Logan Steele
The scalene muscles are a group of three muscles on each side of the neck, identified as the anterior, middle, and posterior scalene muscles. An interscalene block, also known as an interscalene brachial plexus block or interscalene nerve block, involves the insertion of a needle between the anterior and middle scalene muscles to administer local anaesthesia. This procedure is often used to manage pain during and after shoulder and upper arm surgeries, aiding in the rehabilitation process by providing pain relief while the patient undergoes physical therapy.
| Characteristics | Values |
|---|---|
| Definition | Placement of local anesthetic around the brachial plexus near the scalene muscles |
| Goal | Pain management for shoulder and upper arm surgery patients |
| Procedure | Needle inserted between anterior and middle scalene muscles |
| Depth of needle insertion | 2-3 cm |
| Needle type | 22-gauge, short-bevel |
| Muscle type | Three paired muscles of the lateral neck |
| Muscle names | Anterior, middle, and posterior |
| Muscle function | Elevate first and second ribs, increase intrathoracic volume, and allow neck to bend and rotate |
| Muscle origin | Transverse processes of cervical vertebrae |
| Muscle insertion | First and second ribs |
| Innervation | Third to eighth cervical spinal nerves (C3-C8) |
| Anesthetic spread | Around superior and middle trunks of brachial plexus |
| Anesthetic solutions | Ropivacaine 0.5%, bupivacaine 0.25–0.5%, and mepivacaine 1.5% |
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What You'll Learn
Interscalene brachial plexus block
An interscalene brachial plexus block is a nerve block that involves injecting local anaesthetic around the brachial plexus, a nerve network that supplies the upper extremity. The brachial plexus is located between the anterior and middle scalene muscles, and the block is performed by inserting a needle between these two muscles. This procedure was first described by Alon Winnie in 1970 and is typically used to provide anaesthesia or analgesia for surgery of the shoulder, upper arm, elbow, or distal clavicle. It is not suitable for hand or forearm surgery.
The patient is positioned in a semi-sitting or supine position with the head turned away from the side being blocked. The patient is asked to elevate the head slightly, which brings the clavicular head of the sternocleidomastoid muscle into prominence. The palpating hand is placed behind the lateral edge of this muscle, and the fingers are then moved medially to lie on the belly of the anterior scalene muscle. The fingers are then rolled laterally across the belly of the anterior scalene muscle until they fall into the interscalene groove. The needle is inserted between the anterior and middle scalene muscles at the level of C6 in a direction perpendicular to the skin. The needle should not be inserted deeper than 2-3 cm in most patients.
The brachial plexus is formed by the ventral rami of the fifth to eighth cervical nerves and the greater part of the ventral ramus of the first thoracic nerve. It exits the cervical spine and travels between the anterior and middle scalene muscles, distally around the axillary artery. The anterior and middle scalene muscles lift the first rib and bend the neck to the side they are on, while the posterior scalene lifts the second rib and tilts the neck to the same side. These muscles also act as accessory muscles of respiration.
The interscalene brachial plexus block can be performed under ultrasound guidance, which allows for visualisation of the spread of the local anaesthetic and additional injections if needed. This technique has improved block consistency and reduced the volume of local anaesthetic required. Common local anaesthetics used include bupivacaine and ropivacaine, with a typical volume of 15-25 mL. It is important to monitor for local anaesthetic toxicity during block placement, as there is a maximum dose that should not be exceeded.
Side effects and complications of the interscalene brachial plexus block can include pneumothorax, nerve damage, epidural or intrathecal placement, and spinal cord trauma. Patients with pulmonary comorbidities may experience shortness of breath due to blockage of the phrenic nerve.
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Landmarks and nerve stimulator technique
The interscalene block is a procedure that involves placing local anaesthetic around the brachial plexus near the scalene muscles. The scalene muscles are located on each side of the neck and allow the neck to bend and rotate. The brachial plexus is a nerve network that passes between the anterior and middle scalene muscles.
The landmarks and nerve stimulator technique for an interscalene block can be performed as follows:
Patient Positioning
The patient can be positioned in a supine, sitting, semi-sitting, or semi-lateral decubitus position. The most common position is sitting at a 30-degree angle, with a pillow or blanket placed under the chest and the head turned away from the side to be blocked.
Identifying Landmarks
The three major landmarks required for the block are the clavicle, the clavicular head of the sternocleidomastoid, and the external jugular vein. The cricoid cartilage is another helpful landmark.
Palpating the Muscles
After identifying the landmarks, the anterior and middle scalene muscles can be palpated with sterile gloves. This is done just posterior to the clavicular head of the sternocleidomastoid, around the level of the cricoid cartilage.
Needle Insertion
The skin is disinfected and anaesthetized with a local anaesthetic. The needle is inserted just posterior to the external jugular vein, approximately 3-4 cm above the clavicle, and advanced at a perpendicular angle to the skin plane. The needle should not be placed deeper than 2-3 cm in most patients.
Nerve Stimulation
With the nerve stimulator connected, the needle is advanced until stimulation of the brachial plexus is achieved. This is typically done at a current intensity of around 0.8 mA or 0.5 mA. A motor response in the shoulder, arm, or forearm confirms proper needle placement.
