Anaesthesia, 2010, 65 (Suppl. 1), pages 48–56 doi:10.1111/j.1365-2044.2010.06277.

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Upper limb blocks

K. Russon,1 T. Pickworth2 and W. Harrop-Griffiths3
1 Consultant Anaesthetist, Rotherham General Hospital, Rotherham, UK
2 Specialty Trainee in Anaesthesia, Imperial School of Anaesthesia, London, UK
3 Consultant Anaesthetist, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK

Summary
This article discusses recent innovations and changes in practice in upper limb regional anaesthesia,
dividing the blocks into those performed above the clavicle, those performed in the area of the
clavicle and those performed below it. It offers a critical appraisal of the current status with regard
to the use of ultrasound nerve location for upper limb regional anaesthesia and, while accepting that
the use of ultrasound in this way has many theoretical advantages and will therefore continue to
grow, concludes that there is currently insufficient published evidence to determine conclusively
that the use of this technique is associated with nerve blocks that are more successful or safer.
. ......................................................................................................
Correspondence to: Dr Will Harrop-Griffiths
E-mail: harropg@mac.com

duction of ultrasound initially created a spate of ‘new

‘There are no new blocks, just old anatomy’ [1]
blocks’ based on this new technology. Mercifully, the
Upper limb regional anaesthesia is arguably the alpha and focus turned in the 1990s a little away from new
omega of regional anaesthesia, lying at the heart of its past, stimulator blocks and towards extending the duration of
present and future. It was the location of the first recorded action of upper limb blocks with continuous infusions of
plexus block, performed by the American surgeon local anaesthetic drugs. Innovation continued in the
William Stuart Halsted in 1885, a mere months after ‘noughties’ and, although not exclusively driven by
Koller’s first description of the use of cocaine as a local ultrasound, it was inevitably in part led by it. This short
anaesthetic (LA). As the use of major lower limb blocks is review will address itself to the major recent innovations
threatened by demands from surgeons for almost imme- in upper limb regional anaesthesia, but will not seek to list
diate postoperative mobility, and the use of local infiltra- the allegedly ‘new’ upper limb blocks that continue to
tion analgesia, born in response to those demands, jostles seek publication in the journals. The anatomy of the
for its clinical position in the analgesic armamentarium of brachial plexus has changed little in the last few millennia,
anaesthetists [2, 3], the anatomical superficiality of the and the goal of regional anaesthesia – putting the right
brachial plexus makes it ideal as a proving-ground for the dose of the right drug in the right place [4] – has remained
development of ultrasound-guided regional anaesthesia unchanged since Koller described his discovery in the
(UGRA – an ugly acronym but an increasingly used one). Billrothhaus in Vienna in 1884. If, as espoused by the
Shoulder and arm surgery is notoriously painful and, as third named author of this review, ‘there are no new
locomotion is rarely dependent upon full function of the blocks, just old anatomy’ [1], what really is new in upper
upper limb, the brachial plexus is undoubtedly the place limb blocks?
to be in the early 21st century. However, developments
in upper limb regional anaesthesia have not been lying
Blocks above the clavicle
dormant awaiting the arrival of ultrasound. In the
peripheral nerve stimulator era – the 20 years leading In order to provide anaesthesia for shoulder procedures, a
up to the turn of the Millennium – reports of ‘new’ block of at least the upper two roots (C5 and C6) or the
techniques abounded. Many of the ‘new’ blocks in this superior trunk of the brachial plexus is necessary. In
era derived from the use of the nerve stimulator and the addition, blockade of the supraclavicular nerve is needed,
approaches and techniques it allowed, just as the intro- as this covers the ‘cape’ of the shoulder – the skin

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overlying the superior aspect of the shoulder. The root the reported success rate of the middle interscalene
values of the supraclavicular nerve (C3 and C4) are approach was 96.2% in 719 patients; that of the trans-
outwith the brachial plexus in the large majority of scalene technique was 85.2% in 27 patients. With success
patients, and some anaesthetists therefore block the rates for the Winnie approach or its minor directional
nerve separately although, given that most successful modifications comfortably exceeding 97% in experienced
blocks aimed at the C5 and C6 roots also block the clinical hands, there seems little point in adopting new
supraclavicular nerve, this is only rarely required to approaches on the basis of these reported success rates.
