03 brachial plexus anatomy & blockade
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Review of Brachial Plexus Anatomy &
Blockade
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Review of Brachial Plexus Anatomy &
BlockadeRegional and APS Rotations
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Review of Brachial Plexus Anatomy &
BlockadeRegional and APS Rotations
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Review of Brachial Plexus Anatomy &
BlockadeRegional and APS Rotations
(Slides by Randall Malchow MD)
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Brachial PlexusISB, SCB, ICB, and Axillary
n General Anatomy -’applied anatomy’n Anatomy and Techniques
n Interscalenen Supraclavicularn Infraclavicularn Axillary
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C5-T1 Nerve RootsAnt and Mdl ScalenesSubclavian ArteryMid-clavicleCoracoid Process“Sheath”
BrachialPlexus
n General Anatomy
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Brachial Plexus in situAnt and Mdl ScalenesPhrenic NerveVertebral ArterySubclavian VeinMid-Clavicle and 1st Rib
NB: relation of B.P. to 1st part of Ax Art
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C5
C6
C7
C8
T1
-“Hour Glass”-4 Approaches to BrPl
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Rule of 3’sn Roots:
n Phrenic (C3,4,5)n Lg Thoracic (C5,6,7)n N.s to Strap m.s
n Upper Trunk:n Dorsal Scapn Suprascap (C5,6)n Lat Pectoral (C5,6,7)
n Post Cord:n Upper Subscapn Lower Subscapn Thoracodorsal
n Med Cord:n Med Pectoraln Med Brachialn Med Antebrachial
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+
*nerve leaves atcoracoid process
**
**
Supraclavicular Branches
Serratus Anterior
Lat Dorsi
Pect Maj
Pect Min
Infraclavicular Branches
Supra/infraspinatus/75% shoulder joint
Rhom/LevScap
Subscap/TerMaj(Outside Sheath)
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BrachialPlexusn Distal
Anatomy
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Sensory:Dermatomes
(Nerve
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Sensory:Peripheral
NerveDistribution
Lat Antebrachial Cutan N
n Note: Medial Brachial Nerve Not Shown
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Biceps/BrachialisCoracobrachialis
FlexionSupination
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4. Elbow Extension5. Supination (Brachio- radialis;supinator)
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4. Pronation-Pron Teres/Quad
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Interscalene Techniques:n History:
n Kappis, 1912, Posteriorn Mulley, 1919, Ant,
immobilen Classic N. Stim:
n Avoid These Muscle Stim Patterns:
§ Serratus Ant (Lg Th)§ Rhomboid/Lev Scap (Dors
Scap)§ Trapezius (XI)§ Diaphragm (Phren)
n USGn Posterior ISB:
n “Cervical PVB”n Excellent for ISB Caths
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Interscalene Approach:Surrounding Structures
*
*
*
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*Surface Anatomy and Technique:Pos’n (head, arm)At C6 level, IS groove, 2-3cm post to SCM(NB: EJ, and posterior location)
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If too deep, anterior:
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Interscalene Approach- othern Limitations:
n Minimal Blockade of Lower Trunk (C8,T1) (w/ >40ml may get lower trunk)
n Poor approach for surgery distal to shoulder
n If awake, know the operation
n Cath difficult (placement/dislodge)
n Indications:n Shoulder Surgery- esp
openn Proximal humeral or
scapular fx’s, othern Initial Block Eval:
n “Money sign”n “Deltoid sign”n “Triangle Sign”
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Posterior Cervical Paravertebral Blockn Alternate approach for ISBn Advantages:
n Avoids anterior vascular structures: Vert artery, carotid, ext jugular, etc
n Less phrenic nerve block?; improved diaphragm function.
n Less catheter leaking, dislodging, etcn Catheter not in surgical prep area.
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Ant Scalene Muscle
Mid Scalene Muscle
Brachial Plexus
Levator Scapulae Ms.
Trapezius Muscle
Vertebral Artery
Carotid Artery
Internal Jugular Vein
Posterior Cervical PVB
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Levator Scapulae Muscle
Sternocleidomastoid MuscleTrapezius Muscle
Splenius Capitus
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Sitting position; C6 Level
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Direct needle anterior, medial, and caudal towards suprasternal notch, until C6 transverse process reached. Walk needle off laterally using LOR or needle stimulation to Brachial Plexus.
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Interscalene Approach
Distribution:
Will miss med antebrachial
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Interscalene ApproachComplications
n SAB/Epiduraln Intravascular - vert art
leading to sz’sn Other Nerve Blockade:
n Phrenic: 100%n Recurrent Laryngeal:
hoarseness 10-20%n Stellate Ganglion:
horner’s syndrome 25-50%
n Bezold Jarisch/vagal: esp right isb 10-20%
n Seizures 0.7%n Cough/bronchospasmn Pneumothorax - rare
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Supraclavicular Approach
n History:n Kulenkampff, 1911n Adv inf, med, post; paresthesia
techn Indications:
n Excellent for elbow and forearm surgery
n Good for hand and wristn Special considerations:
n Pneumothorax: 0.1-5%n Franco: 1001 SCB’s: no
pneumothoraxn Phrenic Nerve
Blk: 40%
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C5,6
C7
C8,T1
AnteriorPosterior
PSPectoralis Major
Pectoralis Minor
Subclavius
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Supraclavicular – Classic vs USG*Position
of pt and doc.
