We performed the subclavian perivascular approach to the brachial plexus using contrast medium to confirm the location of the tip of the needle and the spread of the injected solution to obtain a high success rate and to minimize the risk of pneumothorax. Review of the cases led to the hypothesis that the solution injected inside the costal attachment of the middle scalene muscle spreads into the interscalene space. Because of the difference in the placement of the tip of the needle using our technique and the supraclavicular approach, including the subclavian perivascular approach, we termed our technique the supracostal approach. We conducted the present study to establish the supracostal approach by proving this hypothesis. A total of 173 blocks in 149 adult patients were studied. Eighty-four blocks in 74 patients were achieved by using the supracostal approach with contrast medium. The needle was inserted 1 cm lateral to the palpated subclavian artery and 1-2 cm above to the clavicle to touch a specific part of the first rib, which we believed to correspond to the inside of the costal attachment of the middle scalene muscle. After injecting the anesthetic solution with contrast medium, radiographs were obtained for each block, while computed tomographic (CT) studies were performed for five blocks. Five blocks in five patients were achieved by using the subclavian perivascular approach with contrast medium and both radiographs and CT studies. In addition, the anatomical difference between the two approaches was evaluated in five adult cadavers. Based on these studies, we determined the proper part of the first rib that corresponded to the inside of the costal attachment of the middle scalene muscle. Eighty-four blocks in the remaining 70 patients were performed with the supracostal approach without contrast medium. Of the 84 blocks with contrast medium, 80 (95%) produced successful blockade defined by sensory and motor examination. The radiological studies showed that, with the supracostal approach, the injected solution, which spread from the middle scalene muscle into the interscalene space, did not spread below the first rib. However, with the subclavian perivascular approach, the solution was confined within the perineural sheath and spread below the first rib to the axilla. The anatomical studies could explain this difference, revealing that the perineural space of the brachial plexus is not identical to the interscalene space. There was no failure in the 84 blocks performed with the supracostal approach without contrast medium after we determined the proper part of the first rib. We conclude that the supracostal approach to the brachial plexus is reliable, easy to perform, and associated with a low complication rate. IMPLICATIONS: A new fluoroscopically guided approach for brachial plexus block has been established on the basis of anatomical and radiological studies to be reliable, easy to perform, and associated with a low complication rate.

Publication Types:
Clinical trial

PMID: 9895072, UI: 99110363 - www.pubmed.com

INTRODUCTION: After mobilisation of a frozen shoulder, patients should work with a physiotherapist one to two times a day. In the remaining time patients must exercise on their own: otherwise, the shoulder is likely to become less mobile. Exercise is only possible in the absence of pain. Therefore, adequate analgesic therapy for four to five days after the first mobilisation is of great importance. We used interscalene blockade of the brachial plexus to achieve mobilisation in patients suffering from a painful frozen shoulder. We investigated the efficacy of this technique by registering the use of additional analgesics and documenting the patient's assessment. The observation time was 18 months. METHODS: Thirty-seven patients were treated with a plexus block using a catheter inserted at the affected side. Catheter location was verified with electric nerve stimulation. In all patients a bolus of 20 ml bupivacaine 0.375% was given for initial mobilisation, followed by 10 ml bupivacaine 0.25% every 6 hours. RESULTS: In 34 of 37 (92%) patients, the shoulder could be mobilised without general anaesthesia. Thirty-three of 37 (89%) patients did not need any additional analgesics during the following mobilizations. The mean duration of catheter treatment was 4 days; no infections occurred. The following side effects were observed at the first mobilisation: Horner's syndrome in 20 patients (54%), paresis of the recurrent nerve in 9 patients (24%) and paresis of the phrenic nerve in 6 patients (16%). During subsequent treatment, Horner's syndrome was observed in 15 patients (41%) and a paresis of the recurrent nerve in 8 patients (22%). In an interview after the end of the treatment period all patients stated that they would use this method again if necessary. CONCLUSIONS: With the use of this regional anaesthesia technique it was possible to provide comfortable pain therapy during the mobilisation period. In order to achieve sufficient analgesia with only a mild motor blockade of the motoneurons, the exact location of the catheter tip is important. The latter can be verified by electrical stimulation.

