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Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

Review Article Blocks for Upper Extremity Orthopaedic

Abstract Benjamin G. Bruce, MD Regional of the upper extremity has several clinical Andrew Green, MD applications and is reported to have several advantages over general anesthesia for orthopaedic surgery. These advantages, Theodore A. Blaine, MD such as improved postoperative pain, decreased postoperative Lee V. Wesner, MD opioid administration, and reduced recovery time, have led to widespread acceptance of a variety of regional blocks. Interscalene block is the most commonly used block for shoulder surgery. Other brachial plexus nerve blocks used for orthopaedic surgery of the upper extremity are supraclavicular, infraclavicular, From the Department of and axillary. Several practical and theoretical aspects of regional Orthopaedics (Dr. Bruce, Dr. Green, and Dr. Blaine) and the Department nerve blocks must be considered to optimize the beneficial effects of (Dr. Wesner), and minimize the risk of complications. Warren Alpert School of Medicine at Brown University, Providence, RI.

Dr. Green or an immediate family egional anesthesia is the admin- administration, decrease overnight member has received royalties from Tornier; serves as a paid consultant Ristration of hospitalizations, increase operating to IlluminOss Medical and Tornier; agents and adjuvants to specific ana- room efficiency, and reduce recovery has stock or stock options held in tomic areas, resulting in a combina- times.1 Recent studies of interscalene IlluminOss Medical and Pfizer; has received nonincome support (such tion of motor and sensory blockade. blocks have reported success rates as equipment or services), Regional anesthesia can be divided (ie, postoperative pain score ≤2of commercially derived honoraria, or into central blocks and peripheral 10) to be >99%.2 other non-researchÐrelated funding blocks based on the proximity of the William Halsted reported the first (such as paid travel) from Arthrex, Linvatec, Smith & Nephew, and infiltration site to the spinal cord. brachial plexus block in 1885, when Synthes; and serves as a board Brachial plexus block is a peripheral he described applying di- member, owner, officer, or block commonly used in both inpa- rectly to a surgically exposed bra- committee member of the American tient and outpatient settings for up- chial plexus.3 However, the morbid- Academy of Orthopaedic Surgeons and the American Shoulder and per extremity surgery and in postop- ity associated with open exposure of Elbow Surgeons. Dr. Blaine or an erative rehabilitation. The type of the brachial plexus limited its wide- immediate family member is a brachial plexus block used depends spread use. Percutaneous brachial member of a speakers’ bureau or has made paid presentations on on the type and magnitude of the plexus blockade was introduced in behalf of and serves as a paid surgery as well as patient characteris- the early 1900s and underwent sub- consultant to Zimmer. Neither of the tics and preferences. sequent refinements. The success of following authors nor any immediate Despite initial reluctance by ortho- brachial plexus blocks was greatly family member has received anything of value from or owns paedic surgeons to embrace regional improved with the development of stock in a commercial company or anesthesia, brachial plexus blocks transcutaneous neurostimulators in institution related directly or are now safely and effectively used the 1950s. The early stimulators indirectly to the subject of this for perioperative pain control for were rudimentary in design and of- article: Dr. Bruce and Dr. Wesner. many arthroscopic and open proce- ten failed to accurately localize the J Am Acad Orthop Surg 2012;20: dures. Compared with general anes- target nerve. Refinements in the de- 38-47 thesia, interscalene blocks have been sign allowed more accurate localiza- Copyright 2012 by the American shown to improve postoperative tion of the needle. Recently, the in- Academy of Orthopaedic Surgeons. pain, decrease postoperative opioid troduction of ultrasound-guided

38 Journal of the American Academy of Orthopaedic Surgeons Benjamin G. Bruce, MD, et al techniques has further improved Figure 1 block placement by allowing the an- esthesiologist to visualize the bra- chial plexus and needle during injec- tion.4 The success of upper extremity re- gional blocks is dependent on several factors, including the skill of the practitioner performing the block, patient characteristics, and needle lo- calization technique. The orthopae- dic surgeon must understand the benefits and risks of this important adjunct to upper extremity surgery.

