Clinical Anatomy 27:210–221 (2014)

REVIEW

Brachial Plexus Anesthesia: A Review of the

Relevant Anatomy, Complications, and
Anatomical Variations
ASMA MIAN,1 IRFAN CHAUDHRY,1 RICHARD HUANG,1 ELIAS RIZK,2
R. SHANE TUBBS,2 AND MARIOS LOUKAS1*
1
Department of Anatomical Sciences, School of Medicine, St. George’s University, Grenada
2
Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama

The trend towards regional anesthesia began in the late 1800s when William
Halsted and Richard Hall experimented with cocaine as a local anesthetic for
upper and lower limb procedures. Regional anesthesia of the upper limb can be
achieved by blocking the brachial plexus at varying stages along the course of
the trunks, divisions, cords and terminal branches. The four most common
techniques used in the clinical setting are the interscalene block, the supracla-
vicular block, the infraclavicular block, and the axillary block. Each approach
has its own unique set of advantages and indications for use. The supraclavic-
ular block is most effective for anesthesia of the mid-humerus and below.
Infraclavicular blocks are useful for procedures requiring continuous anesthe-
sia. Axillary blocks provide effective anesthesia distal to the elbow, and inter-
scalene blocks are best suited for the shoulder and proximal upper limb. The
two most common methods for localizing the appropriate nerves for brachial
plexus blocks are nerve stimulation and ultrasound guidance. Recent literature
on brachial plexus blocks has largely focused on these two techniques to deter-
mine which method has greater efficacy. Ultrasound guidance has allowed the
operator to visualize the needle position within the musculature and has proven
especially useful in patients with anatomical variations. The aim of this study is
to provide a review of the literature on the different approaches to brachial
plexus blocks, including the indications, techniques, and relevant anatomical
variations associated with the nerves involved. Clin. Anat. 27:210–221,
2014. VC 2013 Wiley Periodicals, Inc.

Key words: interscalene; supraclavicular; infraclavicular; axillary; ultrasound;

nerve stimulation; brachial plexus block

INTRODUCTION Regional anesthesia of the upper limb can be

achieved by blocking the brachial plexus at varying
The introduction of anesthetic nerve blocks in the locations along the course of the trunks, divisions,
late 1800’s heralded a new era in pain management. cords, and terminal branches, depending on which
In 1884, William Halsted and Richard Hall began clini-
cal trials injecting 4% solutions of cocaine into the
brachial plexus and the tibial nerve; experimenting
*Correspondence to: Marios Loukas, Department of Anatomical
with the concept of nerve blocks and regional anes- Sciences, St. George’s University, School of Medicine, Grenada.
thesia for upper and lower limb procedures (Lopez- E-mail: [email protected]
Valverde et al., 2011). One of the first applications of
this type of local nerve block was with dental proce- Received 8 October 2012; Accepted 18 March 2013
dures such as tooth extraction (Lopez-Valverde et al., Published online 20 August 2013 in Wiley Online Library
2011). (wileyonlinelibrary.com). DOI: 10.1002/ca.22254

