Supervisors info:
Χρυσάνθη Μπατιστάκη, Επίκουρη Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Θεοδόσιος Σαραντέας, Επίκουρος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Γεωργία Γερολουκά-Κωστοπαναγιώτου, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Brachial plexus blockade was firstly introduced by William Halsted and Richard Hall in 1884.There are four main approaches from which the brachial plexus can be blocked: interscalene, supraclavicular, infraclavicular and axillary. In this thesis, the three last approaches will be dealt with.
There are several techniques used to localise the brachial plexus nerves: eliciting paraesthesias, palpation of accompanying artery, electrical nerve stimulation and most recently, ultrasound guidance. Ultrasound guided blockade has a noninvasive and dynamic nature that leads to higher success rates and less complications.
The brachial plexus is derived from the anterior primary rami of C5-C8 and T1 nerves. These roots form the three trunks (superior, middle and inferior) between the anterior and middle scalene muscles. The three trunks separate into anterior and posterior divisions behind the clavicle and subsequently the divisions join to form the three cords: lateral, medial and posterior in relation with the axillary artery. At the lateral border of the pectoralis minor muscle, the cords give rise to their terminal branches: the musculocutaneous, radial, ulnar, median and axillary nerves.
Infraclavicular blockade of the brachial plexus provides anaesthesia of the distal two thirds of the arm and is ideal for the placement of an indwelling catheter. It can be performed either in the lateral infraclavicular fossa or in the costoclavicular space. Risk of pneumothorax is small but it should perhaps be avoided in patients receiving anticoagulants in case of inadvertent vascular puncture.
Axillary brachial plexus block is the most popular block and provides anaesthesia of the upper limb distal to the elbow. The final branches of the brachial plexus are located in the axillary fossa around the axillary artery. There are several anatomical variations of these nerves and ultrasound guidance is vital for their localization.
Finally, the musculocutaneous, radial, ulnar and median nerves can be blocked further down their course under ultrasound guidance. In this way, a proximal brachial plexus block can be hastened, improved and prolonged. Distal nerve blocks of the upper extremity can be performed above or below the elbow.
Under ultrasound guidance, brachial plexus blockade has become safer, more efficient and accurate. However, the use of ultrasound is dependent on the operator’s experience as well as his/her knowledge of the relevant anatomy.
Keywords:
Ultrasound, Peripheral nerve blocks, Axilla, Elbow