Anatomy

The brachial plexus is composed of the peripheral of the upper extremity from the root level to the terminal branches; it is classically de- Illustration of the of the brachial plexus. The bordered areas scribed as forming from the C5 represent the approximate target areas of the various blocks: interscalene, through T1 nerve roots (Figure 1). supraclavicular, infraclavicular, and axillary. (Redrawn with permission from Although all the musculature of the Netter FH: Atlas of Human Anatomy, ed 2. Teterboro, NJ, ICON Learning Systems, 1997.) upper extremity derives innervation from the brachial plexus, the cutane- ous innervation of portions of the pact in this region as it lies on top of plexus blocks have different indica- shoulder and upper arm is supplied the first rib, where it is closest to the tions for use in upper extremity sur- by nerves that are not part of the dome of the . The infraclavicular gery (Figure 3). The interscalene brachial plexus. The supraclavicular region is defined by the posterior sur- block is the most commonly used nerves, which supply the skin over face of the superiorly, the soft brachial plexus block. It is ideally the upper shoulder, derive from the tissues of the inferiorly, the pec- suited for shoulder surgery. Intersca- third and fourth cervical roots. The toralis minor muscle anteriorly, and the lene blocks cover the supraclavicular axilla and medial aspects of the up- subscapularis muscle posteriorly. The nerves emanating from the third and per arm are supplied by the intercos- cords of the brachial plexus and sub- fourth cervical roots, thereby provid- tal brachial nerves from the second clavian vessels pass through this space ing sensory blockade to the skin to the upper extremity. At the level of thoracic nerve root. Consequently, overlying the shoulder. Compared the coracoid, the terminal branches be- an isolated brachial plexus nerve with suprascapular or gin to leave the cords, thereby reduc- block may fail to provide complete intraoperative bursal of lo- ing the likelihood that a single injection anesthesia of the upper extremity. cal anesthetic, interscalene block has can block the entire plexus at this level. The brachial plexus travels through been shown to provide superior pain The axillary region is a pyramidal four loosely defined anatomic regions: relief for subacromial acromio- space beneath the glenohumeral joint, interscalene, supraclavicular, infracla- plasty.5 Interscalene block can also located between the lateral chest wall vicular, and axillary. The interscalene be used for elbow surgery, although and the medial portion of the upper groove is the potential space between the sensory block may be less com- arm (Figure 2). the anterior and middle scalene mus- plete. It is not indicated for forearm cles. In the supraclavicular region, the or hand surgery because block of the brachial plexus emerges from the inter- Indications inferior trunk is often poor. This has scalene groove and travels laterally and been described as “ulnar sparing,” inferiorly beneath the clavicle. The di- Because of the differences in block and it is thought to result from the visions of the brachial plexus are com- distribution, the various brachial increased distance of the inferior

January 2012, Vol 20, No 1 39 Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

Figure 2 Technical Considerations

Sedation In adults, brachial plexus blocks should be performed on awake or mildly sedated patients by an experi- enced provider and with standard vi- tal sign and appropriate resuscitation equipment immediately available. The risk of sudden, unex- pected movements by the patient that might displace the needle or cause inadvertent damage to the bra- chial plexus or nearby structures is low. Upper extremity regional blocks Clinical photographs demonstrating the anatomic landmarks of brachial are not routinely performed on anes- plexus blocks. A, 1 = interscalene block, 2 = supraclavicular block, 3 = infra- clavicular block. B, 4 = axillary block. SCM = sternocleidomastoid muscle thetized patients because they are un- able to report early warning signs (eg, pain, ) or signs of lo- trunk from the site of local anes- from forearm tourniquet pain.7 Elici- cal or systemic toxicity (eg, heart pal- thetic injection.6 Factors that make tation of distal motor response in the pitations, perioral numbness, shortness interscalene block technically more posterior cord ( or wrist exten- of breath). Although safe placement of difficult (eg, short neck, prior neck sion mediated through the radial interscalene block after induction of surgery) may present relative con- nerve) has been associated with the general anesthesia has been reported, most recent recommendations with traindications to its use. Underlying highest success rates of surgical anes- level I evidence suggest that, in adults, pulmonary disease may present an- thesia for the infraclavicular block.8 interscalene blocks should not be per- other relative contraindication be- The sensory blockade is inadequate formed under heavy or gen- cause of near-universal for upper arm or shoulder surgery. eral anesthesia.10 blockade. Axillary brachial plexus block pro- The supraclavicular block provides In contrast, some reports in the lit- duces analgesia similar to that of the excellent anesthesia of all branches erature suggest that regional blocks infraclavicular block. Therefore, it is of the brachial plexus as they pass can be safely performed with heavy most effective for procedures of the through this relatively confined area. sedation or general anesthesia in pe- hand, forearm, and elbow. Axillary However, without supplemental in- diatric patients. An awake child may blocks have been shown to be signifi- jections, supraclavicular blocks do not be able to provide appropriate cantly more successful than either su- not provide adequate sensory block- feedback secondary to . Fur- ade of the cape of the shoulder. praclavicular or interscalene tech- thermore, the risk of sudden, unex- Thus, its indications should be con- niques for elbow surgery (P < 0.025), pected movements may be higher in fined to upper arm surgery distal to including procedures that involve children than in adults. Marhofer 9 11 the shoulder. Because of the proxim- soft tissue or bone. The sensory et al performed a randomized clini- ity of the brachial plexus to the block to this area may be incom- cal trial and demonstrated safe and dome of the lung in this region, pa- plete, and potential exists for dis- successful ultrasound-guided bra- tients with enlarged lung volumes comfort from the use of a tourniquet chial plexus blocks in sedated chil- (eg, chronic obstructive pulmonary placed proximally on the upper arm. dren. The benefits of postoperative disease) present a relative contraindi- Unlike the other brachial plexus pain control may outweigh the risks cation to supraclavicular block. blocks, the arm must be abducted of block placement under sedation in Infraclavicular brachial plexus 90° to access the axillary space; it the pediatric population. block provides superior regional an- may be difficult for patients with esthesia for surgery of the elbow, trauma or contractures to comfort- Obesity forearm, wrist, and hand. It has been ably achieve the appropriate posi- A successful block is more difficult shown to provide excellent relief tion. to obtain in obese patients than in

