Gross Anatomy of the Brachial Plexus Sheath in Human Cadavers

Franco, Carlo D.; Rahman, Abed; Voronov, Gennadiy; Kerns, James M.; Beck, Robert J.; Buckenmaier, Chester C.

doi:10.1016/j.rapm.2007.09.003

Cited by 22 publications

(22 citation statements)

References 21 publications

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“…Franco et al in a recent cadaver study of the brachial plexus sheath described the membrane as only 1-to 2-mm thick and observed that the sheath could be easily detached from the surrounding muscle bed [10]. Our results suggest that local anaesthetic solution readily diffuses across this membrane, as both groups were equivalent in terms of onset of the sensory and motor block.…”

Section: Discussionsupporting

confidence: 53%

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Ultrasound‐guided interscalene blocks: understanding where to inject the local anaesthetic

Spence

Beach²,

Gallagher

et al. 2011

Anaesthesia

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SummaryAlthough ultrasound-guided regional anaesthesia has gained in popularity, few data exist describing the optimal location(s) to inject local anaesthetic. Our objective was to compare, for interscalene blocks, the effectiveness of an injection between the middle scalene muscle and brachial plexus sheath (peri-plexus) with an injection within the brachial plexus sheath (intra-plexus). We enrolled 170 patients undergoing shoulder surgery with general anaesthesia and interscalene block in this randomised, controlled trial. Our primary outcome variable was loss of shoulder abduction. Block quality was also measured and defined by an evaluation of onset time, sensory and motor loss and duration. There was no difference between the two groups in block onset times or block quality. After adjusting for sex, age and volume injected, intra-plexus blocks lasted a mean of 2.6 h (16%) longer (95% CI 0.25-5.01, p = 0.03) than peri-plexus blocks.

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Section: Discussionsupporting

confidence: 53%

“…Anatomical literature suggests that a connective tissue sheath surrounds the brachial plexus as a thin membrane [9][10][11][12]. Franco et al in a recent cadaver study of the brachial plexus sheath described the membrane as only 1-to 2-mm thick and observed that the sheath could be easily detached from the surrounding muscle bed [10].…”

Section: Discussionmentioning

confidence: 99%

Ultrasound‐guided interscalene blocks: understanding where to inject the local anaesthetic

Spence

Beach²,

Gallagher

et al. 2011

Anaesthesia

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“…Furthermore, we did not consider septae dividing the brachial plexus within the sheath. However, the presence of septae has not been confirmed, and it has been known LA permeates septae and distributes within sheaths [13,16,17].…”

Section: Discussionmentioning

confidence: 99%

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

Chang

Lee

Oh³

et al. 2017

Anesth Pain Med

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“…A paraneural sheath surrounds the brachial plexus as a thin membrane (10,12), and it is possible that the paraneural sheath precludes the need for direct circumferential injection. As the space between nerve roots is limited, the area becomes saturated with LA, and multiple injections force incoming LA molecules to find alternate paths of less resistance.…”

Section: Discussionmentioning

confidence: 99%

“…This may have been due to reduced systemic uptake of LA in the TI group, due to more LA being contained within the brachial plexus sheath, thus increasing the reservoir volume of LA solution (10). Franco et al (12) described the interior of the sheath surrounding the neuronal tissue as a combination of loose connective tissue and fat, with few veins running along the sheath interior. These observations potentially explain the results of the present study, as there may have been decreased systemic absorption of LA in the TI group due to reduced vascularity on the interior of the sheath.…”

Section: Discussionmentioning

confidence: 99%

Comparison of single‑ and triple‑injection methods for ultrasound‑guided interscalene brachial plexus blockade

Wang

Gao

et al. 2018

Exp Ther Med

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Abstract. Ultrasound-guided interscalene brachial plexus blockade (IBPB) has a relatively high success rate in shoulder surgery; however, whether multiple injections are superior to a single injection (SI) is currently unknown. In the present study, ultrasound-guided SI and triple-injection (TI) IBPBs were compared in a prospective randomized trial. A total of 111 patients undergoing arthroscopic shoulder surgery and presenting with an American Society of Anesthesiologists physical status grading of I-II were randomly allocated to receive IBPB with 15 ml of 1% ropivacaine as a SI or TI. Performance time, procedure-related pain scores, success rate and prevalence of complications were recorded. The distribution of sensory and motor block onset in the radial, median, ulnar and axillary nerves were assessed every 5 min until 30 min post-local anesthetic injection. The duration of sensory and motor blocks were also assessed. A significantly longer performance time was recorded in the TI group (P<0.001). No significant difference was observed in success rate (91% in TI vs. 88% in SI) 30 min post-injection, and the prevalence of complications and procedure-related pain were similar between the two groups. Sensory and motor blocks of the ulnar nerve in the TI group were significantly faster and more successful compared with the SI group at all time points (P<0.041). It was also observed that sensory and motor blocks in the TI group were prolonged compared with the SI group (P<0.041). In conclusion, the TI method exhibited a faster time of onset and resulted in a more successful blockade of the ulnar nerve. TI method may be a more effective approach for IBPB in a clinical setting. IntroductionBlockade of the brachial plexus through an interscalene approach has a relatively high success rate in shoulder surgery (1-3). Ultrasound imaging of the brachial plexus between the anterior and middle scalene muscles is feasible (4), and it has been documented that use of ultrasound improves the success rate and reduces the prevalence of complications (5). Furthermore, the site of injection may affect the spread of local anesthetic (LA) (6), and a number of studies comparing different approaches for nerve blocks have documented that multiple injections of LA around the nerve result in a higher prevalence of success and a shorter time of onset compared with LA deposition at a single location (7-9). Furthermore, the present authors have previously observed that triple injection (TI) is necessary if LA is deposited inside the paraneural sheath, and that the paraneurium ʻentrapsʼ LA molecules, thereby ensuring circumferential spread around the interscalene brachial plexus nerve (7). Therefore, ultrasound-guided TI may increase the efficacy and quality of interscalene brachial plexus blocks (IBPBs).In the present study, a prospective, randomized, observerblinded trial was conducted to compare the efficacy and safety of single injection (SI) and TI methods of IBPB for arthroscopic shoulder surgery. The primary aims were to compare the on...

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Gross Anatomy of the Brachial Plexus Sheath in Human Cadavers

Abstract: We observed a macroscopic fibrous structure surrounding the plexus, which was filled with loose connective tissue lacking any apparent organization.

Cited by 22 publications

References 21 publications

Ultrasound‐guided interscalene blocks: understanding where to inject the local anaesthetic

Ultrasound‐guided interscalene blocks: understanding where to inject the local anaesthetic

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

Comparison of single‑ and triple‑injection methods for ultrasound‑guided interscalene brachial plexus blockade

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