A HAND BOOK OF BRACHIAL

PLEXUS BLCOK
From the authors Desk
Dear Friends,
It gives me immense pleasure to bring out this booklet on brachial plexus block.
My aim is to reach out mainly to postgraduate students and practitioners with this ready
reckoner on brachial plexus block
Nowadays, the buword as !ar as regional anaesthesia goes in ultrasound guided blocks.
"ut coming !rom the Indian subcontinent we have limited access to such e#uipment even
in tertiary care centres. $ence, I have !ocused on how to per!orm these blocks with the
cost e!!ective e#uipment available to us vi% the peripheral nerve locator. It should hold a
place in the armamentarium o! any practicing anaesthesiologist with a serious interest in
per!orming regional blocks.
&his booklet covers brachial plexusw blocks in most o! its !orms. I hope it will be a
use!ul guide.

Dr.R.Silamban
BRACHIAL PLEXUS BLOCK
INTRODUCTION:
"rachial plexus block is one o! the most commonly used peripheral nerve blocks in
clinical practice. Itcan be used as the sole anaesthetic tecyhni#ue or in combination with
general anaesthesia !or intraoperative and postoperative analgesia. 'ontinuous
catheteriation o! the brachial plexus is one o! the best methods o! postoperative
analgesia.


&he common sites o! approach to the brachial plexus are(
a. Interscalene approach
b. )upraclavicular approach
c. In!raclavicular approach
d. *xillary approach
e. +osterior approach
It is a must !or the practicing anaesthesiologist to be !amiliar with all the above
approaches as well as each ones advantages and limitations.
HISTORY OF BRACHIAL PLEXUS BLOCKADE
&he bock was !irst per!ormed by ,illiam )teward $alsted in -../. $e directly exposed
the brachial plexus in the neck to per!orm the block and used cocaine. $irschel !irst
described the percutaneous approach to the brachial plexus. 0ulenkamp!! !irst described
the classicial supraclavicular rpproach to the brachial plexus. &he subclavian
perivascular block was !irst described by ,innie and 'ollins. &his approach became
popular as it was associated with less incidence o! pneumothorax than the 0ulenkamp!!
approach. &he in!raclavicular approach was !irst developed by 1a2, an anaesthesiologist
o! Indian origin practicing in 3)*. &he axillary rpproach was !irst per!ormed by *ccardo
and *driano in -/4/.
ANATOMY
Formaion o! "# Pl#$%&
1oots( &he plexus is !ormed by the anterior primary rami o! '5 to '. nerves along with
the bulk o! &- nerve. 6ccasionally there may be a contribution !rom '4 or &7 nerves
leading to the !ormation o! pre%!ixed or post%!ixed plexus. &he roots emerge !rom the
respective intervertebral !oramina to enter the perivascular shealth.
&runk( )andwiched between the scalenus anterior and medius muscle, the roots combine
to !orm the trunks. &he '5 and '8 roots combine to !orm the upper trunk, '9 continues

as the middle trunk and '. and &- combines to !orm the lower trunk
Divisions( "ehind the clavicle the trunks divide into a anterior and posterior divisions
and stream into the axilla.
'ords( In the upper part o! the axilla the six divisions combine to !orm lateral, medial and
posterior cords.
%&he lateral cord is !ormed by the union o! anterior division o! the upper and
middle trunks.
%&he medial cord is the continuation o! the anterior division o! the lower trunk.
%&he posterior cord is due to union o! the posterior divisions o! all the three trunks
&erminal branches( :ower down in the axilla the cords give rise to terminal branches
namely the ulnar, median and radial nerves.
R#laion&"i' o! "# bra("ial 'l#$%&:
1oots( &hese lie between the scalenus anterior and medius muscles. It lies above the
second part o! the subclavian artery. &he classical interscalene approach to the brachial
plexus blocks is at the root level.
&runks( &hese lie in close relationship to the subclavian artery above the clavicle. $ere
also they are sandwiched between the scalene muscles. &he trunks extend upto the lateral
border o! the !irst rib. &he subclavian perivascular approach blocks the plexus at this
level.
Divisions( they start at thelateral border o! the !irst rib and lie behind the clavicle. &he
rib hitching techni#ue causes blockade at this level.