Injecting Anaesthetic
Once the needle is in the correct position, local anaesthetic is injected. The volume of anaesthetic and the number of needle insertions are determined during the procedure, depending on the spread of the anaesthetic.
Ultrasound Guidance
Ultrasound and nerve stimulation can be used together to guide needle placement and confirm correct positioning. The ultrasound probe is placed over the neck or clavicle to identify the brachial plexus and surrounding structures.
The interscalene block is commonly used for shoulder and upper arm surgery, providing effective pain management and facilitating postoperative physical therapy.
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Ultrasound-guided interscalene brachial plexus nerve block
The patient is typically positioned in a supine, beach chair, or semi-lateral decubitus position, with their head facing away from the side to be blocked. The transducer is placed at the level of the cricoid cartilage, medial to the sternocleidomastoid muscle, and the carotid artery is identified. The transducer is then slid laterally to identify the brachial plexus between the anterior and middle scalene muscles. The needle is inserted in-plane to the transducer, entering lateral to medial, and careful aspiration is performed before injecting the local anaesthetic.
Ultrasound guidance allows for visualisation of the spread of the local anaesthetic and additional injections can be made to ensure adequate spread. This technique has a faster onset time and longer duration compared to nerve stimulation, and it requires lower volumes of anaesthetic for an effective block. It also reduces the risk of needle misplacement, which can result in pneumothorax, nerve damage, or spinal cord trauma.
The interscalene block covers most of the brachial plexus, sparing the inferior trunk and the ulnar (C8-T1) nerve. It is not recommended for hand surgery due to the risk of incomplete anaesthesia. The procedure is often performed in the preoperative suite or post-anaesthesia care unit, with the patient mildly sedated.
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Interscalene nerve block indications
An interscalene nerve block is a procedure that numbs the brachial plexus nerves to reduce pain and provide anaesthesia for surgery or pain relief. It is performed on patients undergoing shoulder, upper arm, or elbow surgery. It is not recommended for hand surgery as the inferior trunk may be spared.
The brachial plexus is a nerve network that supplies the upper extremity. It exits the cervical spine, travels between the anterior and middle scalene muscles, and distally around the axillary artery. The space between the scalene muscles is called the interscalene groove. This space is palpable behind the lateral head of the sternocleidomastoid muscle and adjacent to the C6 lateral tubercle, also known as Chaissaignac's tubercle.
The nerve block is typically performed with the patient in a supine, beach chair, or semi-lateral decubitus position, with their head facing away from the side to be blocked. The patient should be asked to reach for the ipsilateral knee to lower the shoulder and provide more space for the nerve block performance.
The ultrasound-guided interscalene brachial plexus nerve block involves inserting a needle into the brachial plexus nerves. A small volume of local anaesthetic is injected through the needle to confirm proper needle placement. A properly placed needle tip will result in the distribution of local anaesthetic between and/or alongside the roots of the brachial plexus.
The interscalene block can be performed with ultrasound, paresthesia, or nerve stimulation techniques to target the brachial plexus' roots at C5, C6, and sometimes C7 levels. This block is not recommended for forearm or hand surgeries as the inferior trunk is spared.
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Interscalene block pain management
The scalene muscles are a group of three muscles on each side of the neck: the anterior, middle, and posterior. They are named after the Ancient Greek word "skalēnós", meaning "uneven". These muscles allow the neck to bend and rotate and also assist in breathing by raising the first and second ribs.
The interscalene block is a pain management technique that involves the placement of local anaesthetic around the brachial plexus nerves near the scalene muscles. The brachial plexus is a system of nerves located in the neck and upper trunk that passes between the anterior and middle scalene muscles. The block is often used to provide pain relief during and after shoulder surgery, reducing the need for general anaesthesia. It can also help patients begin physical therapy and other treatments to speed up the healing process, rebuild strength, and regain their range of motion.
The procedure was first described and popularised by Alon Winnie in 1970. It is typically performed with ultrasound guidance, targeting the trunks of the brachial plexus in the neck shortly after they exit the cervical spine. The patient is usually placed in a semi-sitting or supine position with their head turned away from the side to be blocked. The palpating fingers are then placed in the interscalene groove between the anterior and middle scalene muscles, and a needle is inserted at a depth of 2-3 cm.
A variety of local anaesthetics can be used for interscalene blocks, depending on the desired duration and density of the block. The typical volume is 15-20 mL of ropivacaine or bupivacaine, and the addition of epinephrine can prolong the duration of action. Continuous infusion of local anaesthetics through an interscalene catheter provides better pain control than traditional patient-controlled analgesia with opioids, resulting in greater patient satisfaction.
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Frequently asked questions
An interscalene block, also known as an interscalene brachial plexus block or interscalene nerve block, is a procedure that involves the placement of a local anesthetic around the brachial plexus near the scalene muscles.
The procedure is typically performed to provide anesthesia or analgesia for shoulder and upper arm surgeries. It helps with pain management and can speed up the healing process by allowing patients to begin physical therapy and other treatments earlier.
The scalene muscles are a group of three muscles (anterior, middle, and posterior) located on each side of the neck. During an interscalene block, a needle is inserted between the anterior and middle scalene muscles to anesthetize the nerves at their root or trunk level. This helps to block pain signals and provide relief for a period of time, usually less than a day.
