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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– 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
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 shoulder muscles are innervated by
1) the axillary nerve (C5-C6; deltoid and teres minor)
2) the suprascapular nerve (C5-C6; supraspinatus and infraspinatus)
3) the subscapular nerve (C5-C6; subscapularis and teres major)
4) the medial and lateral pectoral nerves (C5-T1; major and minor pectorals)
5) the musculocutaneous nerve (C5-C7; coracobrachialis and long and short heads of biceps brachii)
6) the thoracodorsal nerve (C6-C8; latissimus dorsi)
7) the radial nerve (C5-T1; long and lateral heads of the triceps brachii)
The muscles innervated by the axillary and suprascapular nerves are the most clinically important for shoulder surgery
1)-3) and the major part of 4)-7) are anaesthetised by an interscalene brachial plexus block
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
The brachial plexus is sandwiched between the anterior and the middle scalene muscles in the interscalene groove