1-2cm from SCM or widthof clavicular head away.
SCM
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Supraclavicular Techniques- Desired Stimulationn Avoid:
n Shoulder stimulationn Upper trunk stim: (musculocutaneous)
n Aim for stimulation:n Franco: 97% success w/ distal twitchn Subclav Art “pushes” local towards upper trk
n If cough, too deep (against pleura)
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variable
Supplement ICBN
Supra-clavicularSpread
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Infraclavicular Approachn Overview:
n Intent: Blockade distal to pleura, prox to branches (ie block at level of cords)
n History: n Bazy 1917; Labat 1927
(aiming med.)n Raj, 1973 (aiming
lateral)
n Indications:n Excellent for forearm/
wrist/hand surgeryn Popular location for
brachial plexus catheter
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Infraclavicular Approach:n Advantages:
n >success w/ MC, Med Brachial & Antebrachial nerves compared to traditional AXB;
n Intercostobrachial often blocked
n Min phrenic block/pneumothorax risk
n Arm in any position
n Disadvantages:n ? Benefit over USG
Axillary block with > riskn Difficult to see needle at
steep anglesn < Patient Satisfaction?
(deeper block)n Sml < success
compared to AXB? (94% vs 99%)
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InfraclavicularApproachAnatomy:
n Landmarks:
n Jugular Notchn AC Jointn Deltopectoral
Grooven Pectoral Major
m.n Deltoid m. n Cephalic Vein
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Biceps-short head
Coracobrachialis
Pect.minorSubscapularis
Teresmajor
Lateral Cord (C5,6,7): MC. & medianMedial Cord (C8,T1): Ulnar, median, med brach and antebrachPosterior Cord (C5-T1): Radial & Axillary
(90% lat to CP)
(65% lat to CP)
ICB:n Specific
Anatomy
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Infraclavicular Approach:techniques
n Nerve Stimulationn Lateral Direction/Raj:
n Mid-clavicle aiming laterallyn Vertical /Coracoid process:
n Wilson 1998: aim directly posterior n Single vs Multi-nerve stim
n USG
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RajTechnique
n Arm at 90 deg
n 21 gu x 4inn Mid-clavicle
entry, 45 deg to skin
n Aim laterally towards ax art
n Depth: ave 4.5cm
n CPNB
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Pect MajorDeltoid
Subscapularis
Pect minor
Lung
RajTechnique:
n Safety of infraclav approach
n Axillary boundariesn Anteriorn Posteriorn Medial
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CoracoidProcess
Technique:n 2cm med
& inf to coracoid
n 21 gu x 4in
n Aim post:n If lat to CP,
could miss MC/ Ax n.s.
n Depth: ave 4cm (2-7cm)
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Infraclavicular Approach: Desired stimulation
n Goal: distal twitch in wrist or hand n Lateral Cord: avoidn Medial Cord: median/ulnar okn Posterior Cord: radial ideal
n Upshot: n flex or ext wrist/digitsn Extension bestn Consider multi-stim
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Axillary Approach
n History: n Hirschel, 1911
n 4in needle to 1st ribn Pitkin, 1927:
n 8in needle to trans proc!
n 1950: > popularityn 1989: Ting, USG
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Axillary Block - continuedn Indications:
n Hand and wrist surgeryn Elbow/forearm w/
multistim/ USG techn Goal:
n simple brachial plexus anesthesia at most distal point to avoid complications
n Advantages:n > 98% successn > Very high Pt satisn Exc USG imagingn Short MC block vs Long
duration AXBn Disadvantages:
n > needle movement? n Arm at 90 deg
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AxillaryAnatomy
n Pyramid shapen (-)MC, Ax, Med
brach and antebrach
n Neurovasc bundle lying atop the lat dorsi/ teres m.
n Between coracobrach. and triceps
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Axillary Approach:Cross sectional anatomy
n Note relationships of:n Bicepsn Coracobrachialisn Long Head of
tricepsn Musculocutaneous
nerve route thru coracobrachialis (variable)
n Lateral: M&Mn Medial: U&R
Long head of triceps
Medial head of triceps
Deltoid
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Techniques of Axillary Approachn 1. Transarterial
n Either all posterior (Urmey)
n or 50% post, 50% antn 2. Single Nerve Stimn 3. Paresthesian NB: No difference in
1st 3 tech, all 80% (Goldberg)
n 4. Multiple Nerve Stimulation(2-3)n Quick onsetn < LA toxicity riskn < Hematoma riskn > Success >95%
n 5. Ultrasound – ideal technique
n NB. > 98 % success w/ these 2 techs
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Mult Nerve Stim AXB(3 injections)
n 5mm above and below artery
n M/M on top
n U/R below
15ml
15ml
10ml
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Axillary Approach
Supplementation
n If operating above elbow
n Not needed for tourniquet
n Medial Brachial Nerve, T1
n Intercostobrachial T2 (not part of brach plex)
n Subcutaneous infiltration above and below sheath
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Axillary Distribution
n Good coverage of:n Ulnarn Mediann Radialn Musculocutaneousn Medial antebrachial
n Supplement prn:n ICBNn Med Brachial
Will capture MCN with separate injection