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Ultrasound-Guided Block of The
Ultrasound-Guided Block of The
Ultrasound-Guided Block of The
doi: 10.1111/j.1399-6576.2011.02420.x
Department of Anesthesia and Intensive Care, Hillerd Hospital, Hillerd, Denmark, 2Department of Anesthesia, Frederiksberg Hospital,
Frederiksberg, Denmark and 3Department of Radiology, Hillerd Hospital, Hillerd, Denmark
Anatomy
The sensory innervation of the shoulder joint is
complex and involves contributions from the axillary, suprascapular, subscapular, musculocutaneous
and lateral pectoral nerves. Of these, the axillary
and suprascapular nerves are considered the most
important. However, variations and communications among the nerves are probably common.
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C. Rothe et al.
Methods
The Committees on Biomedical Research Ethics of
the Capital Region of Denmark approved the study
protocol (protocol no. H-I-2009-100) in accordance
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Ultrasound imaging
Before the study, we identified the axillary nerve in
a healthy volunteer (K. L.) in the following way: the
volunteer was in the sitting position, the shoulder
in the neutral position but rotated 451 inward and
the elbow flexed at 901 while the hand rested on the
knees. After disinfection with ethanolchlorhexidine (83% and 0.5%, respectively), we placed a
sterile transparent drape over the shoulder.
Using a high-frequency linear ultrasound transducer (HFL, 38 /136 MHz, S-ICUt Ultrasound System, SonoSite Inc., Bothell, WA) parallel to the
longitudinal axis of the shaft of the humerus and
approximately 2 cm below the postero-lateral part
of the acromion on the dorsal side of the arm
(Fig. 2), we identified the surgical neck and the
shaft of the humerus and the cross section of the
PCHA, using ultrasound Doppler (Fig. 3). Additional important ultrasonographic landmarks were
also identified: in the transverse section, the teres
minor muscle, which lies cranial to the PCHA, the
posterior part of the deltoid muscle closest to the
probe and as the probe was moved medially the
lateral and long head of the brachial triceps muscle
in longitudinal section just below the deltoid muscle (Fig. 3). The axillary nerve is located cranially in
close relation to the PCHA in the neurovascular
space between the teres minor muscle cranially, the
deltoid muscle posteriorly, the triceps muscle caudally and the shaft of the humerus anteriorly (Fig. 3).
The ultrasound probe was moved medially until
the shaft of the humerus disappeared posteriorly
and then slightly laterally until the shaft of
the humerus just reappeared. In this position, the
important landmarks are the transverse section of
the teres minor muscle, the cross section of the
Fig. 3. Ultrasonographic image of the shoulder region. The transducer is positioned as in Fig. 2 and the left side of the image is
oriented cranially. Important landmarks are the deltoid muscle
(DM) in longitudinal section, the head of the humerus (HH), the
humeral shaft (SH), the teres minor muscle (TM) in transverse
section and the triceps muscle (TrM) in longitudinal section. The
three arrowheads mark the axillary nerve cranially to the posterior
circumflex humeral artery (A) in the neurovascular space between
the TM, DM and TrM.
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C. Rothe et al.
Volunteer study
In the 12 healthy volunteers, we performed and
evaluated the axillary block as described above. C.
R. performed all the blocks and K. L. evaluated all
the blocks.
Table 1
Motor and sensory function of the axillary nerve.
Baseline
15 min
30 min
muscle)
1
1
1
2.5 (14)
3.5 (14)
4 (14)
3 (14)
4 (14)
4 (14)
1
1
Results
Discussion
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sia after minor arthroscopic shoulder surgery. Recently, Price also mentioned an ultrasound-guided
approach to axillary nerve blocking in the NYSORA journal and reproduced similar ultrasound
images as in the present manuscript.22 Interestingly, Checcucci et al.14 used the combined blocks
for both intraoperative anesthesia and post-operative analgesia after arthroscopic shoulder surgery,
i.e. general anesthesia was not performed. Future
clinical studies should therefore investigate the
potential role for the specific axillary nerve block
for intraoperative anesthesia and/or post-operative analgesia either alone or in combination with
a suprascapular nerve block. Another very interesting question is whether a catheter placement is
possible in relation to the axillary nerve for prolonged post-operative analgesia.
In summary, we report a new technique to perform ultrasound-guided specific axillary nerve
blocking. The block is easy to perform and the
ultrasonographic landmarks are easily recognized.
The potential clinical role of this block remains to
be determined.
Acknowledgements
Kristian Antonsen, MD, Head of the Department of Anesthesia
and Intensive Care, Hillerd Hospital, is thanked for providing
excellent working conditions for all authors from the Department of Anesthesia and Intensive Care, Hillerd Hospital.
Funding: Kai Lange received a research grant from Hillerd
Hospital.
Conflicts of interest: The authors have no conflicts of interest.
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Address:
Kai H. W. Lange
Department of Anesthesia and Intensive Care
Hillerd Hospital
Dyrehavevej 29
DK-3400 Hillerd
Denmark
e-mail: klang@hih.regionh.dk