40 Journal of the American Academy of Orthopaedic Surgeons Benjamin G. Bruce, MD, et al patients who are not obese. Nielsen Figure 3 et al12 showed that upper extremity blocks were more likely to fail (P = 0.04) and were associated with sig- nificantly more complications in pa- tients with a body mass index ≥30 kg/m2 (P = 0.001). Markedly in- creased ultrasound imaging time also has been noted with obese patients.13

Awake Regional Anesthesia At select institutions, shoulder sur- gery is performed on the awake pa- tient under regional anesthesia.14 Proponents of this method note an improved ability to monitor neuro- logic status with the patient in the beach-chair position. This improves the ability of the anesthesiologist to safely lower blood pressure, thereby permitting the use of lower arthros- copy pump pressures. Disadvantages of awake anesthesia include respira- tory depression, respiratory obstruc- tion, and disinhibition, with the potential risk of intraoperative con- version to general anesthesia. Cur- rently, no literature supports the ad- vantage of awake over general anesthesia.

Anticoagulation The Consensus Statement of the American Society of Regional Anes- thesia and Pain Medicine states that patients who are mildly anticoagu- Illustration of the anterior and posterior views of the distribution of brachial lated are safe to undergo brachial plexus blocks. A, Interscalene. B, Supraclavicular. C, Infraclavicular axillary: single injection. D, Axillary: multiple injections and high humeral block. plexus blockade; however, a risk- (Redrawn with permission from Chelly JE, ed: Peripheral Nerve Block,ed3. benefit analysis should be performed Philadelphia, PA, Lippincott Williams & Wilkins, 2008.) for each patient.15 In this report, pa- tients with an international normal- ized ratio of <3 were noted to have a Needle Guidance a “loss of resistance” method during 3-month risk of 3%; this The first percutaneous brachial infiltration, indicating entry of the risk increased to 7% for patients plexus blocks were performed based needle into the potential space sur- with an international normalized ra- on identification of anatomic land- rounding the neural structures. tio >4. Patients on thrombolytic ther- marks. Proximity to neural struc- In the past two decades, neuro- apy had the highest bleeding risk. tures was determined by eliciting stimulation became the standard of Nonetheless, we do not routinely im- paresthesias as the needle was ad- care. Neurostimulation involves lo- plement blocks on anticoagulated vanced through the neural sheath. calizing the brachial plexus with an patients for elective surgery. Other described techniques relied on insulated needle that emits a low-