guarantee pain-free surgery. Alon Winnie [5] described Both papers promoted their modification of needle entry
the block that became – and remains – the most popular point and angulation on the premise that the risks of
approach to the upper roots of the brachial plexus: the anatomical complications that included neuraxial entrance
interscalene block. Although in expert hands it is a very would be decreased. However, it was the introduction of
safe and highly successful block, it has been associated ultrasound guidance that has caused the adoption of a
with a variety of complications ranging from blockade of genuinely new needle approach to the interscalene
the cervical sympathetic chain, recurrent laryngeal nerve brachial plexus by a large number of clinicians, and as a
and phrenic nerve blockade [6, 7], through hypotension result threatens to obviate the debate on which entry
and bradycardia that is blamed on the arcane Bezold- point to use when approaching the interscalene portion of
Jarisch reflex [8], via accidental epidural and spinal the brachial plexus and which precise needle angle should
injection [9], and all the way to permanent damage to be used. In common with all UGRA techniques, the
the spinal cord in patients who had undergone attempted needle can be aligned parallel to the ultrasound beam
interscalene block when under general anaesthesia [10]. transmitted from the ultrasound probe – the so-called ‘in-
Concerns about the safety of the interscalene block led in plane’ technique – or at right angles to it – the ‘out-of-
part to it’s being singled out in a recent American Society plane’ technique. There is arguably a degree of logic in
of Regional Anesthesia (ASRA) ‘Practice Advisory on using the in-plane technique for as many blocks as
Neurologic Complications’: ‘Interscalene blocks should possible: with an imaging device that can show the
not be performed in anesthetized or heavily sedated adult operator both the nerves and the entire length of the
or pediatric patients’ [11]. No other peripheral nerve needle, including its tip, which has so often been blamed
block is accorded this degree of recommended caution by for causing trauma to nerves, it seems intuitively correct
ASRA’s Practice Advisory. to use this approach – it is presumed that the continuous
A number of modifications of the block have been observation of both needle and nerve can only aid safety.
described that change the angle of entry of the needle to a The best way to image the brachial plexus as it passes
more caudad direction, in part in the hope that this might between the anterior and middle scalene muscles is in the
decrease the chances of a needle’s entering the neuraxis. transverse plane, which shows the nerve roots neatly
Worthy of mention are the Meier and Borgeat [12, 13] stacked up on top of each other while they lie sandwiched
modifications. Recent work using magnetic resonance between the anterior and middle scalene muscles. An out-
and computerised tomography imaging in healthy vol- of-plane approach to this image will adopt the traditional
unteers and cadavers suggests that the traditional Winnie needle approach associated with an interscalene block and
approach can align the needle trajectory with the is therefore favoured by many. It remains rightly popular
intervertebral foramen, thus allowing the needle access when placement of an interscalene catheter is attempted
to the neuraxis [14, 15]. This work supports the view that as it aligns the needle, and therefore one hopes the
approaches using more caudad needle angulation may be catheter, with the long axis of the nerves. However,
safer in terms of the risks of entering the neuraxis. although logical as argued above, an in-plane approach
Posterior approaches to the brachial plexus or, perhaps will see the needle passing through the belly of the
more accurately, to the cervical paravertebral space, have anterior or, more commonly, middle scalene muscle. A
been described by Pippa [16] and Boezaart [17], although lateral-to-medial needle passage that transits the middle
neither has achieved widespread popularity, notwith- scalene muscle makes the threat to the neuraxis minimal if
standing the fact that they are occasionally useful when not absent. However, the passage of the needle through
providing regional anaesthesia for shoulder surgery in the muscle may be associated with bruising of the muscle
patients with fixed cervical flexion deformities. Other that can manifest itself as neck pain after surgery or, in
more recent attempts to topple the Winnie technique theory at least, may cause damage to two nerves that often
from the throne of block utility for shoulder surgery pass through the muscle: the dorsal scapular nerve and the
include descriptions of a ‘middle interscalene block’ [18] long thoracic nerve. There are not yet sufficient reports of
and a ‘trans-scalene approach’ [19]. These two papers are complications associated with either approach to allow a
worth reading, but their results can be summarised thus: recommendation of which is the safer, and clinicians are,

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K. Russon et al. Æ Upper limb blocks
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therefore, free to use whichever approach they feel suits
them and their patients better.