'ords( &he divisions unite to !orm cords at the upper part o! the axilla. &hey remain
grouped around the axillary artery. &he in!raclavicular approach causes blockade at the
2unction o! cords and divisions.

&erminal "ranches( &hey are !ormed lower down in the axilla. &he reorganiation o! the
cords to !orm the terminal branches occurs at the lateral border o! the pectoralis minor
muscle. &he axillary approach causes blockade at this level
ANATOMICAL CONSIDERATIONS:
&he anatomic !actors which determine the success and complications o! the brachial
plexus blockade are
%&he perivascular sheath
%&he vertical arrangement o! the cervical roots
%&he interconnections ; &his is due to combining, dividing, recombining and
redividing o! the original !ive cervical roots.
%&he relationship o! the site o! needle entry to vital structures.
P#ri)a&(%lar S"#a" * I& Im'oran(#
&he perivascular sheath is a !ibrous sheath covering the brachial
+lexus in its entirety. It extends !rom the origin o! the scalene muscles down to middle o!
upper arm. &he potential space !ormed by this sheath can hold upto .<%-<< ml o! local
anaesthetic.

&his sheath gives a classical =+op 6!! = !eeling when pierced by the needle.
&his sheath is the single most important !actor in determining the success o! bracial
plexus blockade. &he plexus can be blocked by introducing a needle at any point along
the sheath. "ut the site o! needle entry determines which components arepre!erentially
blocked and which compenents are spared. $owever this can be overcome to a certain
extent by increasing the volume o! the local anaesthetic and by applying proximal or
distal digital pressure.
&he suggestion that the covering is discontinuous with septa subdividing the space into
separate compartments that clinically prevent the spread o! local anaesthetic
$owever these septal divisions are more prominent in the axilla than above. &his
probably is the reason !or !re#uent sparing o! the radial and musculocutaneous nerves
during axillary blockade.*s the septa are more prominent in the lower part, there may be
more sparing in the in!raclavicular approach than in the supraclavicular approach. &he
perivascular sheath may also be discontinuous leading to spillage o! drug out side
thesheath.
+#ri(al arran,#m#n o! roo&:
&his arrangement o! the brachial plexus assumes signi!icance in the classical interscalene
approach. $ere the needle is applied close to the '5 and '8 nerve roots. *s the roots
are vertically arranged the local anaesthetic will have to travel caudally to reach '. and
&- level. I! the caudal travel o! the local anaesthetic is de!icient then these roots may be
spared leading to poor analgesia in the ulnar nerve distribution. In the in!raclavicular
approach sparing o! the ulnar nerve is rarely seen.
T"# in#r(onn#(ion&:
&he interconnections between the original !ive cervical roots means that the cutaneous
distribution o! the individual nerve terrioratories di!!ers !rom the myotomal and
detematomal pattern and that the muscular and other deep structures do not underlie the
sensory distribution o! that nerve. For example blockade o! the ulnar nerve at the elbow,
produces sensory loss on the ulnar side o! the hand but motor loss o! the !lexor muscles
on the anterior aspect.
Si# o! n##-l# #nr. an- (om'li(aion&:
%%I! site o! needle entry is at the '8 level, r>the chances o! epidural and
subarachnoid in2ections are more. &he chances o! vertebral artery puncture,
phrenic and recurrent laryngeal nerve paralysis are also higher.
%%I! the site o! needle entry is close to the clavicle the chances o! pneumothorax
and subclavian artery puncture are more.
%%I! the site o! needle entry is below the clavicle as in the in!raclavicular approach,
complication rate is much less than in the above routes but the chances o!
incomplete blockade are more.
%%In the axillary site apart !rom accidental artery puncture other complications are
less but chances o! incomplete blockade increases.
SUPRACLA+ICULAR APPROACH
Inro-%(ion:
'ornerstone o! upper extremity o! regional anaesthesia. It is used extensively in clinical
practice. ?arious techni#ues o! reaching the brachial plexus !rom the supraclavicular site
are described. In this approach the drug is delivered at the level o! the trunks which is the
most compact part o! the brachial plexus.
In any supraclavicular techni#ue the chance o! pneumothorax will always have to be
kept in mind. &he dome o! the pleura is in close relationship to the convacity o! the !irst
rib. I! the needle is introduced close to the lateral border o! the clavicular head o! the
sternocleidomastoid as usual, the chance o! pleural damage is high. In this techni#ue
which we are going to describe, the needle is introduced between the two scalene muscle
which is a sa!e -.5cm away !rom the dome o! the pleura. It is always better to have a sa!e
distance -cm !rom the pleura.
Di&rb%ion o! (on&i&#n ana#&"#&ia
It can be used !or any upper extremity procedure !rom the shoulder to the !ingers. Distal
digital pressure makes the drug to rise up to the level o! the roots and making surgery in
the alteral hal! o! the clavicle also possible.