January 2012, Vol 20, No 1 41 Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery intensity electrical current. Successful The use of ultrasonography may interscalene blocks. Trainees ran- needle placement is demonstrated by improve the safety of peripheral domized to either ultrasonographic an appropriate muscle twitch. Inter- nerve blockade by improving early or neurostimulator guidance per- scalene blocks have been shown to recognition of complications. For ex- formed successful interscalene block be most effective when a deltoid or ample, failure to visualize local anes- faster and more accurately using 16 muscle twitch is observed. thetic spread under ultrasonography ultrasonography.22 Furthermore, When performing supraclavicular may indicate intravascular or intra- trainees who used ultrasonographic block, elicitation of distal motor re- neural injection.26 Nonetheless, a re- guidance caused fewer vascular sponse, as evidenced by wrist exten- cent meta-analysis by Liu et al27 con- punctures.13 sion or finger twitch, has been cluded that there are not adequate shown to be more effective than bi- randomized trials to conclude that ceps or triceps muscle contraction in ultrasonography is superior to neu- Block Agents and achieving successful sensory block- rostimulation. Limitations of ultra- Adjuvants ade (94% versus 75%, P < 0.05).17 sonography include a limited plane The use of needle guidance technol- Short- and long-acting local anes- of view and operator-dependent im- ogy has improved the administration thetic agents can be used. The age quality. and effectiveness of brachial plexus amount of anesthetic injected is not 18 blocks. Boezaart et al demonstrated Indwelling standardized. Rather, the dose is de- neurostimulation to be superior to pendent on agent used, technique, the technique in terms of The effectiveness of a single-shot and preference of the administering success rates and postoperative pain brachial plexus block in improving physician. For example, some studies scores. pain control and reducing opioid use show that use of ultrasonography re- Most recently, ultrasonography has is limited to the immediate postoper- duces the amount of agent required been used to visualize anatomy and ative period. The duration of effect to achieve a successful block. needle placement. The relatively su- of a single-shot brachial plexus block Bupivacaine is a long-acting local perficial location of the brachial has been reported to be between 2 anesthetic that has been successfully 28 plexus permits excellent visualization and 48 hours. Most studies demon- used for interscalene blocks. How- via ultrasonography. strate pain relief lasting approxi- ever, regional blocks using bupiva- 29,30 Although the topic is controversial, mately 12 hours. For most surger- caine have been associated with life- an expanding body of literature sup- ies, postoperative pain is commonly threatening neurotoxicity and ports the use of ultrasonography for expected to last beyond 24 hours, cardiotoxicity. This toxicity was block placement.2,19-24 Ultrasonogra- and continuous indwelling catheters modulated in large part by the ste- phy can be safely and effectively used have been introduced to provide pro- reospecificity of the cellular recep- in a range of brachial plexus blocks. longed anesthesia. Continuous cathe- tors for bupivacaine. In response, In a recent meta-analysis of 13 stud- ters have been shown to significantly levobupivacaine and ropivacaine, ies comparing neurostimulation with reduce postoperative pain scores (P < two optically pure isomers of bu- ultrasound-guided peripheral nerve 0.001), decrease opioid use (P < pivacaine, were developed. Both block, the authors concluded that 0.001), and improve sleep patterns at levobupivacaine and ropivacaine 31 ultrasound-guided blocks were more home (P = 0.013). Indwelling cath- have been shown to have less neuro- likely to be successful, took less time eters have also been effectively used toxicity and cardiotoxicity relative to to perform, had a faster onset, and for pain control in postoperative re- racemic bupivacaine.33 Furthermore, decreased the risk of vascular punc- habilitation for frozen shoulders as Borgeat et al34 showed that, for simi- ture.19 In a study of the multiple- well as in postoperative trauma pa- lar pain control, ropivacaine 0.2% 32 injection technique for axillary tients. The safety of continuous demonstrated improved preservation blocks, ultrasonographic guidance blocks has been aided by the devel- of hand strength and finger sensation was shown to have fewer needle opment of portable, disposable, compared with bupivacaine 0.15%. passes (P = 0.002) and shorter time tamper-resistant infusion pumps. A double-blind, prospective study to onset of anesthesia (P = 0.01) than comparing equal volumes of levobu- nerve stimulation.25 This study also Training pivacaine 0.5% and ropivacaine demonstrated lower rates of Ultrasonographic guidance has also 0.5% demonstrated no difference in procedure-related pain in the ultra- been shown to improve the initial the effectiveness or onset of block; sonography group. success rate of trainees performing however, patients who were adminis-