Although few doubt the supremacy of the interscalene
block for anaesthesia for shoulder surgery, its role in
analgesia after surgery is not unassailable. As mentioned
above, it carries with it a number of potentially dangerous
side effects, and there have been studies that have sought
to compare the analgesia provided by interscalene blocks
with that provided by wound or joint catheters. The
placement of catheters in joints or wounds to allow
postoperative injection or infusion of LA solutions is
attractive from the point of view of simplicity and safety,
notwithstanding recently expressed concerns about the
possibility that LA solutions may in themselves be
chondrotoxic [20]. Beaudet et al. [21] compared the
analgesia provided by interscalene block and catheter with
that provided by a similar LA regimen injected through
an intra-articular catheter at the end of shoulder surgery.
The analgesia experienced by the patients who under-
went interscalene block was markedly superior in the
post-anaesthesia care unit but this advantage was not
extended to the first 24 h after surgery. However, it is
worthy of note that both interscalene and intra-articular
catheters were removed 1 h after surgery; had they not
been, this difference may have been extended into the
postoperative period. Nisar et al. [22] found no difference
between interscalene and intra-articular catheters used for
analgesia after arthroscopic acromioplasty, which is
admittedly not a procedure known to be associated with
severe pain. Webb et al. [23] showed no difference in
analgesia when comparing a single-shot interscalene block
and continuous LA infusion through a subacromial
catheter in the 48 h after arthroscopic shoulder surgery.
However, studies of the use of interscalene catheters for
analgesia after major and painful shoulder surgery suggest
that they are not only effective but also aid mobilisation
and hasten patients’ discharge [24–26]. Although the
potential benefits of interscalene catheters have been
more frequently demonstrated than those of catheters
placed lower down in the brachial plexus, largely because
of the greater number of clinical indications and therefore
literature available, it is reasonable to assume that their use
after painful arm surgery will also be associated with
analgesic and clinical benefits in selected patients. The
insertion of all catheters for the delivery of continuous
regional anaesthesia and analgesia inevitably carries with it
the potential complications of the single-shot block upon
which the catheterisation technique is based. Although
intuition might suggest that the use of the larger needles
that are all but obligatory when placing catheters should
be associated with an increased incidence of nerve
damage, there is currently no evidence for this [27],
although this may be related to the greater experience of
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Anaesthesia, 2010, 65 (Suppl. 1), pages 48–56
those placing catheters and performing studies on their
clinical use. The leaving of percutaneous catheters in
place for hours and even days gives rise to the inevitable
risks of bacterial colonisation [28] and, occasionally,
catheter-related infections [29]. These risks must be
balanced against the likely benefits to the patient.
In the same way that the place of major lower limb
nerve blocks is now open to challenge, it may be that the
place of upper limb nerve and nerve plexus catheters is
open to challenge by simpler techniques that may be
acceptably effective and that (presumably) will enjoy a
lower incidence of complications because they do not
encroach on nerve tissue itself. Price [30] has developed a
technique that combines axillary nerve and suprascapular
nerve block to provide effective analgesia after major
shoulder surgery, and has termed it the ‘shoulder block’.
This immediately drew objections from those who have
devoted much time to study of interscalene catheters [31],
but any verdict on whether the shoulder block has a role
in the regional anaesthetist’s upper limb armamentarium
must await further and larger trials of this potentially
promising technique.
The interscalene block, in its various forms, retains its
supremacy in regional anaesthesia as an effective way of
producing excellent anaesthesia and analgesia for shoulder
and upper, outer arm surgery. However, it is arguably the
most difficult and the most dangerous nerve stimulator-
guided peripheral nerve block. The introduction of
UGRA has led many to believe that the interscalene
block can now be downgraded to a ‘basic’ block that will
become associated with few complications. This cannot
yet be definitively supported, and great care should
continue to be exercised when performing an interscalene
block or indeed any peripheral nerve block that is as close
to the neuraxis and other anatomical structures that it
would be wise not to breach with needle, catheter or LA.