C
V 2013 Wiley Periodicals, Inc.
 Brachial Plexus Anesthesia 211

region of the upper limb is of interest. Brachial plexus with ultrasound has improved the success rate of
blocks (BPBs) are highly important in pain manage- blocks in patients with anatomical variations and this
ment following postoperative procedures in the success was not reproducible with other methods.
shoulder region and distal upper extremities (Borgeat The aim of this paper is to review the various
and Ekatodramis, 2002). approaches to BPBs and the indications, complica-
There are certain benefits to the use of BPB, which tions, and any clinically relevant anatomical variations
makes it a preferred alternative to general anesthesia. associated with the nerves involved in each block. We
These benefits include decreased length of hospitali- will also provide a review of the literature comparing
zation and superior pain management, as well as the advantages and disadvantages of ultrasound-guid-
fewer systemic effects (Neal et al., 2009). Critical to a ance versus nerve stimulation.
successful BPB is a thorough understanding of the an-
atomical landmarks and neurovascular bundles
(Kulenkampff and Persky, 1928). The safety and effi- BRACHIAL PLEXUS ANATOMY
cacy profile of the BPB depends largely on the accu-
racy of needle insertion into the surrounding Before describing the different approaches to BPB,
structures (Evans et al., 2005). Unfortunately, there it is important to understand the basic anatomy of the
have been several reported incident regarding brachial plexus and how it provides sensory and motor
improper needle insertion during BPB procedures innervations to the upper limb. Only after looking at
resulting in pneumothorax or injection of local anes- the relevant anatomical structures can we truly appre-
thetic into the spinal column or vascular system ciate the intricacies of the different block procedures
(Brown, 1993; Childs, 2002). and the advantages and disadvantages that each
Traditionally, there are four main approaches from approach offers.
which to access the brachial plexus: interscalene, su- Proximally, the brachial plexus begins just outside
praclavicular, infraclavicular, and axillary (Brown, of the intervertebral foramina at the lower cervical
1993). Each approach carries its own set of advan- region as five roots, formed from the five ventral rami
tages and indications for use. For example, supracla- of C5–8 and T1 spinal nerves. However, the C4 ventral
vicular blocks are most efficient for anesthetizing at ramus often contributes to the C5 nerve root, and the
the mid-humeral level and below, while the intersca- T2 ventral ramus usually contributes to the T1 nerve
lene block is best suited for the shoulder and proximal root Standring, 2008. Significant rostral shifts (pre-
upper limb. Infraclavicular blocks are useful for proce- fixed) or caudal shifts (postfixed) in the plexus may
dures requiring continuous anesthesia, and axillary occur.
blocks are most effective for procedures distal to the As we move more distally, the roots become
elbow (Brown, 1993). Other approaches to the brach- trunks. Cranially, the C5 and C6 rami unite to form
ial plexus, such as the paravertebral approach and the superior trunk at the lateral border of the middle
blocks at the humeral canal, have been proposed but scalene muscle. Caudally, the C8 and T1 rami unite to
have not yet gained widespread popularity (Bouaziz form the inferior trunk posterior to the inferior aspect
et al., 1997; Boezaart et al., 2003; Tran et al., 2007). of anterior scalene muscle. Between the superior and
There are several techniques to localize the nerves the inferior trunks passes a continuation of the C7
of the brachial plexus, for example, eliciting needle ramus, aptly named the middle trunk (Moore et al.,
paresthesias, palpation of the accompanying artery, 2010).
electrical nerve stimulation, and ultrasound guidance The three trunks continue distally into the axilla,
(Klaastad et al., 2009). The presence of paresthesias and just as they pass posterior to the clavicle, each
was originally the only determinant of needle location, trunk bifurcates into anterior and posterior divisions,
and advantageous because no adjunct devices were which then reunite to form the lateral, medial, and
required (Long et al., 2002). Of the methods currently posterior cords of the brachial plexus. The lateral cord
available, nerve stimulation has been the gold stand- is formed by the anterior divisions of the superior and
ard for some time, with ultrasound guidance gaining middle trunks. The medial cord is formed by the ante-
popularity in recent years (Klaastad et al., 2009). rior division of the inferior trunk. The posterior cord is
Recent literature on BPBs has largely focused on formed by the posterior division of all three trunks.
the use of ultrasound guidance versus nerve stimula- The naming of the cords can be easily recalled by their
tion to determine which method has greater efficacy relative positions to the axillary artery. Specifically,
(Tran et al., 2007; Klaastad et al., 2009; McCartney the lateral cord borders the axillary artery laterally;
et al., 2010). Ultrasound-guided BPBs have the poten- the medial cord lies adjacent to the axillary artery
tial to improve success rates and decrease complica- medially; and as expected, the posterior cord abuts
tions such as vascular puncture (Sandhu and Capan, the axillary artery posteriorly. Furthermore, due to the
2002). One of the greatest advantages of ultrasound cords’ proximity to the axillary artery, they are of sig-
technology in performing BPBs is the noninvasive and nificant clinical importance in the study of BPBs
dynamic nature of this technique, allowing the opera- (Moore et al., 2010).
tor the ability to directly visualize the nerves and sur- As we follow the cords distally, they split to give us
rounding structures. However, the use of ultrasound is the five terminal branches of the brachial plexus. The
greatly dependent on the operator’s expertise with the lateral cord splits to the musculocutaneous nerve and
technology as well as his/her knowledge of the rele- half of the median nerve, and the medial cord splits
vant anatomy. Klaastad et al. (2009), as well as Kap- into the ulnar nerve and the other half of the median
ral et al. (2008) have cited cases where experience nerve. Thus, the lateral cord and the medial cord each
212 Mian et al.