42 Journal of the American Academy of Orthopaedic Surgeons Benjamin G. Bruce, MD, et al tered levobupivacaine required a Table 1 smaller total volume.35 The concen- Maximum Dose of Local Anesthetics for Brachial Plexus Blocks55,56 tration of anesthetic has not been a shown to affect onset, magnitude, or Anesthetic Maximum Recommended Dose 36 duration of sensory blockade (Ta- Bupivacaine 2.5 mg/kg ble 1). Bupivacaine with epinephrine 3 mg/kg Several adjuvant medications, in- Levobupivacaine 2.0 mg/kg cluding epinephrine, clonidine, and Levobupivacaine with epinephrine 3.0 mg/kg dexamethasone, can be added to the Ropivacaine 2.0 mg/kg injectate to potentiate the effective- Ropivacaine with epinephrine 3.0 mg/kg ness of . Each has specific beneficial and detrimental ef- a Recommendations for the United States only. Recommendations may vary from country to fects. country. This table should be used as a guideline; practitioners should use their clinical judgment Epinephrine has been given in con- when administering local anesthetics. junction with short-acting local anes- thetics to improve analgesia. In a Controversy persists regarding perioral anesthesia, dizziness, muscle study of sciatic nerves in rats, epi- whether the addition of an opioid to an fibrillation, and tinnitus, is reported nephrine was shown to decrease sys- interscalene block improves pain con- to be <1 in 1,000 blocks.42 temic absorption and to potentially trol. Opioid receptors are predomi- The incidence of after lo- increase absorption locally by the nantly located on the distal end of sen- cal anesthetic injection, presumably nerve, thereby increasing the inten- sory nerves rather than along the axon, from intravascular injection, is rela- sity and duration of its effective- where an interscalene block would be tively low (<2 in 1,000 for all periph- ness.37 It has been suggested that epi- placed. This raises the question of the eral nerve blocks).43 Orebaugh et al44 nephrine increases the risk of mechanism of action. retrospectively reviewed the records intraoperative bradycardic and hy- Neither gabapentin nor ketamine of 5,436 patients who received potensive episodes, as well as of local appears to improve postoperative brachial plexus blocks administered vasoconstriction and nerve ische- pain control in patients who receive 38 either by ultrasound-guided neuro- mia. interscalene block for shoulder sur- stimulation or by a landmark- Clonidine is an alpha-2 adrenergic gery.40 agonist that has been shown to im- neurostimulation method. Signifi- prove the effectiveness of local anes- cantly fewer seizures were noted in thetics. Clonidine independently acts Complications patients in whom ultrasound-guided as an , potentially by inhib- neurostimulation was used (P = 41 iting impulse conduction. Sedation Lenters et al demonstrated that the 0.044). and are the recognized complication rate is strongly and in- There are no reported cases of circu- side effects of clonidine. Requisite versely correlated to the number of latory collapse or death with the use of monitoring for rebound hypotension blocks performed by the anesthesiol- ropivacaine or levobupivacaine. This is may preclude the use of clonidine in ogist. They noted a 1% mean com- thought to be a result of the decreased outpatient surgery. plication rate for anesthesiologists cardiotoxicity of these local anesthet- Dexamethasone has been shown to who performed >100 blocks in their ics. Appropriate management of local increase the duration of the sensory lifetimes and a 5% mean complica- anesthetic–induced cardiotoxicity be- blockade. The mechanism by which tion rate for those who performed gins with basic life support treatment. this occurs is not well understood, but <100 blocks in their lifetimes (P = Case reports demonstrate the effective- it has been postulated to be a result of 0.0015). ness of lipid emulsion (10% Intralipid decreased inflammatory response. In a [Fresenius Kabi, Pune, India]) infusion prospective, randomized, double-blind Systemic to manage local anesthetic cardiac study of patients undergoing shoulder Several systemic complications have toxicity.45,46 Even though it is rarely surgery, dexamethasone was shown to been reported, including cardiac ar- used, the physical location in the oper- increase the duration of sensory block rest, , seizures, and ating suite of this potentially life-saving and decrease opioid consumption death.41 The incidence of systemic lo- drug should be reviewed with each when given with clonidine and bupi- cal anesthetic toxicity, including agi- member of the surgical team. vacaine.39 tation, anxiety, visual disturbances, Up to 18.8% of patients undergo-