Po&iion:
+atient is supine, hands on the side, head turned to the opposite side.
Lan-mar/&

'lavicle, lateral head o! sternocleidomastoid, scalenus anterior and medius muscle,
external 2ugular vein.
Si# o! n##-l# #nr.
In the interscalene groove about -.5 to 7 cm above the clavicle.

T#("ni0%#
&he patient is asked to li!t his head up to make the lateral head o! sternocleidomastoid
prominent. *!ter the lateral border o! the sternocleidomastoid is identi!ied, the !ingers
are slowly moved laterally to !eel the anterior and medial scalene muscles and the groove
between them is appreciated. * point -.5 to 7cm above the clavicle is marked in the
groove and a 5cm long needle with nerve locator attached is entered through the skin.
&he needle is directed towards the ipsilateral toe. &he needle is advanced till a =pop o!!
is !elt signi!ying entry into the perivascular sheath. Now the nerve locator isswitched on
at -m* current. *t this point muscle twitches are invariably seen. * current greater than
-m* may be uncom!ortable to the patient. *s the brachial plexus is in close proximity to
the in!erior sur!ace o! the scalene muscle, di!!iculty in nerve location does not occur.
&he current is slowly reduced %.7m* to get the desired response below <.8m*. *t this
point the drug is given.
Moor r#&'on&# o n#r)# &im%laion
&he !ollowing motor responses are elicited and result in the same success rate.
%+ectoralis muscle twitch
%Deltoid muscle twitch
%&riceps muscle twitch
%"iceps muscle twitch
%$and and !orearm muscle twitch
1hythmic movements o! the shoulder, elbow, hands and !ingers are seen. Form ideal
results the twitches should be obtained at less than <.8m*. &witches o! the neck muscles
and movement o! the scapula are not considered.
The initial sign of supraclavicular blockade is loss of should abduction which occurs
before sensory block.
A-)ana,#&
-. Drug is delivered at the level o! the trunks which is the most compact part o! the
brachial plexues. )o success rates are high.
7. 1apid onset
@. Dense anaesthesia
4. +redictable result
5. *s the needle is entered about -.5cm above the calvicle, chance o!
phenumothraox are very rare.
INFRACLA+ICULAR APPROACH
&here are 7 approaches
aA 1a2 in!raclavicular block
bA :ateral in!raclavicular block
Po&iion: It is the same !or both approaches
+atient supine, neck turned to opposite side, arm pre!erably in abduction. In cases where
arm abduction is not possible it can be done in any position.
RA1INFRACLA+ICULAR BLOCK
Lan-mar/&:
%*cromioclavicular 2oint
%)ternoclavicular 2oint
%Midpoint o! clavicle
%"rachial artery pulsations in the axilla
Di&rib%ion o! (on&i&#n ana#&"#&ia
&he onset o! predictable anaesthesia is at the hand, wrist, !orearm, elbow and distal arm.

Si# o! N##-l# Enr.