Periclavicular blocks
Whereas blocks of the upper roots or superior trunk of
the brachial plexus will provide analgesia that is usually
limited to the shoulder and upper, outer arm, blocks
performed as the plexus passes behind the clavicle or in
this immediate area will provide anaesthesia and analgesia
of the whole arm: the upper arm, elbow, forearm and
hand. Indeed, it is often said that the brachial plexus is at
its most compact as it passes behind the clavicle and it is
here that a relatively small volume of LA can produce a
‘spinal of the arm’ [32]. One of the earliest percutaneous
blocks to be described was a supraclavicular block [33],
and this approach remained popular until the 1970s and
1980s, when fear of the complication of pneumothorax,
which may have occurred in up to 10% of patients, led
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Anaesthesia, 2010, 65 (Suppl. 1), pages 48–56
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anaesthetists to develop other periclavicular blocks.
Winnie’s [34] subclavian perivascular approach had been
devised in the 1960s and had anatomical logic behind it,
but did not enjoy widespread acceptance. Likewise, the
‘plumb-bob’ approach was designed with the minimisa-
tion of the incidence of pneumothorax in mind but failed
to become universally popular [35]. A number of
infraclavicular approaches have been described and all
have been used, but only two seem to have stood the test
of time: the coracoid approach [36] and the vertical
infraclavicular block [37], although the more cumber-
somely named and more recently introduced ‘lateral
sagittal infraclavicular block’ is finding favour and seems
well suited to those who use ultrasound for nerve location
[38]. These blocks exploit anatomy and needle direction
to minimise – but not obviate [39] – the chances of a
pneumothorax, while approaching the brachial plexus at a
level above the departure of the axillary and musculocu-
taneous nerves from the main body of the plexus, thus
providing ‘whole arm’ anaesthesia without the need for
additional, more distal, nerve blocks.
The introduction of UGRA has rekindled interest in
supraclavicular approaches to the brachial plexus. Chan
et al. [40] were instrumental in introducing the concept
of the ultrasound-guided supraclavicular brachial plexus
block in 2003, using a lateral-to-medial, in-plane
technique that produced a 95% success rate in 40
patients. Chan then pushed the art of this technique
further with a letter to the journal Regional Anesthesia and
Pain Medicine in 2007 that has become an almost seminal
– if brief – publication in the development of this
technique [41]. Entitled: ‘Eight ball, corner pocket: the
optimal needle position for ultrasound-guided supracla-
vicular block’, it claimed that if the needle is placed in
the ‘corner’ visualised with an ultrasound probe placed
posterior and parallel to the clavicle, i.e. that formed by
the subclavian artery medially, the first rib inferiorly and
the divisions of the brachial plexus superio-laterally, the
LA will first bathe the inferior-most portion of the
divisions of the brachial plexus, will then spread to all the
constituent divisions of the plexus, and that a reliable and
consistent whole-arm anaesthetic will result. The pub-
lication of this letter led to a debate in the correspon-
dence pages of the journal about whether, given that
UGRA is not always performed with the best equipment
and by experienced anaesthetists, a technique that takes
the tip of the needle very close to the pleura and a large
artery (the subclavian), and that demands that the
operator keep the entirety of the needle in ultrasono-
graphic view at all times lest the tip inadvertently stray
into one of these anatomical structures, is one that
should be widely promoted [42–44]. Chan’s group has
recently published a series of > 500 patients undergoing
Ó 2010 The Authors
Journal compilation Ó 2010 The Association of Anaesthetists of Great Britain and Ireland
K. Russon et al. Æ Upper limb blocks
this procedure [45]. They report a 94.6% success rate in
the hands of trainees, with no pneumothoraces and a low
incidence of other complications: 1% hemidiaphragmatic
paralysis; 1% Horner’s syndrome; 0.4% accidental vascular
puncture; and 0.4% transient sensory deficits. Opposing
this up-beat assessment of the technique, Borgeat’s group
has recently questioned the confident assertion that
ultrasound guidance makes supraclavicular blocks safer
[46]. Borgeat’s [47] view seems to have been supported by
the recent report of a pneumothorax occurring after an
ultrasound-guided supraclavicular block, proving perhaps
that when needles and the pleura are brought into close
apposition, even under direct imaging observation,
breaches of the pleura are inevitable.