January 2012, Vol 20, No 1 43 Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery ing shoulder surgery with an inter- less respiratory compromise without ciated with increased risk of postoper- scalene block in the beach-chair posi- a significant difference in pain score, ative neurologic symptoms.50 tion have had sudden episodes of opioid consumption, or sleep quality When working up a postoperative clinically significant hypotension and 24 hours after surgery.4 neurologic injury, we recommend bradycardia requiring pharmacologic baseline electromyography and nerve treatment.47 This vasovagal response Nerve Injury conduction velocity tests at 3 to 6 is thought to be mediated by the The incidence of nerve injury after weeks as well as at 3 months if Bezold-Jarisch reflex. Venous pool- brachial plexus block is low; how- symptoms persist. ing caused by the seated position is ever, permanent injury can result in thought to increase sympathetic substantial disability. Peripheral tone, resulting in a low-volume, hy- nerve injury can be caused by me- Pneumothorax is a potentially seri- percontractile ventricle. A sudden chanical trauma from needles or ous complication after brachial parasympathetic reflex is triggered, catheters, drug neurotoxicity, ische- plexus block. Although it is most which causes rebound bradycardia mia, compression, or nerve stretch.49 common during supraclavicular and hypotension. It has been sug- The reported rate of neurologic se- block, where the brachial plexus gested that the addition of epineph- quelae lasting >1 year after upper ex- passes close to the dome of the lung, rine in the local anesthetic mixture tremity regional anesthesia is <1%.49 it has been reported in association increases the risk of hypotensive and Large differences in reported compli- with interscalene and infraclavicular 38 bradycardic events. cation rates between studies are de- blocks, as well. The incidence of pendent on multiple factors of study pneumothorax during supraclavicu- Phrenic Nerve design, including threshold for re- lar block has been reported to be as Underlying pulmonary disease is porting, reporting mechanisms, and high as 6.1%, which has limited its 52 considered to be a relative contrain- timing of the screening. Most of implementation. However, some dication to proximal brachial blocks these deficits resolve within weeks. authors suggest that ultrasono- because ipsilateral phrenic nerve Fredrickson and Kilfoyle50 reported graphic guidance significantly de- block is noted in almost all patients an incidence of postoperative neuro- creases the risk of pneumothorax, with interscalene block. The close logic symptoms after ultrasound- and they predict a resurgence in use 52 proximity of the phrenic nerve to the guided block placement of 8.2% at of the supraclavicular block. A pro- brachial plexus accounts for this 10 days, 3.7% at 1 month, and spective study published in 2009 phenomenon.48 Long-term paralysis 0.6% at 6 months. A prospective demonstrated no clinically apparent is another serious complication. It study evaluating >7,000 peripheral pneumothoracies in 510 patients can be caused by intraneural injec- nerve blocks demonstrated neuro- who received ultrasound-guided su- 53 tion, mechanical trauma from the logic deficit of 0.4 per 1,000 blocks praclavicular blocks. needle, or toxicity of the anesthetic at a follow-up of 1 to 6 weeks after Chest radiographs should be ob- agent. Clinically, phrenic nerve palsy surgery.42 Another study noted sen- tained immediately if pneumothorax can manifest as dyspnea, orthopnea, sory paresthesias of 2.3%, which re- is suspected. Emergent chest tube and insomnia. However, blocks of solved by an average of 9 weeks.51 placement should be performed in the more distal brachial plexus (eg, Twenty-nine percent of neurologic the patient who demonstrates signs axillary region, infraclavicular re- injuries are identified after dis- of instability. Persistent hemody- gion) rarely result in blockade of the charge.41 It has been suggested that namic instability may be managed phrenic nerve. unexpected resistance or increased with intubation and positive pressure For patients with underlying pul- paresthesias during the injection are ventilation. monary disease, recent literature sug- indications for immediate needle re- gests that ultrasonographic guidance positioning. Patients should be as- Vascular Puncture with low-volume local anesthetic sured that most postoperative neuro- Inadvertent vascular puncture can re- may be a safe option. A randomized logic deficits resolve. sult from errant needle advancement. clinical trial that compared General consensus suggests that se- Patients may experience increased ultrasound-guided injections of ropi- rious neurologic compromise is less neck tenderness, ecchymosis, and he- vacaine 20 mL and 5 mL found that likely to develop in the awake, alert matoma. Thus, it has been suggested patients who received the low- adult patient. Elicitation of paresthesia that patients who are anticoagulated volume injection had significantly during block placement has been asso- should not undergo brachial plexus

