Anatomy of the brachial plexus and its implications for daily clinical practice: regional anesthesia is applied anatomy

Abstract

Safety and effectiveness are mandatory requirements for any technique of regional anesthesia and can only be met by clinicians who appropriately understand all relevant anatomical details. Anatomical texts written for anesthetists may oversimplify the facts, presumably in an effort to reconcile extreme complexity with a need to educate as many users as possible. When it comes to techniques as common as upper-extremity blocks, the need for customized anatomical literature is even greater, particularly because the complex anatomy of the brachial plexus has never been described for anesthetists with a focus placed on regional anesthesia. The authors have undertaken to close this gap by compiling a structured overview that is clinically oriented and tailored to the needs of regional anesthesia. They describe the anatomy of the brachial plexus (ventral rami, trunks, divisions, cords, and nerves) in relation to the topographical regions used for access (interscalene gap, posterior triangle of the neck, infraclavicular fossa, and axillary fossa) and discuss the (interscalene, supraclavicular, infraclavicular, and axillary) block procedures associated with these access regions. They indicate allowances to be made for anatomical variations and the topography of fascial anatomy, give recommendations for ultrasound imaging and needle guidance, and explain the risks of excessive volumes and misdirected spreading of local anesthetics in various anatomical contexts. It is hoped that clinicians will find this article to be a useful reference for decision-making, enabling them to select the most appropriate regional anesthetic technique in any given situation, and to correctly judge the risks involved, whenever they prepare patients for a specific upper-limb surgical procedure.

Anatomical variations detected during ultrasound-guided interscalene brachial plexus block and clinical implications

“…In our clinical practice, when these anomalies are observed, we perform ISB 2-3 cm caudal to the variation point, if possible. Vascular structures, which will restrict the spread of LA or inhibit the needle advancement such as dorsal scapular artery, can be present between the cervical roots in this region [8,9]. While an artery crossing the roots or trunks was revealed in 23% of the patients in the study by Gutton et al, the rate was observed as 4.5% in the current study.…”

“…The variations associated with some nerves, muscles and vascular structures in the interscalene area may affect the technique of the procedure [7][8][9]. In the presence of such variations, especially in the cephalad approach and ISB conducted with low volume, the scalene muscles can prevent the spread of local anesthesia (LA) by acting as a barrier [10,11].…”

Brachial plexus injury after clavicle fracture operation: a case report and literature review

“…The brachial plexus is an important peripheral nerve plexus in the human body. It is composed of C5–C8, T1 nerve roots, and innervates the sensory and motor functions of the shoulder and upper limbs [ 9 ]. Once injured, the disability rate is high, which seriously affects the quality of life of patients.…”

Anatomy of Brachial Plexus Above the Clavicle

“…The Interscalene Sub-areas (Figure 5), Feigl [5] notified two anatomically distinct spaces are contained in the interscalene gap:…”

“…The superior and middle trunks may be separated from the inferior trunk at the level of subclav ican ar ter y (Zuckerkandl-Sebileau ligaments) [5].…”