Whereas the use of ultrasound has caused a resurgence
in the use of supraclavicular blocks, it has served only to
maintain interest in infraclavicular blocks. Ultrasound can
be safely and effectively used for infraclavicular blocks,
although there is yet to be definitive proof that it offers
real advantages over the use of nerve stimulation. Sauter
et al. [48] randomised 80 patients to undergo lateral
sagittal infraclavicular block under ultrasound or nerve
stimulator guidance. The assessment of the two blocks
was remarkably similar: performance times were similar,
as were onset times, times to readiness for surgery, and
median discomfort related to both block performance and
tourniquet. Although the block success rate was higher in
the ultrasound group (95%) than in the nerve stimulator
group (85%), this difference did not achieve statistical
significance. The authors concluded that: ‘favorable
results can be obtained when either nerve stimulation or
ultrasound guidance is used’. In a terse paper that used
Doppler ultrasound, rather than ultrasound imaging, in
addition to nerve stimulation to identify the correct
position for LA injection when performing a vertical
infraclavicular brachial plexus block, Renes et al. [49]
achieved a laudable 98% success rate. As with so many
areas of anaesthetic practice in general, and regional
anaesthesia in particular, more large-scale studies are
needed to define the contemporary and relative role of
supraclavicular and infraclavicular brachial plexus blocks
in the management of upper limb surgery and postoper-
ative pain.
The axillary approach and beyond
From the axilla downwards, regional anaesthetic tech-
niques for the upper limb target the four terminal nerves
of the arm or their branches. Traditionally, blocks of the
arm have focussed on areas near joints at which arterial
pulses are readily palpable: the axilla, the elbow and the
wrist. The axillary block has endured the greatest
variation in described techniques since its introduction:
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K. Russon et al. Æ Upper limb blocks
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single-shot, multiple injection, transarterial, paraesthesia,
peripheral nerve stimulator guided and ultrasound guided
– and combinations of the above [32]! Although a block
that can have a relatively high failure rate and that can
suffer a relatively slow onset time, its popularity has
endured because it carries no risk of pneumothorax and
can provide excellent anaesthesia and analgesia for elbow
and forearm surgery.
Until relatively recently, the jury was deemed to be
‘out’ when it came to the question of whether axillary
blocks were more effective with multiple injections rather
than a single one. Alon Winnie, in his seminal 1983 book
on brachial plexus anaesthesia, promoted the use of a
single-injection technique that was based upon the
premise that a sheath surrounded the brachial plexus
during its descent from the cervical vertebrae to the axilla
[50], and that a large volume of LA inserted with a single
injection into the sheath will readily bathe all the contents
of the sheath. However, recent studies have indicated that
a multiple injection technique is more likely to produce
consistently successful blocks [51, 52]. A recent Cochrane
review has supported this assertion [53], and an increasing
number of anaesthetists are using multiple injection
techniques, both with and without a nerve stimulator.
With the introduction of ultrasound for nerve location,
proponents and enthusiasts were keen to use the axillary
approach to the brachial plexus. They allege to have
shown that the use of ultrasound is associated with a
decrease in the time taken to perform the block and has
the potential to increase the success rate: from 62.9% to
82.8% [54] or from 81.9% to 91.6% [55] with no increase
in the incidence of complications [55, 56]. These studies,
like so many other publications purporting to demon-
strate the greater success rates of ultrasound-guided
techniques when compared with stimulator techniques,
seem to achieve very modest success rates when using a
nerve stimulator to find nerves. It may well be that
unconscious bias is at play, although there is little doubt
that the authors would – perhaps rightly – claim that what
clinicians believe to be their success rates and what they
are when they are properly and scientifically scrutinised
can be two very different numbers. With most anaesthe-
tists who specialise in axillary brachial plexus blocks now
using multiple injection techniques, it may be that single-
injection ultrasound-guided supraclavicular blocks will
prove to be quicker to perform while being just as
effective. As in many other areas of anaesthetic practice,
the perception of risk related to pleural puncture may be
more significant than the proven actuality of risk when it
comes to individual choice of technique; only time (once
again) will tell.
Before the advent of ultrasound guidance for peripheral
nerve blocks, blocks of the four terminal nerves of the
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Anaesthesia, 2010, 65 (Suppl. 1), pages 48–56
arm below the mid-humeral level focussed on the elbow
and the wrist, at which bony landmarks and palpable
arteries could act as landmarks that point towards nerves.