* point 7 to 7.5cm below the midpoint o! the clavicle
T#("ni0%#:
Mark acromioclavicular and stemoclavicular 2unction. &he line 2oining the two points
determines the length o! the clavicle. Market the mid point o! the line. Mark another
point 7 to 7.5cm below the !irst point. &his is the site o! needle entry.
*9.5cm insulated needle connected to a nerve locator is pre!erred. *!ter skin in!iltration
with 7B xylocaine, the insulated needle is inserted at 45 degree angle into the skin and
directed towards the axillary artery pulsations in the axilla. &his maneuver directs the
needle laterally posteriorly and slightly caudally.
* initial current o! -.5 to 7m* is pre!erred. *s the needle passes through the pectoralis
muscle twitches can be seen due to direct stimulation o! the muscle. 6nce the muscle is
crossed the twitches cease. Now the current is reduced to -m* and needle is advanced to
get the nerve response. * lower current causes less patient discom!ort and is pre!erred.
&he needle is directed in a cephalocaudal are to search !or motor response. In thin
individuals the response may be obtained at a depth o! @cm. In obese the response may be
obtained at about 5%9.5cm.
Moor r#&'on&#:
Flexion o! the wrist and the !ingers due to nerve stimulation is pre!erred. )timulation o!
the radial and ulnar nerves leading to any movement in the region o! !orearm, wrist and
!ingers can be taken as the end point. 'ontraction o! the deltoid and biceps are not
acceptable as the axillary and musculocutaneous nerve leave the plexus at a higher level.
For a success!ul blockade, response at a current less than <.4m* is re#uired. 1esponse to
higher current leads to unsuccess!ul and incomplete blockade.
LATERAL INFRACLA+ICULAR BLOCK
&his block was developed to present a more constant landmark, the coracoid process.

Lan-mar/ % 'oracoid process
Po&iion % )imilar to 1a2 techni#ue
Si# o! n##-l# #nr. % -cm medial and caudal to corocoid process

T#("ni0%#
&he coracoid process o! scapula is identi!ied. Marked shrugging helps identi!y the
coracoid process better. * point -cm medial and -cmcaudal to the medial aspect o!
coracoid process is marked. &his is the point o! needle entry. *!ter skin in!iltration with
local anaesthetic the stimulation needle is inserted directly perpendicular to the skin. &he
usual depth o! desired response is about @cm in thin individuals but may vary upto 9.5cm
in obese individuals. &he needle sie, motor response and eliciting parasthesia are
similar to the 1a2 approach
In#r'r#in, r#&'on&#& o n#r)# &im%laion
&here are some common responses that occur due to nerve stimulation. &hen corrective
measures will have to be taken to obtain the desired response.
)timulation Motor responses Cxplanation 'orrective action
+ectrolis muscle
direct stimulation
*rm abduction )hallow needle
placement
'ontinue to advance
the needle
*xillary nerve Deltoid muscle
contraction
Needle placed
in!eriorly
,ithdraw needle to
the skin and reinsert
with a superior
angulation
Musculocutaneous
nerve
"iceps twitch Needle placed
superiorily
,ithdr!aw the
needle to skin and
reinsert with caudal
angulation
A-)ana,#:
%Decreased incidence o! lung in2ury and pneumothorax
%Decreased incidence o! arterial in2ury
%'an be per!ormed, with the hand in any position
%Ideal site !or continuous catheter insertion
%More patient com!ort a!ter catheteriation
%&he chances o! unilateral phrenic nerve blockade are nil. In the classical
approach it is almost -<<B and about @<%5<B in the supraclavicular approach.
Di&a-)ana,#&:
%&he plexus is deeply placed at this site. &he pectoralis ma2or and minor muscles
will have to be pierced to reach the plexus. )o, more pain!ul to the patient
%*s the plexus is deeply placed, blind approach is not possible. Cliciting
paraesthesia is more di!!icult. )o a nerve locator or ultrasound guidance
becomes mandatory !or per!ormance o! the block.
%"ecause o! the above problem a more deep sedation may be re#uired during
per!ormance o! the block
%)urgeries on the shoulder and upper humerus cannot be done.
Po#nial Probl#m&:
'omplications are less when compared to classical and supraclavicular approaches.
+neumothorax and arterial puncture are possible and mostly related to a wrongly directed
needle.
Despite ade#uate initial needle position, i! the catheter is threaded too much it may be
away !rom the plexus resulting the ine!!ective blockade.
3sage o! a large volume o! local o! local anaesthetic may lead to systemic toxicity.
&orni#uet application can be a problem as musculocutaneous nerve is not blocked.
CLASSICAL APPROACH
6ne o! the !irst techni#ues o! brachial plexues block to be established. &his is not
!re#uently practiced nowadays.
Lan-mar/&