44 Journal of the American Academy of Orthopaedic Surgeons Benjamin G. Bruce, MD, et al block. Hematoma formation is most orthopaedic of the upper ultrasound guidance: The outcome in likely to occur with multiple needle extremity. These blocks have been 200 patients. J Clin Anesth 2009;21(4): 272-277. passes. In instances of suspected vas- shown to improve postoperative cular puncture, hematoma formation 3. Russon K, Pickworth T, Harrop- pain, decrease postoperative opioid Griffiths W: blocks. can be minimized by applying con- administration, decrease overnight Anaesthesia 2010;65 suppl 1:48-56. stant pressure for 5 minutes after the hospitalizations, increase operating 4. Riazi S, Carmichael N, Awad I, Holtby needle is withdrawn. room efficiency, and reduce recovery RM, McCartney CJ: Effect of local times. Interscalene block is most ap- anaesthetic volume (20 vs 5 ml) on the Indwelling Catheters efficacy and respiratory consequences of propriate for shoulder surgery. Other ultrasound-guided interscalene brachial Indwelling placement is not brachial blocks are indicated for plexus block. Br J Anaesth 2008;101(4): without drawbacks. Indwelling cath- more distal surgeries of the upper ex- 549-556. eter insertion can be technically more tremity. 5. Singelyn FJ, Lhotel L, Fabre B: Pain relief difficult than a single-injection inter- For those trained in its use, ultra- after arthroscopic shoulder surgery: A comparison of intraarticular analgesia, scalene block, although some studies sonographic needle guidance may block, and have demonstrated success rates as provide faster, more accurate, and interscalene brachial plexus block. high as 99% with postoperative an- more successful brachial plexus Anesth Analg 2004;99(2):589-592. esthesia.54 Furthermore, the catheter blocks. Levobupivacaine and ropiva- 6. Orebaugh SL, Williams BA: Brachial plexus anatomy: Normal and variant. failure rate at 24 hours has been re- caine are safer than bupivacaine, ScientificWorldJournal 2009;9:300-312. ported to be as high as 10% to with a duration of effect of approxi- 31 7. Desroches J: The infraclavicular brachial 20%. Concerns have also been mately 12 hours. Indwelling cathe- plexus block by the coracoid approach is raised that continuous infusion could ters may provide extended postoper- clinically effective: An observational result in administration of toxic vol- ative pain relief, but placement may study of 150 patients. Can J Anaesth 2003;50(3):253-257. umes of local anesthetic. Continuous be technically more difficult and may interscalene block results in longer have higher complication rates. Bra- 8. Bloc S, Garnier T, Komly B, et al: Single- stimulation, low-volume infraclavicular duration of hemidiaphragm paresis, chial plexus blocks are associated plexus block: Influence of the evoked which may exclude patients with un- with multiple complications of vari- distal motor response on success rate. Reg Anesth Pain Med 2006;31(5):433- derlying cardiac or pulmonary dis- able magnitude and significance. 437. ease. Other risks associated with in- These complications must be recog- 9. Schroeder LE, Horlocker TT, Schroeder dwelling catheters include catheter nized and appropriately managed. DR: The efficacy of axillary block for site as well as catheter mi- surgical procedures about the elbow. gration or breakage. Some studies Anesth Analg 1996;83(4):747-751. have suggested that prolonged appli- References 10. Bernards CM, Hadzic A, Suresh S, Neal JM: Regional anesthesia in anesthetized cation of anesthetics can cause myo- or heavily sedated patients. Reg Anesth toxicity; however, this effect is rarely Evidence-based Medicine: Levels of Pain Med 2008;33(5):449-460. 57 evidence are described in the table of clinically relevant. 11. Marhofer P, Sitzwohl C, Greher M, contents. In this article, references 4, Kapral S: Ultrasound guidance for Other 5, 11, 19, 21, 24, 30, 31, 39, and 40 infraclavicular brachial plexus are level I studies. References 12, 37, anaesthesia in children. Anaesthesia Other reported complications of in- 2004;59(7):642-646. 38, and 49 are level II studies. Refer- terscalene block include prolonged ence 1 is a level III study. References 12. Nielsen KC, Guller U, Steele SM, Klein Horner syndrome, brachial plexus SM, Greengrass RA, Pietrobon R: 2, 10, 13, 42-45, 47, 48, 50, and 52 Influence of obesity on surgical regional neuritis, complex regional pain syn- are level IV studies. anesthesia in the ambulatory setting: An drome, and bronchospasm (ie, hic- analysis of 9,038 blocks. Anesthesiology cups).49 The incidence of hoarseness References printed in bold type are 2005;102(1):181-187. has been shown to be 11% after those published within the past 5 13. Orebaugh SL, Williams BA, Kentor ML, years. Bolland MA, Mosier SK, Nowak TP: ultrasound-guided supraclavicular Interscalene block using ultrasound block, lasting a mean of 2 days.58 1. Wu CL, Rouse LM, Chen JM, Miller RJ: guidance: Impact of experience on Comparison of postoperative pain in resident performance. Acta Anaesthesiol patients receiving interscalene block or Scand 2009;53(10):1268-1274. general anesthesia for shoulder surgery. Summary Orthopedics 2002;25(1):45-48. 14. Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU: Interscalene 2. Davis JJ, Swenson JD, Greis PE, Burks block for shoulder arthroscopy: Brachial plexus blocks are routinely RT, Tashjian RZ: Interscalene block for Comparison with general anesthesia. used in both inpatient and outpatient postoperative analgesia using only Arthroscopy 1993;9(3):295-300.

January 2012, Vol 20, No 1 45 Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

