If the perineural spread of local anaesthetic is not perfect, the needle can be relocated in real-time before injection of the remaining local anaesthetic

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Another example of relocation of the needle tip to obtain the endpoint of spread of local anaesthetic alongside the spinal nerve branches of C5 and C6

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The in-plane approach to the interscalene brachial plexus block

Local anaesthetic is deposited lateral to C5 and C6

You often feel a “pop” as you enter the interscalene groove

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It is possible to follow the spinal nerve roots all the way to the sulcus for the spinal nerve of the transverse process of the appertaining cervical vertebra

The seventh cervical vertebra does not have an anterior tubercle

At the top of the interscalene groove the brachial plexus presents as the C5 and the C6 spinal nerve branches – and usually the C6 is split in two branches

The three profiles of C5 and C6 are usually lined up like a string of black pearls sandwiched between the anterior scalene muscle and the middle scalene muscle

Each spinal nerve can be tracked from the branches of the brachial plexus in the transition zone behind the subclavian artery on top of the first rib to the sulcus of the spinal nerve of each transverse process

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– Insert the needle from the posterior end of the probe

– Empty the hose and the needle of air by injecting 1/2 mL of local anaesthetic subcutaneously before advancing the needle

– Advance the needle with in-plane technique until the needle tip touches the lateral side of the BP between C5 and C6

– The endpoint of injection is complete spread of local anaesthetic along the lateral side of the C5 and C6 spinal nerve branches

– Reposition the needle tip as necessary to reach the endpoint

The indications of the interscalene block are:

– Anaesthesia for shoulder surgery & shoulder
procedures

– Analgesia after shoulder surgery & shoulder
procedures

The ultrasound guided interscalene brachial plexus block is a basic level block

– Select a high-frequency linear probe
– Adjust gain, focus, and depth 2-3 cm
– Turn the orientation mark on the probe postero-lateral on the right side and antero-lateral on
the left side of the patient
– Place the probe behind the clavicle on top of the first rib oriented practically in the
parasagittal plane
– Locate the black, pulsatile subclavian artery (SA) on top of the first rib between the anterior
and the middle scalene muscles
– Locate the branches of the brachial plexus (BP) posterior to the SA
– Track the BP branches proximally until the profiles of the C5 and C6 spinal nerve roots line
up like a string of black pearls in the interscalene groove. C5 appears as one profile, C6 as
two
– Capture the best possible cross sectional image by tilting the probe and fine-tuning gain,
focus, and depth

The cutaneous innervation of the shoulder is:

1) the axillary nerve (C5-C6; superior lateral brachial cutaneous nerve)

2) the supraclavicular nerve (C4; from the cervical plexus)

3) intercostal nerves (T2-T4; anterior cutaneous branches)

4) radial nerve (C5-T1; inferior lateral brachial cutaneous branches)

The interscalene brachial plexus block typically covers only C5-C6