REGIONAL ANESTHESIA AND ACUTE PAIN

ORIGINAL ARTICLE

Ultrasound-Guided Interscalene Block

Reevaluation of the Stoplight Sign and Clinical Implications

Carlo D. Franco, MD* and James M. Williams, PhD
Background and Objectives: The stoplight sign is a frequently
described image during ultrasound-guided interscalene block, referring to 3 hypoechoic structures found between the anterior and middle scalene muscles.
This study was designed to establish the ultrasound-anatomy correlation of this sign and to find any other anatomical features within the
roots that could help with the interpretation of the ultrasound images
obtained at the interscalene level.
Methods: We performed 20 dissections of the brachial plexus in 10
embalmed human cadavers and systematically analyzed and measured
the roots of C5 to C7 and then correlated these findings with ultrasonographic images on file.
Results: We found that the C5 root is significantly smaller than either C6
or C7 (P < 0.0001). We also found that C6 and C7, but not C5, frequently
present macroscopic evidence of intraroot splitting visible to the naked eye.
We also found that the roots of C5 and C6, but not of C7, present frequent
variations in their relationship with the scalene muscles.
Conclusions: Our results provide the anatomic basis to define the
stoplight sign as one made of, from cephalad to caudal, the root of
C5, the upper fascicle(s) of C6, and the lower fascicle(s) of C6 without
contribution from C7. The important clinical implication is that an
injection attempted between what is commonly perceived as the
gap between C6 and C7 would indeed be an intraneural injection
at C6, which could potentially spread toward the neuraxial space.
(Reg Anesth Pain Med 2016;41: 452459)

he interscalene brachial plexus block was introduced by Winnie1 in 1970 and has since become the approach of choice
for anesthesia and analgesia of the shoulder.2 Ultrasound-guided
interscalene block, a more recent modality,3,4 is now widely practiced around the world.512
Ultrasound-guided interscalene block requires imaging the
brachial plexus at the most cephalad portion of the interscalene
space (usually referred to as interscalene groove in anesthesia literature). This space, triangular in shape,13 is bound by the anterior
and middle scalene muscles that diverge from each other as they
approach their insertion on the first rib (Fig. 1). Ultrasound imaging of the plexus around the apex of the interscalene space usually
reveals 3 hypoechoic round structures individually delineated
by thin hyperechoic halos14 and arranged from cranial to caudal in between the anterior and middle scalene muscles. This

From the *Department of Anesthesiology, John H. Stroger Jr. Hospital of Cook

County; and Department of Anatomy and Cell Biology, Section of Clinical
Anatomy, Rush University Medical Center, Chicago, IL.
Accepted for publication February 24, 2016.
Address correspondence to: Carlo D. Franco, MD, Regional Anesthesia, John
H. Stroger Jr. Hospital of Cook County, 1901 West Harrison St, Suite 5670,
Chicago, IL 60612 (email: carlofra@aol.com).
Only intradepartmental funds were used.
The authors declare no conflict of interest.
This study has not been presented either in part or as a whole anywhere nor was
it submitted for consideration to any other journal.
Copyright 2016 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000407

452

ultrasonographic image has been referred to as the stoplight

sign.1518 Despite our familiarity with this image, there is no
consensus as to what the hypoechoic nodules represent and
where to inject.19 The majority of authors think that they represent the most proximal roots (C5-C7) of the brachial
plexus,7,12,14,16,17,2022 whereas others believe that they correspond to the 3 brachial plexus trunks.5,15,23,24
In our experience, tracing these hypoechoic structures proximally under ultrasound reveals that not every hypoechoic structure corresponds with a single nerve. This is especially the case
of the C6 root that is frequently imaged as a bifascicular or
multifascicular structure that converges into a single nerve as
the root approaches the intervertebral foramen (Fig. 2, A and B).
Although this impression is shared by other practitioners through
personal communications, it is only rarely mentioned in the literature.2528 In addition to this, our experience in the anatomy
laboratory has demonstrated that the root of C5 is usually significantly smaller than C6 and that C6 frequently shows macroscopic evidence, to the naked eye, of some degree of bifurcation.
Based on this experience, we decided to perform a series
of dissections to analyze the macroscopic appearance and relative sizes of the proximal roots (C5-C7) of the brachial plexus,
with the aim of determining the anatomical basis of the stoplight sign as well as finding any other macroscopic features
within the roots that could correlate with ultrasound images obtained at the interscalene level.

