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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When local anaesthetic is injected it generates a contrast effect that enhances visualisation of the target nerves, because of the black background of the fluid
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It is important to advance the needle tangential to the target nerves and NOT penetrate the nerves
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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
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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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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To localise the brachial plexus you should start by localising the pulsating subclavian artery where it runs across the first rib
The branches of the brachial plexus are located just lateral to the artery
Track the branches of the brachial plexus proximally until they line up as a string of black pearls in the interscalene groove
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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
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