'lavicular head o! sternocleidomastoid
Cxtenarnal 2ugular vein
'hassaignac tubercle D'8A
'ricoid cartilage
Po&iion:
+atient is supine, head partially turned to the opposite side to be blocked and arm by the
side.
Di&rib%ion o! (on&i&#n ana#&"#&ia

&his drug is usually consistent at the shoulder, arm and elbow. &he !orearm, wrist and
!ingers may sometimes be blocked but ideally re#uires more distal approach to the
brachial plexus.
T#("ni0%#:
*@.5 cm or 5cm long needle is used. &he needle is introduced at the level o! the
'hassaignacs tubercule with a caudal angulation. &he needle should not be introduced
perpendicularly or with a cephaloid direction as there is a chance o! cervical cord in2ury.
3sually motor response is obtained at a depth o! -%7cm.

Moor r#&'on&# o n#r)# &im%laion:
&witches o! the shoulder and arm are seen. *dministration o! local anaesthesia to any o!
the above responses has the same success rate. &he commonest response is the twitching
o! the deltoid muscle Dc5,8A
Diaphragmatic movement due to stimulation o! the phrenic nerve and scapular movement
due to stimulation o! the serratus anterior muscle or dorsal scapular nerve should not be
considered..
AXILLARY RPPROACH
It is a very basic nerve block techni#ue and very commonly employed. $ere the durg is
delivered within the perivascular sheath close to the axillary artery.
Di&rib%ion o! (on&i&#n ana#&"#&ia

&his block provides anaesthesia o! the lower part o! arm, elbow, !orearm, wrist and hand.
*s the musculocutaneous nerve leaves the plexus much be!ore the site o! needle entry,
tourni#uet pain is not abolished.
Po&iion:
+atient is in supine position with head turned away !rom the side to be blocked. &he arm
is abducted and to !orm a /< degree angle in the elbow. Cxcessive abduction makes
palpation o! axillary artery pulse di!!icult and also stretches and !ixes the brachial plexus
making it vulnerable to in2ury during needle placement.
Lan-mar/&:
*xillary artery pulsation
'oracobrachalis muscles
+ectrolis ma2or muscle


%&he axildlary artery pulsation are best !elt high in the axilla between the
coracobrachalis and pectrolis ma2or muscle.
%,hen location o! the pulse is not immediately apparent, adduction o! the arm
decreases the resistance and makes the groove between the coracobrachalis
and pectrolis ma2or muscle prominent. &his maneuver helps to identi!y the
pulse better.
T#("ni0%#

6ne !inger is kept on the axillary pulse and a 5cm needle is advanced 2ustg below the
pulse. In most patients motor response obtained at 7cm depth at about -m* current. &he
needle tip is ad2usted to get a motor response below <.4m* and drug is in2ected.
Moor r#&'on&#
&witches in the region o! the wrist and !ingers are indicators o! success!ul blockade.
"iceps and triceps twitch should not be considered.
In#r'r#in, r#&'on&#& o n#r)# &im%laion
Lo(al 2i("# o!
arm m%&(l#
Dir#( &im%laion
o! bi(#'& an-
ri(#'&
N##-l# "a& b##n
in&#r#- !or
&%'#rior or
in!#riorl.
3i"-ra2l "#
n##-l# an- -ir#(
Needle contacts
bone at @cm
Needle stopped by
humerus
"rachial plexus
missed
,ithdraw the needle
to skin and reinsert
at an angle o! -5%@<
degree superiorly or
in!eriorly
POSTERIOR APPROACH
* very rarely used approach. It is not per!ormed in many centres. It does not some
indication especially in a pain clinic setup.
Lan-mar/&: '8 spine
'9 spine

Po&iion:
'an per!ormed in sitting or lateral decubitus position
Di&rib%ion o! (on&i&#n ana#&"#&ia
Mainly around the shoulder upto the middle o! the clavicle and upper arm. )o this is
use!ul in surgeries involving the clavicle, shoulder and upper arm.