METHODS
A total of 20 brachial plexuses in 10 embalmed human cadavers (5 males and 5 females) were dissected. The dissections
were performed at the anatomy laboratory of Rush University
Medical Center in Chicago using regular dissecting tools and
the unaided eye. The cadavers were obtained from the Anatomical
Gift Association of Illinois, and their procurement and handling
were in accordance to the policies and procedures of Rush University as well as state and federal laws and regulations.
The specimens were lightly embalmed, as done for medical
anatomical research. Their ages at the time of death ranged from
61 to 95 years. After partial removal of the prevertebral fascia,
the anterior and middle scalene muscles were exposed, as well
as the nerves of the brachial plexus, with special attention to the
roots of C5, C6, and C7. The trajectory of the roots and trunks
with respect to the scalene muscles was verified and noted. Notes
were also made concerning the appearance of the roots looking for
any evidence of macroscopic splitting or bifurcation.
The roots were then excised as close to the distal end of the
transverse process proximally and at the level of the respective
trunk distally. A digital caliper (Fisher Scientific, Pittsburgh,
Pennsylvania) was used to measure (in millimeters) the diameter of the roots at midpoint of the available length by a single
observer (C.F.). After measurements and macroscopic examination, some roots underwent careful removal of epineurial
layers to better reveal their structural arrangement. Notes were
made and photographs were taken throughout.
Simple descriptive statistics were used to summarize root
location, diameter, and presence of anatomical variation. To

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Reevaluation of the Stoplight Sign

FIGURE 1. Dissection of left brachial plexus, medial view as seen from the shoulder, to show the diverging scalene muscles and the resulting
triangular space in-between. The roots and divisions are long compared with the short trunks. A, anterior division upper trunk; AS, anterior
scalene; MS, middle scalene; P, posterior division upper trunk; SA, subclavian artery; SS, suprascapular nerve; TRAP, trapezius; UT, upper trunk.

assess diameter size differences between root levels, we performed

a 1-way analysis of variance. To adjust for multiple comparisons, a
post hoc analysis was performed using the Tukey highly significant
difference test.

to the anterior scalene muscle. Although C5 and C6 roots

showed some variability in this respect, C7 was found consistently between the scalene muscles. Table 1 summarizes these
findings. An asymmetric pattern between both sides was found
in 4 (40%) of 10 specimens.

RESULTS
The dissection findings were categorized as 1) root trajectory
and symmetry, 2) nerve root diameter, and 3) macroscopic signs
of intraroot splitting.

Root Trajectory and Symmetry

The trajectory of the C5 to C7 roots with respect to the scalene muscles was noted to follow 3 different patterns: the root
was located between the anterior and middle scalene muscles,
passed through the anterior scalene muscle, or traveled anterior

Root Diameter
From the dissection of 20 brachial plexuses, 60 individual
roots (C5-C7) were collected for measurement. The root of C5
was clearly the smallest root (P < 0.0001) in 19 of 20 cases (Fig. 3),
whereas C6 and C7 roots were almost equally larger. The diameters of C5 to C7 roots in all specimens are shown in Table 2.
The mean diameters of C5 to C7 roots in millimeters, with
standard deviations, were as follows: C5, 3.2 0.9; C6, 5.1
0.6; and C7, 5.3 0.7. Statistical analysis revealed a significant

FIGURE 2. Ultrasound tracing of the root of C6, with 2A showing C6 root bifurcated and, 2B, the same root seems monofascicular as it
approaches the intervertebral foramen. AS, anterior scalene; MS, middle scalene.
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Franco and Williams

TABLE 1. Trajectory of C5 to C7 With Respect to Scalene

Muscles

Between
Through
Anterior
Total (n)

TABLE 2. Diameter of C5 to C7 Roots in All 20 Plexuses

C5 (n)

C6 (n)

C7 (n)

14
4
2
20

17
2
1
20

20
0
0
20

Between, in-between anterior and middle scalene muscles; through,

through anterior scalene muscle; anterior, anterior to anterior scalene
muscle.

difference between the size of C5 compared with both C6 and C7,

whereas no difference was found between the sizes of C6 and C7.
Size difference among the 3 roots with a 95% confidence interval
(CI):
C5 compared with C6: 95% CI, 1.33 to 2.45 mm, P < 0.0001;
C5 compared with C7: 95% CI, 1.58 to 2.70 mm, P < 0.0001;
C6 compared with C7: 95% CI, 0.31 to 0.81 mm, P = 0.53.

Macroscopic Appearance
The macroscopic examination of the roots revealed that C5
was significantly smaller than C6 and C7 and rarely showed any
macroscopic evidence of splitting, with 1 exception in which the
root of C5 was as large as C6 (4.87 vs 4.51 mm), and both were
split (Fig. 4). The root of C6 was not only larger than C5 but frequently showed evidence of splitting in situ (intact epineurium)
(Fig. 5). The evidence of fascicular splitting became more apparent after the outer layers of the epineurium were removed, as
shown in Figures 6, 7, and 8. The summary of these findings is
presented in Table 3.

