artery (16) lies anterior to the brachial plexus.

Surface anatomy1 = Phrenic nerve2 = Brachial plexus3 = Dorsal scapular nerve (to rhomboid muscles)4 = Nerve to levator scapulae

POSTERIOR APPROACH (ORCONTINUOUS CERVICAL PARAVERTEBRAL BLOCK)

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.

AnatomyThe 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).

AnatomyThe point of needle entry is in the apex of the “V” formed by thetrapezius muscle posterior and the levator scapulae muscle anterior –the “B”-spot

Surface anatomyNeedle 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 placementThe 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 ofresistance to air and muscle twitches of the shoulder girdle appearsimultaneously.

Ultrasound guided Interscalene Brachial plexus block

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 structures

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 (<20 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 anteriorand posterior divisions, which separate theinnervation of the ventral and dorsal halves of the upper limb.

Classic Kulenkampff technique

In 1988 Brown described the plumb-bob technique

Ultrasound guidedSupraclavicular Brachial Plexus Block

POSITIONING• The patient is placed supine

• The patient’s 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

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.

It will not diffuse to the lower roots of the cervical plexus, and thus will not block the upper aspect of the shoulder.

•Typical Indication : For surgeries below the mid-humerus level.

•Twenty to Forty mls local anaesthetic is adequate for reliable block

•Peripheral Nerve InjuryMost 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 InjuryThe risk of hematoma immediately after brachial plexus techniques is small (0.001 to 0.02%)

•Muscle InjuryMyonecrosis 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, continuouslocal anesthetic administration may worsen injury.

Possible Complications

•Hemidiaphramatic ParesisThe 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 block

•PneumothoraxThe reported incidence of pneumothorax after supraclavicular block is 0.5% to 6.1%

•Intravascular Injectionlocal 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 Horner’s syndrome.with20% to 90% incidence

•Recurrent Laryngeal Nerve. •Hoarseness may transpire after interscalene block or after 1.3% of supraclavicular blocks

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 satisfaction.

Advantages of Ultrasound Guidance

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.

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.

Anatomic structures of importance. Pectoralis muscle (shown cut to expose brachial plexus)clavicle (removed)coracoid processhumerusbrachial plexussubclavian/axillary artery and vein

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 LandmarksThe following surface anatomy landmarks are useful in identifying the estimated site for an infraclavicular block:1.Sternoclavicular joint 2.Medial end of the clavicle 3.Coracoid process 4.Acromioclavicular joint 5.Head of the humerusAnatomic LandmarksLandmarks for the infraclavicular block include:1.Coracoid Process2.Medial clavicular head 3.Midpoint of line connecting 1 and 2 and 3cm caudal

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 block

Needle insertionA 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 guidedInfraclavicular Brachial Plexus Block