• See Also
  1. Supraclavicular Nerve Block
  2. Superficial Cervical Plexus Nerve Block
  3. Superior Trunk Block
  4. Brachial Plexus
  5. Regional Anesthesia (Nerve Block)
  6. Local Skin Anesthesia
  7. Point of Care Ultrasound (POCUS)
  • Indications
  1. Anesthesia to Shoulder, upper arm and clavicle
  2. Does not provide Anesthesia to ulnar aspect of the Forearm or hand
  • Anatomy
  1. Brachial Plexus Nerve Roots (C5-T1) form the Brachial Plexus trunks and arm Peripheral Nerves
    1. Brachial Plexus runs 1-3 cm deep in the supraclavicular region, inferolateral to sternocleidomastoid Muscle
    2. Nerve roots C5-C7 are most accessible to Nerve Block
  2. Risk of adverse effects on nearby structures
    1. Carotid Artery and Internal Jugular Vein are medial to injection site
    2. Phrenic Nerve (transient diaphragm paralysis)
    3. Superficial Cervical Plexus Block (Transient Horner Syndrome)
  • Preparation
  1. Patient positioning
    1. Patient lies supine
    2. Head and neck rotated away from the side of the Nerve Block
  2. Identify and mark landmarks
    1. Lateral to Carotid Artery and internal Jugular Vein, posterior sternocleidomastoid Muscle
    2. Level 2-3 inches (5-7.5 cm) above the clavicle
  3. Skin Preparation (e.g. Chlorhexidine)
  4. Drape region
  5. Sterile covering over Ultrasound high frequency linear probe (sterile gel inside and outside)
  6. Medication
    1. Confirm maximum dose for Ropivacaine (or Bupivacaine ) to prevent LAST Reaction
    2. Ropivacaine 0.5% (preferred over Bupivacaine 0.25% to 0.5%) 7-15 ml
    3. Syringe 20 ml
    4. Needle 22 gauge, 2" (5 cm)
  • Technique
  1. Images
    1. interscaleneBrachialPlexusBlockUS.jpg
  2. Ultrasound in transverse plane over lateral neck (lateral to Thyroid cartilage)
    1. High frequency linear probe
    2. Roughly 2-3 inches (5-7.5 cm) above the clavicle
    3. Probe overlies posterior aspect of sternocleidomastoid Muscle
    4. Slide probe laterally until both Carotid Artery and Jugular Vein are visible
    5. Identify anterior and middle scalene Muscles
      1. May need to slide laterally to fully visualize the Muscle groups
      2. Identify Brachial Plexus between the 2 Muscle groups
  3. Injection Plane
    1. Inject from lateral to medial
      1. Under the lateral border of the sternocleidomastoid Muscle
    2. Target is 1-3 cm deep at the Cervical Nerve Roots (C5-C8)
      1. C5-C7 Nerve roots will appear as a vertical stop light (3 round stacked nerve-like structures)
      2. Do NOT inject the actual nerves, only in their vicinity
  4. Alternatives: Supraclavicular Brachial Plexus Block
    1. Injection site may be shifted inferiorly to supraclavicular region
    2. Performed in similar fashion as Interscalene Block
    3. Only performed under Ultrasound guidance (risk of Pneumothorax)
    4. Unlike the Interscalene Block, the supraclavicular does not block the Shoulder (only distal to Shoulder)
  • Complications
  1. See Regional Anesthesia
  2. LAST Reaction (as with any Nerve Block)
  3. Phrenic Nerve paralysis (common, do NOT perform bilaterally)
  4. Recurrent laryngeal nerve paralysis (results in Horner Syndrome)
  • References
  1. Warrington (2025) Crit Dec Emerg Med 39(3): 18-9
  2. Zisquit and Nedeff (2020) Interscalene Block, Stat Pearls, accessed 12/21/2020
    1. https://www.ncbi.nlm.nih.gov/books/NBK557382/
  3. Martel (2020) Regional Anesthesia for Acute Care Conference, attended 12/11/2020
    1. https://stabroom.com/
  4. Ultrasound-Guided Interscalene Brachial Plexus Block, NYSORA, accessed 12/21/2020
    1. https://www.nysora.com/techniques/upper-extremity/intescalene/ultrasound-guided-interscalene-brachial-plexus-block/