DISCUSSION
This study was undertaken to better understand the correlation between the images commonly obtained during ultrasound-

No.

Sex

Side

C5, mm

C6, mm

C7, mm

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Male
Male
Male
Male
Male
Male
Female
Female
Female
Female
Female
Female
Male
Male
Male
Male
Female
Female
Female
Female

Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left

2.21
1.72
3.25
3.69
4.53
3.88
2.93
3.15
2.18
1.80
2.08
2.45
3.94
3.36
3.84
3.70
4.87
3.62
3.46
3.11

4.84
4.58
6.16
5.79
5.52
5.54
4.43
4.79
4.28
4.68
5.34
4.36
5.78
5.26
5.38
5.57
4.51
4.51
5.52
4.70

5.44
4.83
5.75
5.82
6.11
6.11
4.14
4.38
4.26
5.35
5.31
4.79
5.98
6.33
4.52
5.16
4.90
5.04
6.36
6.11

guided interscalene block and the macroscopic anatomy of

the brachial plexus at that level. The most important issues that
we tried to address were, first, the anatomical correlation of the
so-called stoplight sign and, second, the anatomical features
within the roots that could support the contention that not every
hypoechoic structure found at the interscalene level, specifically the root of C6, corresponds with a single nerve, as we
and others have noticed.2528 Two important findings were made.
First, we established that the root of C5 is significantly smaller
than the roots of either C6 or C7. Second, we found that the roots
of C6 and C7, but not of C5, frequently present at least 1 visible

FIGURE 3. Comparative sizes of C5 to C7 roots. MT, middle trunk; UT, upper trunk.

454

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Reevaluation of the Stoplight Sign

FIGURE 4. A case of C5 splitting. C5 and C6 are shown to be about equal sizes, and both demonstrate evidence of macroscopic splitting.
Shown after partial removal of epineurium.

FIGURE 5. Dissection of left brachial plexus (different specimen from that of Fig. 1). Frontal view, after removal of prevertebral fascia and most
of connective tissue to show bare nerves and muscles. C5 is clearly the smallest root, and C6 shows some evidence of macroscopic splitting
(arrow) with intact epineurium. MS, middle scalene; Ph ner, phrenic nerve; SA, subclavian artery.
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FIGURE 6. C5 to C6 roots forming upper trunk (UT), right side. A, With intact epineurium. B, After partial removal of the epineurium.

FIGURE 7. C5 to C6 roots forming upper trunk (UT), left side. A, With intact epineurium. B, After partial removal of the epineurium.

FIGURE 8. C5 to C6 roots forming the upper trunk (UT), left side. The C6 root shows macroscopic evidence of double splitting (arrows).

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TABLE 3. Macroscopic Appearance of Roots C5 to C7

C5
C6
C7

No Visible Split (n)

At Least 1 Visible Split (n)

19
1
2

1
19
18

sign of splitting within their structure. This was even more apparent in those specimens that had some layers of epineurium
removed. These 2 findings provide, in our view, solid evidence
for the stoplight ultrasound sign to be interpreted as the crosssectional image of C5 and C6 roots, without participation of
C7. Of the 3 components of the sign, the superior 1, or the red
light, would correspond with C5; the middle component, or the
yellow light, would be the upper fascicle(s) of C6; and the distal
component, or the green light, would be the lower fascicle
(s) of C6. The fact that C5 was found to be significantly smaller
than C6, and the splitting of a larger C6, correlates well with
this sign being usually composed of 3 hypoechoic structures
of similar size. The anatomy/ultrasound correlation is shown
in panels A and B of Figure 9.
However, we believe that even more important than establishing a credible correlation between the ultrasound images
and the anatomy of the interscalene block are the clinical implications of these findings. The macroscopic bifurcation of C6
into 2 fascicles or 2 groups of fascicles, frequently mistaken
as being 2 separate roots (C6 and C7), could lead to an unintended intraneural injection29 at this level. We have not failed
to notice30 that such a bifurcation provides an entrance path
into the neuraxis and could help explain some catastrophic outcomes associated with interscalene blocks.3135 The spread into
the neuraxial space from an interscalene injection has been usually explained as an injection within the dural sleeve of a spinal
nerve. However, because this sleeve rarely extends beyond the
intervertebral foramen,3638 our findings seem to provide a
more likely mechanism for such spread. Furthermore, it seems
fair to speculate that an unintended intraneural injection at C6
could also be associated with the relatively high incidence of
dysesthesias observed after interscalene blocks,3943 for which
no credible explanation has ever been offered. An injection