PMID: 9871969, UI: 99089135 - www.pubmed.com

OBJECTIVE: To evaluate the efficacy and incidence of side effects of parascalene brachial plexus block for shoulder surgery and for postoperative analgesia. PATIENTS AND METHODS: This prospective descriptive study enrolled 186 patients scheduled for conventional (open) and arthroscopic shoulder operations. The parascalene approach to the brachial plexus was used, with an 18-G x 4.5 cm cannula (30 degrees bevel), applying the technique of detecting perforation of the prevertebral fascia. Mepivacaine 1.5% was administered for anesthesia, beginning with a test dose of 5 ml followed by doses of 25 ml. Bupivacaine 0.125% with 1/400,000 adrenaline was given for postoperative analgesia. Two groups were established according to type of surgery. In group A were patients undergoing open surgery and those with articular stiffness undergoing arthroscopic surgery; analgesics were delivered in continuous perfusion of 5 to 8 ml/h. Group B patients, who underwent arthroscopic surgery, received the analgesic in boluses of 10 to 14 ml every 4 to 6 hours. We assessed perception of perforation of the fascia, provocation of paresthesia, number of puncture attempts, anesthetic efficacy, postsurgical analgesia (visual analogue scale from 0 to 10) and complications. RESULTS: Blockade was effective for 155 of the 186 patients (83.33%). In 118 (63.44%) the perception of perforation of the prevertebral fascia was ostensible, in 52 (27.95%) it was slight and in 16 (8.6%) it was undetectable. Paresthesia was triggered by the cannula in 18 cases (9.13%) and by the test dose in 181 cases (97.31%). The mean number of puncture attempts was 1.2 +/- 0.09 per patient. During the early postoperative period analgesia was adequate for 92 (84.40%) of the 109 patients in group A. In group B, 45 patients (97.82%) required 1 to 2 analgesic doses (mean 1.4 +/- 2 doses) and one patient (2.17%) needed 6 doses within the first 24 hours. Catheters remained inserted as long as 36 hours to 10 days (mean 3.5 days) in group A. In group B they had been removed by 24 hours. Complications were transitory and slight. No cases of pneumothorax, no intra- or epidural anesthesia was required and no instances of vascular puncture occurred. CONCLUSIONS: The parascalene approach is easy to use and entails few risks while providing excellent anesthetic conditions for open and arthroscopic shoulder operations. It is useful for ambulatory analgesia to facilitate early rehabilitation after surgery.

Publication Types:
Clinical trial

PMID: 9847655, UI: 99064121 - www.pubmed.com

OBJECTIVE: The purpose of this study is to describe the sonographic appearance of the normal brachial plexus and to evaluate the use of imaging guidance for brachial plexus anesthesia. SUBJECTS AND METHODS: Twenty adults requiring upper limb surgery underwent sonography with a high-frequency transducer to identify the brachial plexus at the interscalene (n = 16) and supraclavicular (n = 4) regions. Catheters for brachial plexus anesthesia were placed using sonographic guidance and evaluated using radiography and CT after injection of contrast material. The success of the neural blockade and surgical anesthesia was assessed. General anesthesia was chosen preoperatively or used for supplementation if blockade was incomplete. RESULTS: The brachial plexus appeared as three discrete rounded hypoechoic nodules between the scalenus anterior and medius muscles on transverse sonography at the lower cervical (C6) region, representing the trunks in sagittal oblique section. A cluster of hypoechoic nodules corresponding to the divisions was seen cephalad to the subclavian artery on sagittal scans of the supraclavicular region. Radiography was used to verify correct catheter placement; the brachial plexus sheath appeared as a tubular area of contrast material in the neck that was well circumscribed in patients who had supraclavicular injections of contrast material and corrugated in those who had interscalene injections. CT scans showed contrast material spread around the scalenus muscles in most patients with interscalene injections. Successful neural blockade at 20 min and postoperative analgesia were achieved in all patients. Surgical anesthesia was achieved in nine of 15 patients. Five patients chose general anesthesia before surgery and therefore did not have surgical anesthesia assessed. CONCLUSION: High-resolution sonography can show normal brachial plexus anatomy and facilitate catheter-based brachial plexus anesthesia without complications.

PMID: 9843302, UI: 99057436 - www.pubmed.com

We describe a novel supraclavicular approach to the brachial plexus. Designated as the intersternocleidomastoid technique, this new approach was tested in unembalmed cadavers. It was then applied for evaluation to 150 ASA grade I or II patients scheduled for elective surgery or physiotherapy of the upper limb or for treatment of reflex sympathetic dystrophy associated with painful shoulder. The new approach was easy to master because of a very simple surface landmark, i.e., the triangle formed by the sternocleidomastoid heads, which were visible and palpable in most patients studied (90%). The procedure was effective intraoperatively, providing satisfactory anesthesia in 140 patients (93%), partially satisfactory blocks in 6 (4%), and unsatisfactory blocks in only 4 (3%). The catheter entry point is cephalad enough not to obscure the surgical field on the shoulder. Catheter insertion was successful in 63 of 70 patients. Postoperative analgesia was provided for 48 h or more in 45 patients and for 24 h in 18 patients. Only minor complications were observed: asymptomatic phrenic nerve block in 89 patients (60%), transient Horner's syndrome in 15 (10%), transient recurrent laryngeal nerve blockade in 2, and misplacement of the catheter into the subclavian vein in 1 patient. No pneumothorax was observed.