However, the use of ultrasound seems to be taking the
location of nerve blockade in the arm away from the
joints and towards locations in the upper arm or forearm.
The radial nerve is arguably at its most ultrasonograph-
ically visible and reliably positioned as it runs along the
spiral groove on the lateral side of the humerus [57].
Similarly, the ulnar and median nerves are readily visible
with an ultrasound machine in the forearm, and this is
becoming an increasingly popular site for blocks [58–60].
The ulnar nerve is accompanied by the ulnar artery for
much of its course in the distal forearm and, given the
potential that this anatomical proximity creates for
intravascular injection, it would appear reasonable to
block the nerve more proximally, where it lies a short
distance away from the nerve [59]. Prospective studies
that compare ultrasound-guided forearm blocks with
traditional blocks at the elbow and wrist are currently
lacking, so it is not possible at present to determine
whether ultrasound-guided forearm blocks will supersede
their more traditional counterparts at the elbow and wrist.
And what of the future?
As discussed above, upper limb regional anaesthesia in
2010 is in a state of transition. While the interscalene
block remains popular for shoulder surgery, and is likely
to remain so, periclavicular blocks are seeing an increase
in popularity driven by the use of ultrasound. Regional
anaesthesia enthusiasts see the ‘eight-ball, corner pocket’
approach as offering great potential, but it may be that the
skills and expertise required to practise this technique will
be limited to a relatively small number of ultrasound
fetishists. In addition to this, reports of complications
following attempted supraclavicular blocks may once
again scare off clinicians, and send them to the relative
safety of the axilla. A careful assessment of the anatomy of
the infraclavicular portion of the brachial plexus might
lead one to understand that provided an appropriate
needle length and angle is used, and provided one’s
understanding of the sometimes hazy ultrasound images in
this area is secure, a pneumothorax is a very unlikely
eventuality. However, even the three experienced
authors of this article cannot ignore the small voice inside
their heads that quietly warns them away from the pleura
when performing infraclavicular blocks. If the voice is
audible in our heads, it must be at least equally loud or
perhaps more so in the heads of less experienced regional
anaesthetists. It is therefore possible that the axillary
approach really will stand the test of time and will remain
popular outside of the hospitals that profess great expertise
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in the use of ultrasound. The ultrasound-guided axillary
block is not an easy one – even experienced regional
ultrasonographers can take some time correctly to identify
the four nerves. In the face of high success rates with
multiple-injection nerve stimulator-guided axillary
blocks, perhaps the tradition of the wire, the battery
and the evoked muscle twitches will persist for some time
in the lower reaches of the brachial plexus.
Perhaps the most interesting topic in upper limb
regional anaesthesia in the next few years will be its use as
a proving ground for the bold assertions made by
ultrasound enthusiasts: that UGRA is quicker, has a high
success rate and is safer. Papers on ultrasound often boldly
shout the views of their authors on the superiority of
ultrasound [54, 55, 61], claiming improved success rates
or faster onset times in their boldly declarative titles.
Whether the onset of anaesthesia with ultrasound is
quicker than with nerve stimulation depends to a large
extent on whether one measures the interval between the
start of LA injection and the onset of anaesthesia, or that
between the removal of the needle from the patient and
the onset of anaesthesia. Some papers that claim a faster
onset for UGRA either do not define onset with
sufficient accuracy or take the start of onset time as being
that of the removal of the needle from the patient. This
latter would favour UGRA, as LA injection when using
ultrasound often starts soon after insertion of the needle
and continues for some minutes before removal of the
needle, whereas, when using a nerve stimulator, the first
few minutes are taken up with positioning the needle and
the actual injection occurs only just before removal of the
needle.
Claims of much higher success rates with UGRA have
mostly derived from units that are committed to its use
and, as noted above, unconscious bias may be unavoid-
able in such studies. Some recent studies performed by
both experts and trainees have suggested that ultrasound is
not associated with success rates that are markedly
different with those found when using a peripheral nerve
stimulator [62]. The likely truth is that an experienced
clinician, or a trainee who has been properly taught and is
appropriately supervised, is likely to achieve a high success
rate using any one of a number of nerve location
techniques. If ultrasound is to become increasingly widely
used, as we are sure it will, it will not do so because it
produces higher success rates than nerve stimulation but
because it is perceived to be safer, easier to use or the
current ‘standard of care’.