15. Horlocker TT, Wedel DJ, Benzon H, 26. Chin KJ, Perlas A, Chan VW, Brull R: 37. Sinnott CJ, Cogswell LP III, Johnson A, et al: Regional anesthesia in the Needle visualization in ultrasound- Strichartz GR: On the mechanism by anticoagulated patient: Defining the risks guided regional anesthesia: Challenges which epinephrine potentiates lidocaine’s (the second ASRA Consensus Conference and solutions. Reg Anesth Pain Med peripheral nerve block. Anesthesiology on Neuraxial Anesthesia and 2008;33(6):532-544. 2003;98(1):181-188. Anticoagulation). Reg Anesth Pain Med 2003;28(3):172-197. 27. Liu SS, Ngeow JE, Yadeau JT: 38. Sia S, Sarro F, Lepri A, Bartoli M: The Ultrasound-guided regional anesthesia effect of exogenous epinephrine on the 16. Silverstein WB, Saiyed MU, Brown AR: and analgesia: A qualitative systematic incidence of hypotensive/bradycardic Interscalene block with a nerve review. Reg Anesth Pain Med 2009; events during shoulder surgery in the stimulator: A deltoid motor response is a 34(1):47-59. sitting position during interscalene block. satisfactory endpoint for successful Anesth Analg 2003;97(2):583-588. block. Reg Anesth Pain Med 2000;25(4): 28. Gohl MR, Moeller RK, Olson RL, 39. Vieira PA, Pulai I, Tsao GC, Manikantan 356-359. Vacchiano CA: The addition of interscalene block to general anesthesia P, Keller B, Connelly NR: Dexameth- 17. Jeon DG, Kim WI: Comparison of a for patients undergoing open shoulder asone with bupivacaine increases supraclavicular block showing upper procedures. AANA J 2001;69(2):105- duration of analgesia in ultrasound- arm twitching response with a 109. guided interscalene brachial plexus blockade. Eur J Anaesthesiol 2010;27(3): supraclavicular block showing wrist or 285-288. finger twitching response. Korean J 29. Klein SM, Greengrass RA, Steele SM, et al: A comparison of 0.5% Anesthesiol 2010;58(5):464-467. 40. Adam F, Ménigaux C, Sessler DI, bupivacaine, 0.5% ropivacaine, and Chauvin M: A single preoperative dose 18. Boezaart AP, de Beer JF, du Toit C, van 0.75% ropivacaine for interscalene of gabapentin (800 milligrams) does not Rooyen K: A new technique of brachial plexus block. Anesth Analg augment postoperative analgesia in continuous interscalene nerve block. Can 1998;87(6):1316-1319. patients given interscalene brachial J Anaesth 1999;46(3):275-281. plexus blocks for arthroscopic shoulder 30. Chin KJ, Singh M, Velayutham V, Chee surgery. Anesth Analg 2006;103(5): 19. Abrahams MS, Aziz MF, Fu RF, Horn V: Infraclavicular brachial plexus block 1278-1282. JL: Ultrasound guidance compared with for regional anaesthesia of the lower electrical neurostimulation for peripheral arm. Cochrane Database Syst Rev 2010; 41. Lenters TR, Davies J, Matsen FA III: The nerve block: A systematic review and (2):CD005487. types and severity of complications meta-analysis of randomized controlled associated with interscalene brachial trials. Br J Anaesth 2009;102(3):408- 31. Ilfeld BM, Morey TE, Wright TW, plexus block anesthesia: Local and 417. Chidgey LK, Enneking FK: Continuous national evidence. J Shoulder Elbow interscalene brachial plexus block for Surg 2007;16(4):379-387. 20. Casati A, Baciarello M, Di Cianni S, postoperative pain control at home: A et al: Effects of ultrasound guidance on randomized, double-blinded, placebo- 42. Barrington MJ, Watts SA, Gledhill SR, the minimum effective anaesthetic controlled study. Anesth Analg 2003; et al: Preliminary results of the volume required to block the femoral 96(4):1089-1095. Australasian Regional Anaesthesia nerve. Br J Anaesth 2007;98(6):823-827. Collaboration: A prospective audit of 32. Waszczykowski M, Fabis´J: The results more than 7000 peripheral nerve and 21. Fredrickson MJ, Ball CM, Dalgleish AJ: of arthroscopic capsular release in the plexus blocks for neurologic and other A prospective randomized comparison of treatment of frozen shoulder: Two-year complications. Reg Anesth Pain Med ultrasound guidance versus follow-up [English, Polish]. Ortop 2009;34(6):534-541. neurostimulation for interscalene Traumatol Rehabil 2010;12(3):216-224. catheter placement. Reg Anesth Pain 43. Auroy Y, Benhamou D, Bargues L, et al: Med 2009;34(6):590-594. 33. Leone S, Di Cianni S, Casati A, Fanelli Major complications of regional G: Pharmacology, toxicology, and anesthesia in France: The SOS Regional 22. Mariano ER, Loland VJ, Sandhu NS, clinical use of new long acting local Anesthesia Hotline Service. et al: A trainee-based randomized anesthetics, ropivacaine and levobu- Anesthesiology 2002;97(5):1274-1280. comparison of stimulating interscalene pivacaine. Acta Biomed 2008;79(2):92- perineural catheters with a new 105. 44. Orebaugh SL, Williams BA, Vallejo M, technique using ultrasound guidance Kentor ML: Adverse outcomes alone. J Ultrasound Med 2010;29(3): 34. Borgeat A, Kalberer F, Jacob H, Ruetsch associated with stimulator-based 329-336. YA, Gerber C: Patient-controlled peripheral nerve blocks with versus interscalene analgesia with ropivacaine without ultrasound visualization. Reg 23. Orebaugh SL, Williams BA, Kentor ML: 0.2% versus bupivacaine 0.15% after Anesth Pain Med 2009;34(3):251-255. Ultrasound guidance with nerve major open shoulder surgery: The effects stimulation reduces the time necessary on hand motor function. Anesth Analg 45. Corcoran W, Butterworth J, Weller RS, for resident peripheral nerve blockade. 2001;92(1):218-223. et al: Local anesthetic-induced cardiac Reg Anesth Pain Med 2007;32(5):448- toxicity: A survey of contemporary 454. 35. 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46 Journal of the American Academy of Orthopaedic Surgeons Benjamin G. Bruce, MD, et al

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