contribute to half of the median nerve. Lastly, the pos- techniques used in the clinical setting are the intersca-
terior cord splits into the axillary nerve and the radial lene block, supraclavicular block, the infraclavicular
nerve (Standring, 2008). block, and the axillary block. Thus, which technique is
While the aforementioned five nerves are the five used will primarily determine the block pattern. Fur-
main terminal branches of the brachial plexus, there are thermore, due to the variations in anatomy of the
several other nerves that branch off earlier in the plexus brachial plexus, further indications and contraindica-
that are responsible for innervating other musculocuta- tions are to be noted for the different techniques.
neous structures of the upper limb and trunk. For exam- While these four blocks are described separately, in
ple, the thoracodorsal nerve arises from the posterior practice, they may be used together to achieve a
cord to innervate the latissimus dorsi muscle. greater anesthetic outcome when desired. For exam-
The innervation of the upper limb is supplied exclu- ple, the interscalene block reliably anesthetizes the
sively by the brachial plexus. While a detailed break- upper arm and shoulder, but often misses the C8 and
down of the innervation is too extensive to be covered T1 ventral rami, thereby failing to anesthetize the ul-
in this paper, a brief overview will be given. nar side of the arm, forearm, and hand (Vries, 2007).
The most proximal structures of the upper limb, On the other hand, the axillary block effectively anes-
such as the shoulder, the deltoid muscle and the skin thetizes the forearm and hand, but often misses parts
over the deltoid region are supplied mostly by the of the upper limb, or more specifically the musculocu-
axillary nerve. Moving more distally, the muscles in taneous nerve due to the nerve’s exit from the brach-
the anterior compartment of the arm, which are re- ial plexus sheath proximal to the point of anesthetic
sponsible for the flexion of the elbow, are innervated injection (Jeng and Rosenblatt, 2010). However, if the
by the musculocutaneous nerve. The muscles in the interscalene block and the axillary block are used in
posterior compartment of the arm (triceps brachii), conjunction as a multiple-injection procedure, then a
which are responsible for the extension of the elbow, more complete and reliable analgesia of the arm can
are innervated by the radial nerve. The cutaneous be achieved (Jeng and Rosenblatt, 2010). In this sec-
innervation of the arm is shared mostly by two tion, we will cover the relevant anatomy, indications,
nerves: the skin over the posterolateral aspect of the technique, and complications of the four aforemen-
arm is innervated by the radial nerve; the skin of the tioned BPB methodologies.
over the anteromedial aspect of the arm is innervated
by the medial cutaneous nerve of the arm, which is a
terminal branch off of the medial cord of the brachial INTERSCALENE BLOCK
plexus (Standring, 2008).
Moving into the forearm, the posterior compart- Relevant Anatomy
ment muscles, which extend both the wrist and the
digits, are innervated by the continuation of the radial The interscalene block targets the trunks of the
nerve into the region. Anteriorly, the muscles of the brachial plexus, which are sandwiched between the
anterior compartment of the forearm are mostly in- anteromedially located anterior scalene muscle and the
nervated by median nerve. The exceptions to this are posterolaterally located middle scalene muscle (Fig. 1).
the flexor carpi ulnaris and the ulnar half of the flexor The space between the two muscles is called the inter-
digitorum profundus, which are innervated by the ul- scalene groove, which is a key landmark for this tech-
nar nerve. The skin of the entire posterior aspect of nique. The scalene muscles travel obliquely from the
the forearm is innervated by the radial nerve. The cervical transverse processes to the rib cage (Standring,
skin of the anterior forearm is innervated by the lat- 2008). The anterior scalene muscle lies in a posterome-
eral cutaneous nerve of the forearm (the continuation dial position relative to the sternocleidomastoid. Just
of the musculocutaneous nerve into the forearm) lat- superficial to the anterior scalene muscle is the phrenic
erally, and by the medial cutaneous nerve of the fore- nerve, which travels inferiorly and across the belly of
arm (a terminal branch off of the medial cord of the the muscle. Superficial to the anterior scalene muscle is
brachial plexus) medially (Moore et al., 2010). the clavicle and medial is the carotid sheath and its con-
Most distally, most of the intrinsic muscles of the tents. Deep to this muscle is the cupula of the lung and
hand (muscles that both originate from and insert into the second segment of the subclavian artery (Standr-
the hand) are innervated by the ulnar nerve. The cuta- ing, 2008). Medial to the anterior scalene muscle is the
neous innervation of the hand is somewhat complicated, entry of the vertebral artery into the transverse foramen
but generally, the skin of the dorsum of the hand is in- of the C6 vertebra. The middle scalene muscle is deep
nervated by the radial and ulnar nerves, while the skin to its anterior counterpart. Sandwiched between these
of the palmar aspect of the hand is innervated by the two muscles are the subclavian artery and the roots and
median nerve laterally (including digits 1, 2, 3, and trunks of the brachial plexus (Moore et al., 2010). Su-
medial half of 4) and by the ulnar nerve medially (includ- perficial to all of the aforementioned structures are the
ing digits 5 and ulnar half of 4) (Standring, 2008). sternocleidomastoid muscle and the external jugular
vein, which runs vertically along the neck just external
to the fascia of the sternocleidomastoid.
APPROACHES TO THE BRACHIAL
PLEXUS Indications
Depending on the desired anesthetic outcome, The interscalene technique can reliably anesthetize
different BPBs can be used. The four most common all of the shoulder and the radial aspect of the arm,
 Brachial Plexus Anesthesia 213

Fig. 1. Interscalene brachial plexus block; a. Ultra- probe positioning with a diagram of the upper limb repre-
sound image of the trunks of the brachial plexus within senting the region that is successfully anesthetized using
the interscalene groove; b. Artist’s depiction of the inter- this approach.[Color figure can be viewed in the online
scalene block illustrating proper needle and ultrasound issue, which is available at wileyonlinelibrary.com.]

with the exception of the ulnar aspect of the arm, (Winnie, 1970; Brown, 1993). The clinician’s fingers
forearm, and hand (Vries, 2007). However, because should then move to a position just lateral to the belly
the anatomical landmarks are easy to identify in all of the anterior scalene, and enter the interscalene
patient populations, including obese patients, this groove at the C6 level of the cricoid cartilage (Brown,
block can be performed in nearly any clinical situation 1993). While the index and middle finger exert a firm
where anesthesia of the shoulder or the proximal arm pressure on the muscle, a 22-gauge needle is slowly
is required. Another advantage of this block is that it inserted perpendicular to the skin surface and into the
can be performed with the arm in any position, thus it interscalene groove in a slightly caudal direction until a
can be useful when the arm cannot be moved or paresthesia occurs in the arm (Winnie, 1970). Misdirec-
placed in the optimal position, such as when fixing a tion can result in contact with the transverse process,
dislocated shoulder or during a prolonged upper limb and the needle should be repositioned in the space
surgery (Brown, 1993). Last, a significant appeal of between the C6 process and cricoid cartilage (Winnie,
the interscalene block is the minimal risk for pneumo- 1970; Brown, 1993). Since Winnie’s first description of
thorax, since the entry point of the needle is located this technique, variations in needle position have been
away from the pleura of the lung (Brown, 1993). suggested to improve efficacy. Magnetic resonance
imaging (MRI) studies of 50 patients who underwent
interscalene block found the ideal needle angle to be at
Technique 60 and suggested a more posterocaudal needle direc-
tion to avoid iatrogenic injury (Long et al., 2002).
The interscalene block can be performed with two
Low interscalene block (LISB): In this technique, the
different variations: The classical approach and the
interscalene groove was identified and marked from C6
low interscalene block (LISB) (Kim et al., 2011). The
to the clavicle. This area is then sectioned off equally
most frequently cited ultrasound-guided technique for
into three equal parts and the block is performed at
the interscalene block involves an in-plane approach
two-thirds of this distance caudally from C6 using a 22-
through the middle scalene muscle (Nadeau et al.,
gauge needle (Kim et al., 2011). In a study comparing
2013).
the classical interscalene block with the LISB, Kim et al.
Classic. The classical interscalene block was (2011) found that the LISB method delivers more local
described by Winnie (1970) in his paper, Interscalene anesthesia to the region and provides a more effica-
Brachial Plexus Block. With the patient in a supine posi- cious block of the distal hand muscles. Hadzic (2011)
tion, the head is angled slightly up and turned away reports that the LISB offers the advantage of utilizing
from the side being blocked (Brown, 1993). The clini- one injection to anesthetize all the trunks of the brach-
cian should palpate the lateral boundary of the sterno- ial plexus, rather than the classical interscalene block
cleidomastoid muscle, and ask the patient to relax their which is prone to missing the lower trunk. To avoid
head, thereby exposing the interscalene groove injury of adjacent structures, Hadzic (2011)
214 Mian et al.