This leaves the third claim of the ultrasound enthusiasts:
that the use of ultrasound is safer for patients. In this
respect, the upper limb is an excellent proving ground if
safety is taken to relate to the incidence of neurological
complications. The quoted incidence of postoperative
Ó 2010 The Authors
Journal compilation Ó 2010 The Association of Anaesthetists of Great Britain and Ireland
K. Russon et al. Æ Upper limb blocks
neurological abnormality after brachial plexus block is as
high as the 16% reported after interscalene block by
Borgeat et al. [27], and this produces the tempting
possibility that differences in postoperative adverse neu-
rological sequelae might be shown in relatively small
studies. Liu et al. [62] have recently published a fascinat-
ing paper in which they attempted to determine whether
ultrasound-guided interscalene blocks are associated with
a lower incidence of postoperative neurological symp-
toms than nerve stimulator-guided blocks. Two hundred
and thirty patients were randomised to the two tech-
niques; all were given large volumes of LA (45–65 ml
mepivacaine 1.5%) and all were assessed after surgery with
a standardised neurological assessment tool, in the form of
a questionnaire and physical examination, by blinded
observers. The results make interesting reading. There
was no difference between the two groups in the time
taken to perform the block (mean for both groups = 5
min), the overall success rate for the blocks (a laudable
100% in both groups) and patient satisfaction (> 90% in
both groups). The incidence of postoperative neurolog-
ical symptoms was also similar: 11% and 8% respectively
in the nerve stimulator and ultrasound groups at 1 week
and 7% and 6% at 4–6 weeks after surgery. Their power
calculation had been based on a reported incidence of
postoperative neurological symptoms after brachial plexus
block in the range 4% [63] to 16% [27]; they based the
calculation on the assumption that the use of ultrasound
would be associated with the lower incidence of com-
plications and that of nerve stimulation with the higher.
In their useful and honest discussion, the authors rework
the power calculation on the basis of the results of their
study. To determine whether or not there is a difference
between the two techniques in postoperative neurological
symptoms would require a randomised, controlled trial
that recruited approximately 3000 patients. It therefore
seems likely that the answer to the question of whether
ultrasound is safer than peripheral nerve stimulation from
the point of view of postoperative neurological symptoms
will not be resolved until large-scale studies are per-
formed. Finally, it is worth noting that this and other
studies use transient postoperative neurological abnor-
mality as a proxy for significant nerve damage caused
directly by the regional anaesthetic technique; these two
are not the same, as is freely admitted by Liu et al.
We will finish with two quotes from recent publica-
tions that seek to summarise the current status with regard
to the use of ultrasound for regional anaesthesia. We will
reassure the reader that we have not lost sight of the title
of this chapter by pointing out that comfortably in excess
of 75% of the papers cited by these two publications that
refer to work done on a limb refer to the upper limb,
which is, as we have stated, the ‘proving ground’ for
53
K. Russon et al. Æ Upper limb blocks
. ....................................................................................................................................................................................................................
current concepts in regional anaesthesia. The first is from
an editorial in Anesthesiology by Hebl: ‘Although many
advocates of ultrasound theorize that direct visualization
of neural targets and needle advancement may decrease
the frequency (and severity) of neurologic injury,
preliminary results do not support the hypothesis that
ultrasound guidance decreases the risk of neurologic
complications’ [64]. The second is from a systematic
review by Liu et al. [65]: ‘Current evidence does not
suggest that use of ultrasound improves success of regional
anesthesia versus most other techniques. However, ultra-
sound was not inferior for efficacy, did not increase risk,
and offers other potential patient-oriented benefits. All
randomized, controlled trials are rather small, thus
completion of large randomized, controlled trials and
case series are encouraged to confirm findings’. For both
upper limb regional anaesthesia specifically and for
regional anaesthesia in general, the jury is still out.
Conflicts of interest
Dr Harrop-Griffiths has been paid for consultancy by
Astra Zeneca and B Braun and for lecturing by Abbott.
Dr Russon has received fees for teaching workshops
organised by B Braun. Dr Pickworth declares no conflicts
of interest.
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