Si# o! n##-l# #nr.
* point @cm lateral to the midpoint o! '8 and '9 spine
T#("ni0%#
In the sitting position '8 and '9 spine are identi!ied. * point @cm lateral to the midpoint
o! the spine is the site o! needle entry. &he needle entered perpendicular to the !loor and
directed slightly laterally. &he depth at which stimulus is obtained is between 4%8cm. *
nerve locator starting with a current strength o! @.5m* is connected to the needle.
1esponse to nerve stimulation is mainly movement o! the shoulder muscles. I! response
is obtained at a current o! <.4m*, drug can be given.
In-i(aion
%Mainly surgeries on the clavicle shoulder and upper arm
%For relie! o! severe pain due to apical lung cancer inadvertently in!iltrating the
brachial plexus.
Di&a-)ana,#
%*s it is deeply placed it is a pain!ul procedure
%)urgeries on the !orearm, wrist and !ingers cannot be done
%'hances o! neuraxial catheter placement and blockade are high
CONTINUOUS CATHETRI4ATION
'atheteriation o! the brachial plexus !or postoperative pain relie! is becoming increasing
popular nowadays. It is one o! the best modality o! pain relie!. 1outinely catheters can
be kept !or upto 5 days in the postoperative period. Daily cleaning and dressing o! the
catheter entry site is a must.
&hese cathetes are similar to the epidural catheters with markings. &hey are about @<cm
in length.
&he catheters are placed about @cms past needle tip. I! placed more the chances o!
moving away !rom the plexus may arise.
&he catheter can be used!or intermittent or continuous drug administration. +'* pumps
can also be attached.
PHARMACOLO5Y
&he drugs used !or anaesthesia are
-.:ignocaine 7B with adrenaline
7. "upivacaine <.5B
@.&he addition o! opioids to the local anaesthetic ensures a more intense pain
relie!
6pioids commonly used are
aA Fentanyl
bA )u!entanyl
cA Marphine
For anaesthesia a minimum volume o! @<ml is re#uired !or a success!ul blockade. &he
above drugs can be mixed 2udiciously taking care not to exceed the toxic dose.
POSTOPERATI+E PAIN RELIEF
"upivacaine is the pe!erred drug. *s :ignocaine causes tachyphylaxis it is not pre!erred.
It is also better to combine local anaesthetic along with opoids.
&he advantages o! combining local anesthetics with opioids are
-.)uperior postoperative analgesia
7.Decreased dose and concentration o! local anaesthetic
@.+rolongs the duration o! action o! local anaesthetic
In#rmi#n a-mini&raion:
75ml o! <.-75B bupivacaine along with 5<mcg o! Fentanyl is given .
th
hourly.
Conin%o%& a-mini&raion
-<mlEhr o! a solution containing <.-75B bupivacaine
along with -<%7<mcgEhr o! Fentanyl is given
Doses o! various opioids that can be used.
O'ioi-& In#rmi#n In!%&ion
Fentanyl 5<%-<< mcg -<%75 mcgEhr
)u!entanyl -<%5<mcg -<%7<mcgEhr
Morphine -%5 mg <.- ; - mgEhr
"uprinorphine 7%@ mcgEkg
Br#a/ "ro%," 'ain
&his is managed by giving a bolus o! 5ml o! local anaesthetic every 7 hours. &hen the
in!usion can be reduced to 9.5mlEhr. Increasing the in!usion rate or concentration o! the
local anaesthetic has not e!!ect on breakthrough pain.
CONCLUSION:
In the days o! !re#uent trauma to the upper limb especially with !ull stomach patients the
routine use o! brachial plexus block decreases complications and ensures patient com!ort.
* good learning under expert hands is a must to develop a good technical expertise. It is
a must know regional techni#ue !or all anaesthesiologist.