Fig. 2. Supraclavicular brachial plexus block; a. ultrasound probe positioning with a diagram of the upper
Ultrasound image of the trunks of the brachial plexus limb representing the region that is successfully anesthe-
sandwiched between the subclavian artery and the ante- tized using this approach. [Color figure can be viewed in
rior and middle scalene muscles; b. Artist’s depiction of the online issue, which is available at
the supraclavicular block illustrating proper needle and wileyonlinelibrary.com.]

recommends the needle depth should not exceed However, there have been documented cases where
2.5 cm. Long et al. (2002) recommend the use of a the brachial plexus roots lie within the muscle belly of
nerve stimulator due to the proximity of the phrenic the anterior scalene muscle; for example, the C5 and
and spinal accessory nerves to the interscalene groove. C6 ventral rami pierce the anterior scalene muscle
A hiccupping patient indicates needle contact with the (Klaastad et al., 2009). Moreover, there are identified
phrenic nerve over the anterior scalene muscle and cases where the C5 ventral ramus descends anterior
stimulation of the spinal accessory nerve causes con- to the anterior scalene muscle (Loukas et al., 2008).
traction of the trapezius muscle (Long et al., 2002). In these patients, the interscalene block may be suc-
cessfully completed by injecting anesthetic into the
interscalene groove as well as in areas adjacent to the
Complications variant nerve roots. The frequency and unpredictabil-
Since the regional anatomy of the interscalene block ity of the variations between the scalene muscles and
is similar to that of the supraclavicular block, the inter- the roots of the brachial plexus may provide further
scalene technique can produce similar complications. support for the use of imaging in this region for proce-
These include vocal hoarseness, Horner’s syndrome, dures such as nerve blocks (Harry et al., 1997). In
and hemidiaphragmatic paresis due to the temporary their study comparing the success rates of intersca-
blockade of the ipsilateral recurrent laryngeal nerve, lene blocks performed under ultrasound-guidance to
stellate ganglion, and phrenic nerve, respectively (Jeng nerve stimulation alone, Kapral et al. (2008) noted
and Rosenblatt, 2010). These side effects are due to several advantages to the use of ultrasound-guidance;
the spread of injected anesthesia to the surrounding one of them being the ability to visualize and identify
neural tissue. However, these complications are mostly anatomical variations of the nerve roots prior to anes-
self-limiting, thus they are not of life-threatening con- thetic injection.
cern if the patient is monitored properly. Last, since this
technique cannot reliably block the C8 and T1 ventral
rami, the ulnar aspect of the arm cannot be fully anes- SUPRACLAVICULAR BLOCK
thetized. Therefore, the patient would feel a significant
amount of pain if an upper limb procedure accidentally Relevant Anatomy
encroached upon the medial aspect of the arm. The trunks of the brachial plexus lie deep to the
area above the clavicle, and are sandwiched between
Anatomical Variation the anterior scalene muscle anteromedially and the
middle scalene muscle posterolaterally. The trunks are
Normally, the ventral rami targeted by the intersca- also enclosed in a compact fascial sheath, thus mak-
lene block are located within the interscalene groove. ing it the most compact portion of the brachial plexus
 Brachial Plexus Anesthesia 215