Reevaluation of the Stoplight Sign

between the fascicles of C6, indeed intraneural but extrafascicular,

could be accompanied by low opening pressures44 (false-negative).
The possibility that the stoplight sign could instead correspond to the cross-sectional image of the trunks seems highly
unlikely for many reasons. First, the usual insonation for an
interscalene block is too cephalad and angled too medial to
be able to show all 3 trunks in 1 image12; second, it is unlikely
that a cross-sectional image of the lower trunk would not demonstrate in the same image the subclavian artery in its immediate vicinity; third, the trunks are indeed more multifascicular4547 than
the roots as they start to take the appearance of more peripheral
nerves with more abundant connective tissue.22
Our extensive literature review found supportive anatomical
and clinical evidence for C5 being the smallest root, especially
when compared with C6 and C7.4751 However, although strong
when present, the evidence is surprisingly not as pervasive as it
would be expected considering the significant difference in root
size that we and others have documented. Regarding the macroscopic bifurcation of C6, Kerr's48 comprehensive 1918 publication on the human brachial plexus presents a diagram depicting
a C5 root significantly smaller than C6 and the latter showing a
structure that seems to suggest cephalad and caudal groups of fascicles. Unfortunately, no explicit statement to that effect is made.
To our knowledge, other than this cryptic diagram, the literature
does not explicitly describe the roots of the plexus as exhibiting
any macroscopic evidence of septation that would betray their
multifascicular nature. Thus, we believe that our anatomical findings, which nicely correlate with known ultrasonographic images,
are indeed novel.
The ultrasound image of a split C6 converging into a single
hypoechoic structure when traced proximally is supported by the
literature that shows the ventral branch of the spinal nerve as being
monofascicular,52 whereas the C5 to T1 roots are multifascicular
(27 fascicles).52 Our study suggests that at least C6 and C7 roots
not only are multifascicular but part of that arrangement is usually
visible to the naked eye and likely to ultrasound.
Although we did not intend to study brachial plexus variations or asymmetry, our findings are in accordance with the literature.47 That lack of symmetry involves the size and structure of
individual nerves, as well as their relationship with the scalene
muscles. Whatever their importance, these findings are only incidental to our study.

FIGURE 9. Ultrasound-anatomy correlation of the stoplight sign. A, Depiction of a short segment of roots of C5 and C6 as they converge to
form the upper trunk (UT). The splitting of C6 is clear after removal of the epineurium. B, Ultrasound image depicting the stoplight sign
formed by 3 hypoechoic dots between the anterior scalene (AS) and the middle scalene (MS) muscles.
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Franco and Williams

In light of our findings, and considering that the brachial

plexus contribution to the innervation of the shoulder comes almost exclusively from C5 and C6, with only marginal contribution from C7,27,53 our advice is that, during an interscalene
block, the single target of injection be the space between C5
and C6. No attempt should be made to inject or place a catheter
distal to this level.54 It would also be advisable that, when in
doubt, the operator traces the hypoechoic structure(s) proximally to ascertain whether they correspond to a splitting of a
single nerve or indeed to 2 separate roots.
Our findings do not support the concept of common epineurium between 2 different roots, as some have suggested.55 It seems
clear from the literature that every single root exits through a particular intervertebral foramen surrounded by its own dural sleeve,
which at the level of the intervertebral foramen becomes continuous with the epineurium of that root.13,3638 The multifascicular
arrangement of the root does not contradict this fact, as all these
fascicles form 1 nerve and 1 single epineurium individualizes it.
Our study has some limitations. The use of lightly embalmed
cadavers could be questioned. However, the main findings: relative
(not absolute) size of nerves and macroscopic evidence of fascicular
arrangement within the roots should not be affected by it. In fact, we
have found similar features in fresh cadavers. The evidence that C5
is the smallest root among C5 to C7 is overwhelming. Another limitation is that we did not study the histological features of the roots
so we could not establish the exact number of fascicles per root nor
their course and disposition. We believe that the absence of this information at this time does not diminish the anatomical-ultrasound
correlation we have established and the potentially relevant
clinical implications.
In summary, we found that C5 is frequently the smallest root
of the brachial plexus and that C6 is both one of the largest and
frequently exhibits macroscopic signs of splitting. These anatomical features provide the anatomical basis for the stoplight sign to
correspond with the cross-sectional image of C5 and both (or
more) fascicles of C6. This stoplight sign usually has 3 lights,
but they are made of only 2 nerves.
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Reevaluation of the Stoplight Sign

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