Comments:
Comment in: Anesth Analg 1998 May;86(5):1149-50

PMID: 9212132, UI: 97355651 - www.pubmed.com

OBJECTIVES. To compare a modified supraclavicular perivascular approach with the axillary perivascular technique for providing brachial plexus blockade. PATIENTS AND METHODS. We studied 100 ASA I/II patients undergoing surgery on upper extremities. Patients were divided into two groups: group 1 (axillary, n = 50) and group 2 (modified supraclavicular, n = 50 ). Patients needing shoulder surgery were excluded from group 1. In both groups 35 ml of 1.5% mepivacaine plus 0.05 mEq/ml of bicarbonate was used. The Winnie axillary perivascular technique was used in group 1. In group 2 we used a modification of the lateral perivascular supraclavicular technique described by Brown, with the needle directed cephalad, medial and posterior to provide paresis in the upper extremity. We recorded the degree of difficulty and time needed for each technique, time until start of paresis and time of motor paralysis in the extremity, area of nerve deficit, and quality of block. In group 2 we measured the depth of paresthesia. Perioperative complications were noted for each group. RESULTS. There were no significant differences in difficulty, time or quality of block. Time until start of paresis and time of motor paralysis were significantly shorter in group 2 (12.0 +/- 2.5 versus 4.9 +/- 0.2 min, and 15.2 +/- 6.9 min versus 35.3 +/- 5.2, in groups 2 and 1, respectively). Mean depth of paresthesia was 44.1 +/- 5.2 min. The most frequently recorded complications were Horner's syndrome in group 2 and vascular puncture in group 1. CONCLUSIONS. The modified perivascular lateral supraclavicular technique is a safe, effective method for providing brachial plexus block.

Publication Types:
Clinical trial
Multicenter study
Randomized controlled trial

PMID: 8848646, UI: 96221771 - www.pubmed.com

Interscalene brachial plexus blockade is a well-established means of providing analgesia and anesthesia for upper extremity surgery. Extension into the postoperative period with continuous infusions of 0.25% bupivacaine provides several added advantages. Our survey over two years covered 126 patients undergoing surgery by the Department of Hand Surgery of our hospital. Postoperative verbal analogue pain scores obtained for three days showed scores of 4 or less (range 0 to 10) being reported by more than 70% of all patients with 6.3% and 11.9% requiring additional narcotics and non-steroidal anti-inflammatory drugs, respectively. Compliance with early occupational therapy was good with only 7 patients having difficulty with active mobilisation as a result of excessive motor blockade. The insertion complication rate was 11.1%; all these cases were attributed to the bolus dose given and resolved over the next few hours. Eighteen (14.3%) of the patients developed complications while on continuous infusion, the most frequent being catheter dislodgement and pain at the insertion site. In all we found this method of providing postoperative analgesia to be effective, inexpensive and easy to implement in our large hospital setting.

PMID: 8572522, UI: 96119605 - www.pubmed.com

There is controversy over the choice of anaesthesia for carotid surgery. The aim of this retrospective study was to report the early results of carotid surgery performed with loco-regional anaesthesia by blockade of the cervical plexus. From 1987 to 1992, 405 consecutive operations on the carotid bifurcation were performed using this technique. Among these patients, 202 (50%) were asymptomatic, the indication being carotid narrowing of 80% or more, while clinical signs were observed in the other 203 patients (50%). According to the Sundt classification, 360 patients (89%) had a medical risk and 45 (11%) had a neurological risk. Occlusion of the controllateral internal carotid was present in 47 patients (12%). The deep blocade affected roots C2-C3-C4 followed by a superficial block using 0.5% Bupivacaine. An endarteriectomy was performed in 96% of the cases. In 10 (2.5%), there were complications or the cervical plexus blocade was insufficient: 6 caused the operation to be postponed and/or use of general anaesthesia, but none of these led to postoperative complication. In 35 patients (8.6%) neurological events during clamping required establishing a shunt (6.1% and 27.6% in cases with permeable or occluded controlateral carotids respectively). Neurological recovery was rapid and complete except in 4 cases. There were 8 central neurological complications which persisted or appeared postoperatively: 5 regressive ischaemic events, 2 persistent ischaemic events and one which led to the patient's death. No cardiac complications were seen. We conclude that blocade of the cervical plexus is a simple and effective technique for surgery of the carotid bifurcation. With this method, detection of clamp intolerance is more reliable and it gives enough time for endarteriectomy. The risk of coronarian complications is low due to good haemodynamic stability. This method is a low-cost technique and is better adapted to understanding the mechanisms of neurological complications.

Publication Types:
Review
Review, tutorial

PMID: 7805485, UI: 95104003 - www.pubmed.com