(Fig. 2) (Vries, 2007). Running parallel to the trunks, Chan and colleagues (2003). In this method, the
and also enclosed by the fascial sheath, is the subcla- patients were asked to lie supine with the head turned
vian artery. However, the subclavian artery abuts the 45 degrees to the contralateral side, and the ultra-
trunks anteromedially. Closely inferior to the trunks, sound probe was placed in the coronal oblique plane
but outside of the neurovascular fascial sheath, the in the supraclavicular fossa. This allowed for visualiza-
cupula of the lung is located. Superficial to all of the tion of the subclavian artery and brachial plexus in the
aforementioned structures is the external jugular transverse sectional view. A 22-gauge 50 mm insu-
vein, which runs vertically down the neck just external lated block needle was placed on the lateral end of
to the fascia of the sternocleidomastoid (Standring, the probe and advanced along the long axis of the
2008). probe, in the same plane as the ultrasound beam.
Once the brachial plexus was reached, a nerve stimu-
lator was used to elicit a muscle twitch. Following
Indications nerve stimulation, the anesthetic was released into
Since the nerve trunks are packed closely together the tissue (Chan et al., 2003). A successful block was
at the supraclavicular region, this technique can reli- defined by Chan et al. (2003) as complete sensory
ably block the whole brachial plexus distal to the point and motor block in all regions assessed with 30 min of
of injection, thus produce virtually full upper limb an- local anesthetic injection.
esthesia (Vries, 2007). The supraclavicular block is
usually the technique of choice for procedures involv- Complications
ing the distal two thirds of the upper limb, especially
for surgeries needing upper limb ligation by tourni- Because of the proximity of the lung cupula to the
quet, such as hand surgery (Jeng and Rosenblatt, brachial plexus trunks, there is a significant risk of
2010). puncturing the lung and producing a pneumothorax if
needle placement is not exact. However, this compli-
cation can be mostly mitigated by using the correct
Technique landmarks (Dupre et al., 1982; Vries, 2007). Further-
more, image guided placement of the needle can be
First described by Kulenkampff in 1910, the supra-
done with ultrasound to significantly reduce the risk of
clavicular block is one of the oldest brachial plexus
a pneumothorax (Jeng and Rosenblatt, 2010). Other
blocks to be performed (Fingerman et al., 2009).
complications of a supraclavicular block of the brachial
There are two approaches to performing a supracla-
plexus include vocal hoarseness, Horner’s syndrome,
vicular block: the classic approach described by
and hemidiaphragmatic paresis, due to the temporary
Kulenkampff and the “plumb-bob” approach (Kulen-
blockade of the ipsilateral recurrent laryngeal nerve,
kampff and Persky, 1928; Brown, 1993; Klaastad
stellate ganglion, and phrenic nerve, respectively
et al., 2003).
(Jeng and Rosenblatt, 2010). These side effects are
Classic. The classic technique, as described by due to the spread of injected anesthesia to the sur-
Kulenkampff and Persky (1928), requires the patient rounding neural tissue. However, these complications
to be sitting upright in a chair, with shoulders relaxed are mostly self-limiting, thus they are not of life-
and the arms at the patients’ side. More commonly threatening concern if the patient is monitored
now, the patient lies supine with the head turned properly.
away from the side to be blocked (Brown, 1993). The
point of entry of the needle is 1 cm above the mid-
clavicle and just lateral to the external jugular vein,
which can be visualized by having the patient perform Anatomical Variations
a Valsalva maneuver (Kulenkampff and Persky, 1928). Normally, the superior, middle, and inferior trunks
The needle is inserted in a plane parallel to the length are ensheathed in fibrous fascia and sandwiched
of the head and neck, directed towards the first rib. between the anterior scalene and middle scalene
According to this method, a 35 mm long and 0.5 mm muscles. However, there have been documented
diameter needle is used. cases where the superior trunk lies entirely anterior
Plumb-Bob. The plumb-bob technique was to or pierces the anterior scalene muscle (Natsis
designed as an alternative to the classic technique in et al., 2006). In these patients, the supraclavicular
order to decrease the risk of pneumothorax (Brown block can still be successfully completed by injecting
et al., 1993). For this technique, the patient is asked anesthetic into the fascial sheath that normally enc-
to lie supine with the head turned away from the side loses the three trunks of the brachial plexus as well
to be blocked, just like one would for the classic tech- as in areas adjacent to the variant trunks. Further-
nique. After marking the skin immediately lateral to more, given the existing risk of pneumothorax when
the lateral-most border of the sternocleidomastoid on performing the supraclavicular block, it follows that
the clavicle, a blunt 22-guage needle is inserted in the the risk would increase in clinical situations where
parasagittal plane, perpendicular to the operating additional needle penetrations are required to block
table (Brown et al., 1993). Again, when this technique variant trunks. Thus, extra planning and care, such
was described by Brown et al. (1993), it was done by as visualizing the aberrant regional anatomy using
eliciting a paresthesia distal to the elbow. ultrasound prior to performing the procedure is
An ultrasound-guided approach to the supraclavic- recommended to reduce the additional risk of
ular block has been described in a study conducted by complications.
216 Mian et al.

Fig. 3. Infraclavicular brachial plexus block; a. Ultra- probe positioning with a diagram of the upper limb repre-
sound image of the cords of the brachial plexus wrapped senting the region that is successfully anesthetized using
around the axillary artery; b. Artist’s depiction of the infra- this approach. [Color figure can be viewed in the online
clavicular block illustrating proper needle and ultrasound issue, which is available at wileyonlinelibrary.com.]

