Ultrasound-Guided Interscalene Brachial Plexus Block

Aka: Ultrasound-Guided Interscalene Brachial Plexus Block, Interscalene Nerve Block, Brachial Plexus Block, Interscalene Block, Interscalene Brachial Plexus Block

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II. Indications

  1. Anesthesia to Shoulder, upper arm and clavicle
  2. Does not provide Anesthesia to ulnar aspect of the Forearm or hand

III. Anatomy

  1. Brachial Plexus Nerve Roots (C5-T1) form the Brachial Plexus trunks and arm Peripheral Nerves
    1. Brachial Plexus runs 1-3 cm deep in the supraclavicular region, inferolateral to sternocleidomastoid Muscle
    2. Nerve roots C5-C7 are most accessible to Nerve Block
  2. Risk of adverse effects on nearby structures
    1. Carotid Artery and Internal Jugular Vein are medial to injection site
    2. Phrenic Nerve (transient diaphragm paralysis)
    3. Superficial Cervical Plexus Block (Transient Horner Syndrome)

IV. Preparation

  1. Identify and mark landmarks
    1. Lateral to Carotid Artery and internal Jugular Vein, posterior sternocleidomastoid Muscle
    2. Level 2-3 inches (5-7.5 cm) above the clavicle
  2. Skin Preparation (e.g. Chlorhexidine)
  3. Drape region
  4. Sterile covering over Ultrasound high frequency linear probe (sterile gel inside and outside)
  5. Medication
    1. Confirm maximum dose for Ropivacaine (or Bupivacaine ) to prevent LAST Reaction
    2. Ropivacaine 0.5% (preferred over Bupivacaine 0.25% to 0.5%) 7-15 ml
    3. Syringe 20 ml
    4. Needle 22 gauge, 2" (5 cm)

V. Technique

  1. Images
    1. interscaleneBrachialPlexusBlockUS.jpg
  2. Ultrasound in transverse plane over lateral neck
    1. High frequency linear probe
    2. Roughly 2-3 inches (5-7.5 cm) above the clavicle
    3. Probe overlies posterior aspect of sternocleidomastoid Muscle
  3. Injection Plane
    1. Inject from lateral to medial
      1. Under the lateral border of the sternocleidomastoid Muscle
    2. Target is 1-3 cm deep at the Cervical Nerve Roots (C5-C8)
      1. C5-C7 Nerve roots will appear as a vertical stop light (3 round stacked nerve-like structures)
      2. Do NOT inject the actual nerves, only in their vicinity
  4. Alternatives: Supraclavicular Brachial Plexus Block
    1. Injection site may be shifted inferiorly to supraclavicular region
    2. Performed in similar fashion as Interscalene Block
    3. Only performed under Ultrasound guidance (risk of Pneumothorax)
    4. Unlike the Interscalene Block, the supraclavicular does not block the Shoulder (only distal to Shoulder)

VI. Complications

  1. See Regional Anesthesia
  2. LAST Reaction (as with any Nerve Block)
  3. Phrenic Nerve paralysis (common, do NOT perform bilaterally)

VII. References

  1. Zisquit and Nedeff (2020) Interscalene Block, Stat Pearls, accessed 12/21/2020
    1. https://www.ncbi.nlm.nih.gov/books/NBK557382/
  2. Martel (2020) Regional Anesthesia for Acute Care Conference, attended 12/11/2020
    1. https://stabroom.com/
  3. Ultrasound-Guided Interscalene Brachial Plexus Block, NYSORA, accessed 12/21/2020
    1. https://www.nysora.com/techniques/upper-extremity/intescalene/ultrasound-guided-interscalene-brachial-plexus-block/

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