title: [Clinical experience in interscalene brachial plexus block combined with Ho's method of C3-4 block for shoulder and proximal upper extremity surgeries].
abstract: BACKGROUND
  Brachial plexus block, first performed in 1889 by Halsted, has been widely used for surgery of shoulder and upper third of upper extremity. But the level of block is inadequate for surgery of the deeper tissue. If high volume of local anesthetic (40 ml) is used to block C3-4, complications like Horner's syndrome and phenic nerve palsy would be frequent. The landmark of C-3 and C-4 nerve root is difficult to identify. The purpose of this study was to design a new method to block easily the C-3 and C-4 nerve roots for surgery of shoulder deep tissue.
  
  
  METHODS
  Sixty-five patients with ASA physical status I-III and age from 15 to 65 yr were studied. They included 42 male and 23 female patients who received interscalene brachial plexus block together with Ho's method of C-3, C-4 block in the space of 10 mon since 1985. The Ho's point which circumscribes the landmark for C3-4 block is a point at which the outer margin of the external jugular vein intersects the sternocleidomastoid muscle. In this technique we punctured the skin with a needle vertically at the chosen point until it touched the anterolateral side of the C-4 transverse process, normally, not deeper than 1.25 cm. This block was usually done for surgery of the shoulder and upper third of upper extremity. We used 0.5% bupivacaine 10 ml combined with 2% lidocaine 10 ml for interscalene brachial plexus block and 2% lidocaine 10 ml only for C3-4 block.
  
  
  RESULTS
  Only 3 out of total 65 blocks failed. For these 3 cases we shifted the regimen from nerve block to general anesthesia. The successful rate was 95.4%. One case was initially planned for general anesthesia. However, difficult intubation was encountered due to masseter muscle spasm/rigidity during anesthetic induction. Three days later, this case was successfully anesthetized with this block. BP, EKG, and SaO2 did not differ preoperatively and intraoperatively. If the operation time is limited to 3 h, the result has always been satisfactory.
  
  
  CONCLUSIONS
  Interscalene brachial plexus block combined with Ho's method of C3-4 block is technically safe and economical for patients receiving shoulder and proximal third of upper extremity surgery. We must make selection of patients carefully and exclude those whose anatomical landmarks are difficulty identified. As such, good result is expected.
authors.affiliation: Department of Anesthesiology, Taiwan Adventist Hospital, Taipei Medical College Hospital.
authors.forename: C S
authors.initials: CS
authors.lastname: Ho
authors.forename: N P
authors.initials: NP
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001132:Arm / Q000601:surgery; D001917:Brachial Plexus; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009407:Nerve Block; D012785:Shoulder Joint / Q000601:surgery*