INFRACLAVICULAR BLOCK used because it allows for the placement of an indwell-

ing catheter since the regional anatomy facilitates sta-
Relevant Anatomy ble positioning of the catheter and easy catheter care
(Jeng and Rosenblatt, 2010). Last, for those who are at
Deep to the area below the clavicle lie the cords of
risk for pneumothorax, this block is preferred since
the brachial plexus (Fig. 3). The cords encircle the ax-
there is little risk for pneumothorax as compared to the
illary artery at this point, with the lateral cord, medial
supraclavicular approach (Neal et al., 2009).
cord, and the posterior cord abutting the artery in the
manner in which they are named. Therefore, it is im-
portant to be careful when performing the infraclavic- Technique
ular block so as to not pierce the axillary artery.
Overall, the cords are located roughly 3 cm inferome- The infraclavicular block can be performed via three
dially from the coracoid process, which makes the traditional approaches: the coracoid approach, the
coracoid process a good landmark for locating the vertical approach, and the lateral sagittal approach
brachial plexus cords (Neal et al., 2009). Immediately (Neal et al., 2002).
overlying the cords is the pectoralis minor muscle, Coracoid. This approach is performed at the division
and superficial to that is the pectoralis major muscle. level of the brachial plexus. The patient is asked to lie
Medial to the cords is the lateral chest wall, formed by supine with the head turned away from the side to be
the serratus anterior muscle, ribs and intercostal blocked. The patient’s arm is abducted 45 from the
muscles, and with the pleura of the lung immediately chest wall (Whiffler, 1981). The relevant surface anat-
deep to that (Standring, 2008). omy was first marked with a pen on the patient’s skin.
First, the subclavian artery was palpated at the clavic-
Indications ular midpoint and followed until it disappeared under
the clavicle. This point was marked with an X. The
A block at the level of the brachial plexus cords pro- next landmark is the coracoid process, which is also
duces anesthesia of the distal two thirds of the arm marked on the surface of the skin. Finally, the axillary
including reliable numbing of the axillary and musculo- artery is palpated with the index finger at the highest
cutaneous nerves, as well as the forearm, wrist, and point in the axilla. The thumb is placed on the anterior
hand. Thus, infraclavicular blocks are often used for chest wall over the site where the index finger pal-
surgeries of the upper limb distal to and including the pated the axillary artery. This is also marked with an X
elbow (Wilson et al. 1998; Vries, 2007). Furthermore, and a line is made joining the two X’s. In most cases,
in medical procedures that require continuous anesthe- this line has been noted by Whiffler (1981) to pass
sia of the upper limb, the infraclavicular technique is directly inferior and medial to the coracoid process.
 Brachial Plexus Anesthesia 217

Whiffler also suggested that the depth of needle pene- Complications

tration needed to reach the axillary sheath and brach-
ial plexus can be approximated by the distance Infraclavicular blocks can produce complications
between the thumb and index fingers when palpating similar to supraclavicular blocks, such as vocal
the axillary artery. As per Whiffler (1981), this elimi- hoarseness, Horner’s syndrome, and hemidiaphrag-
nates the need for direct nerve stimulation. Once matic paresis, due to the temporary blockade of the
these landmarks have been approximated, the needle ipsilateral recurrent laryngeal nerve, stellate ganglion,
is inserted directly inferior and medial to the coracoid and phrenic nerve, respectively (Jeng and Rosenblatt,
process along the line that was drawn previously. The 2010). These side effects are due to the spread of
needle is inserted at a right angle to the skin surface injected anesthesia to the surrounding neural tissue.
(Whiffler, 1981). In Whiffler’s description of this However, these complications are mostly self-limiting,
approach, he used a 22-guage, 51 mm needle thus they are not of life-threatening concern if the
attached to a 20 ml syringe. patient is monitored properly. Incorrect insertion of
Vertical. This approach was originally described by the needle during an infraclavicular block can result in
Kilka et al. in 2008. For this approach, the patient is puncturing of the lateral chest wall and subsequently,
asked to lie supine with the arms flexed at the elbow the pleura, leading to a pneumothorax. However, this
and placed over the chest or upper abdomen (Rettig can be prevented through the use of correct anatomi-
et al., 2005). There are two pertinent landmarks for cal landmarks (Vries, 2007). Last, due to the anatomi-
this approach; the most ventral part of the acromion cal arrangement of the brachial plexus cords around
and the medial part of the jugular notch. The needle the axillary artery, there is a risk of intravascular
is inserted just below the clavicle, midway between injection of anesthetic during the procedure. Thus,
these two landmarks. As with the coracoid approach, ultrasound guidance for needle placement is recom-
the needle is inserted perpendicular to the skin sur- mended to avoid vascular puncture (Jeng and Rose-
face (Rettig et al., 2005). Rettig et al. (2005) used a nblatt, 2010).
22-guage 50 mm insulated needle and used a nerve
stimulator to elicit a flexor response to stimulation of Anatomical Variation
the medial or lateral cords or an extensor response by
stimulating the posterior cord before injecting the Normally, the three cords of the brachial plexus
anesthetic. encircle the axillary artery. However, there have been
Lateral Sagittal. Klaastad et al. (2004) proposed documented cases where the all three cords of the
this method using MRI studies to confirm. This brachial plexus lie lateral to the axillary artery or all
approach has the patient lying supine with the arm three cords are fused together as a single cord also
adducted and shoulder relaxed. The head of the lying lateral to the axillary artery instead of the stand-
patient is slightly rotated away from the side being ard perivascular relationship (Aggarwal et al., 2012;
blocked. The anesthesiologist is positioned behind the Satapathy and Coventry, 2011). Clinically, if this vari-
patient’s shoulder and the medial aspect of the cora- ation is visualized prior to a blocking procedure, the
coid process is identified by sliding a finger along the anesthesiologist could potentially take advantage of
inferior border of the clavicle. The point where these this offset by inserting the anesthesia needle lateral to
two structures meet is the point of needle insertion. the axillary artery, thus avoiding the artery entirely.
With the aid of a nerve stimulator, the needle is This modification could potentially produce an equally
inserted caudally along the sagittal plane at an angle effective infraclavicular block while reducing the risk
between 0 and 30 degrees, to a depth of no more of intravascular injection.
than 6.5 cm (Klaastad et al., 2004).
An ultrasound-guided posterior approach to the
infraclavicular block has been described by Hebbard AXILLARY BLOCK
and Royse (2007). In this method, the ultrasound Relevant Anatomy
probe is placed on the anterior shoulder, inferior to
the clavicle and medial to the coracoid process and The axillary block anesthetizes the brachial plexus
the axiallry vessels are identified (Hebbard and at the level of the terminal nerves in the area of the
Royse, 2007). The needle is inserted over the trape- proximal arm and distal axilla (Fig. 4). The main
zius muscle sufficiently posterior to allow for needle nerves blocked by this approach are the median
passage between the clavicle and scapula in the nerve, the ulnar nerve, the radial nerve, and the mus-
direction of the axillary artery. The insertion point is culocutaneous nerve (Brown, 1993). The axillary
aligned with the long axis of the the ultrasound nerve is not involved in this block because of its
beam and the insertion length passing into the ultra- egression from the plexus at a point proximal to
sound beam is approximately 30–40 mm. The nee- where the anesthesia injection takes place (Brown,
dle is initially inserted inferiorly to allow the probe to 1993). Anatomically, the median, ulnar, and radial
be manipulated so the needle may be visualized in nerves are enclosed within a sheath separately from
long axis of the ultrasound probe. Completion of the the musculocutaneous nerve (Standring, 2008), thus
block requires visual perineural targeting of the the musculocutaneous nerve may need to be blocked
nerve cords, a nerve stimulator, or by perivascular separately to achieve full anesthesia of the radial as-
infiltration. The local anesthetic is seen as a black pect of the forearm. At the level of the terminal
space surrounding the nerves (Hebbard and Royse, nerves, the axillary artery is still surrounded by the
2007). brachial plexus similar to its arrangement at the level
218 Mian et al.

Fig. 4. Axillary brachial plexus block; a. Ultrasound probe positioning with a diagram of the upper limb repre-
image of the terminal branches of the brachial plexus sur- senting the region that is successfully anesthetized using
rounding the axillary artery; b. Artist’s depiction of the this approach. [Color figure can be viewed in the online
axillary block illustrating proper needle and ultrasound issue, which is available at wileyonlinelibrary.com.]

of the cords, but the relationship of the neurovascula- brachial plexus anesthesia (Monkowski and Larese,
ture changes. The relationship between the nerves 2006). In the axillary block the patient is positioned
and the artery can be thought of as a clock face, with supine with the arm abducted at 90 , and the forearm
the axillary artery in the center of the clock, and with flexed to a 90 angle. This is the optimal position for pal-
four main terminal nerves occupying a quadrant: me- pating the axillary artery. This brings the axillary artery
dian nerve between 12 to 3 o’clock, ulnar nerve to a more superficial position, and causes fixation of the
between 3 and 6 o’clock, radial nerve between 6 and brachial plexus (De Jong and Rudolph, 1961). The skin
9 o’clock, and musculocutaneous nerve between 9 should be shaved if necessary, cleaned, and the patient
and 12 o’clock (Brown, 1993). appropriately draped. Utilizing the index and middle fin-
gers, the arterial pulse is palpated at the axillary surface
adjacent to the upper border of the pectoralis major (De
Indications
Jong and Rudolph, 1961; Monkowski and Larese,
A block at the level of the terminal branches of the 2006). Once the pulse is identified, a 50 mm, 22-gauge
brachial plexus produces anesthesia of the upper limb needle is inserted over the fingers toward the axillary
distal to the elbow, including the forearm, wrist, and apex at a 20- to 30 angle. As the needle pierces the ax-
hand. Thus, axillary blocks are often used for sur- illary sheath, a characteristic click is produced. Further
geries of the upper extremities, making it a popular confirmation of the needle’s location can be obtained by
technique in outpatient hand surgery clinics (Brown, needle aspiration. Aspiration of blood, for example,
1993). Last, because the location of the axillary block would indicate improper positioning of the needle
is near the proximal arm, this technique generally has (within a blood vessel) (De Jong and Rudolph, 1961;
a greater safety profile when compared with other Brockway and Wildsmith, 1990; Monkowski and Larese,
brachial plexus blocks. Since the anesthesia needle 2006). The needle is advanced until the patient experi-
completely avoids contact with the pleura and other ences a paresthesia in the hand, and is followed by
potentially sensitive nervous structures in the distal injection of local anesthetic (Monkowski and Larese,
neck and proximal axilla, such as the phrenic nerve or 2006). A second injection is made below the axillary
the stellate ganglion, the risk for pneumothorax and pulse, as this ensures the spread of anesthetic into the
neurologic complications is greatly reduced (Satapa- perivascular sheath (Monkowski and Larese, 2006).
thy and Coventry, 2011).
Complications
Technique
Because the structures surrounding the axillary
Axillary brachial blocks were first performed by Hir- region are significantly different from the regional
schel in 1911 and have become increasingly popular anatomy of the other brachial plexus blocks, it does
given the safer profile when compared to other forms of not suffer from the usual complications of
 Brachial Plexus Anesthesia 219

pneumothorax or unwanted blocking of the phrenic stimulation and ultrasound guidance. Nerve stimula-
nerve. However, due to characteristic ensheathment of tion has been the standard method for nearly four
the terminal branches of the brachial plexus and their decades. However, with improvements in ultrasound
arrangement around the axillary artery, the axillary technology, ultrasound guidance has risen in popular-
block has its own unique set of challenges. Since the ity over the last two decades (Klaastad et al., 2009).
musculocutaneous nerve is not ensheathed with the The nerve stimulation method is considered a blind
median, ulnar, and radial nerves, it is often missed method because the anesthesiologist cannot see the
during a single injection of anesthesia. This separation needle and its targeted nerves. Nonetheless, by elicit-
of terminal branches necessitates injections in and ing characteristic cutaneous paresthesias and muscle
outside the sheath to ensure proper anesthesia of the contractions, the operator is able to determine the
musculocutaneous nerve (Monkowski and Larese, needle’s position relative to the nerve of interest. The
2006). If the musculocutaneous nerve is not properly greatest logistical hindrance to the use of the nerve
blocked, then the radial aspect of the forearm will not stimulation method in a clinical setting is that this
be anesthetized, since the lateral cutaneous nerve of method is a two-person three-handed technique, thus
the forearm, a continuation of the musculocutaenous it cannot be carried out by a single clinician (Brown,
nerve, innervates the skin in the area. This problem 1993). However, since nerve stimulation works by ba-
can be overcome by utilizing transarterial techniques, sic electrophysiology, the only equipment necessary is
which involve inserting the needle around the axillary a modified needle with a conductive tip and insulated
artery to reach the musculocutaneous nerve. However, shaft, and an attached current generator. Another
this technique can cause arterial puncture thereby downfall of the nerve stimulation technique is that the
leading to hematoma formation and systemic toxicity paresthesias elicited may startle the patient and cause
from the anesthesia entering the bloodstream (Brown, unwanted discomfort (Fanelli and Casati, 1999). More-
1993). An alternative to transarterial techniques is over, since the anesthesiologist cannot visualize the
using multi-injection procedures to complete the axil- placement of the needle, there is an increased risk of
lary block. This is accomplished by using one injection unwanted penetration of the needle into sensitive
to block the median, ulnar, and radial nerves as nor- structures, and the injection of anesthesia into collat-
mally done, and another separate injection into the eral areas. For example, accidental needle penetration
body of the coracobrachialis muscle to anesthetize the into the pleura can cause pneumothorax. Accidental
musculocutaneous nerve (Jeng and Rosenblatt, 2010). puncture and injection of anesthetic into the axillary
Most of the complications of the axillary block can be artery can cause systemic toxicity. Accidental penetra-
avoided when doing the block under ultrasound guid- tion and injection of drugs into a nerve can cause
ance of the anesthesia needle (Russon et al., 2010). intraneural damage and unwanted prolonged anesthe-
sia. Lastly, because nerve stimulation is a blind
method, anatomical variations in patients cannot be
Anatomical Variations accounted for and adapted to by the clinician (Brown,
1993).
Normally, the median, ulnar, and radial nerves are
On the other hand, an ultrasound-guided block
ensheathed together, while the musculocutaneous
allows the operator to visualize, in real time, needle
nerve travels separately, piercing the coracobrachialis
placement and its relation to the target nerves. This
muscle. Thus the musculocutaneous nerve needs to
allows a single operator to actively engage certain
be blocked separately with a localized injection of an-
structures (such as the axillary sheath), avoid others
esthesia into the belly of the coracobrachialis muscle.
(such as the pleura, blood vessels), and detect and
However, there have been documented cases in which
accommodate for anatomical variations in the patient
the musculocutaneous nerve did not pierce the cora-
(Fingerman et al., 2009). Another study used ultraso-
cobrachialis muscle (Chitra, 2007). There have also
nography to determine the level of the roots of the
been cases in which the musculocutaneous nerve
brachial plexus based on the morphology of the trans-
fuses with the median nerve (Chitra, 2007). In these
verse processes of neighboring vertebrae (Martinolli
scenarios, the axillary block procedure must be modi-
et al., 2002). This has the potential benefit of allowing
fied to accommodate the variations. In the case where
one to determine the exact level of brachial plexus
the musculocutaneous nerve does not pierce the cora-
pathology prior to surgical intervention. The ability to
cobrachialis muscle, ultrasound guidance should be
visualize the needle as it penetrates the surrounding
used to locate the aberrant nerve so that it may be
structures significantly reduces the risk of intravascular
blocked separately at its new location. In the case
and intraneural injections, as well as pneumothorax
where the musculocutaneous nerve fuses with the
(Chin et al., 2008; Klaastad et al., 2009; Gelfand et al.,
median nerve, there is potentially no need for an addi-
2011). Furthermore, since the injection of the anes-
tional anesthetic injection into the coracobrachialis
thetic can be observed, the operator can see when the
muscle belly since the target nerve, the musculocuta-
drug has sufficiently surrounded the target nerves. This
neous nerve, is ensheathed along with the other
allows for the usage of a lower anesthetic dose, mini-
nerves of interest in the axillary block procedure.
mizing unwanted effects of the anesthesia (Klaastad
et al., 2009). Ultrasound-guided blocks also allow for
Nerve Stimulation vs. Ultrasound Guidance greater accuracy during first pass placement of the
anesthesia needle. This equates to fewer penetrations to
Currently, the two main methods of localizing tar- correct needle position, which translates to decreased
get nerves for brachial plexus blocks are nerve patient discomfort during the block procedure, which
220 Mian et al.

may be particularly useful in difficult patients (Casati procedures by decreasing patient discomfort, length
et al., 2007; Gelfand et al., 2011). of hospitalization, and optimizing pain management
A meta-analysis of 16 randomized controlled trials both during and post-procedure. The use of ultra-
(RCTs) conducted by Gelfand et al. (2011) measured sound guidance has not only allowed for a reduction in
the overall success rate for blocks performed using complications due to incorrect needle placement, but
ultrasound-guidance compared to all other non-ultra- also avoidance of other complications and improved
sound techniques, such as nerve stimulation. They overall block efficacy, especially in patients with ana-
reported a significant increase in overall success rate for tomical variations.
blocks performed using an ultrasound-guided tech-
nique. More specifically, they found an increase in block
success with ultrasound (compared to non-ultrasound)
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