title: Frontal slab composite magnetic resonance neurography of the brachial plexus: implications for infraclavicular block approaches.
abstract: BACKGROUND
  Magnetic resonance neurography (MRN) is an imaging method by which nerves can be selectively highlighted. Using commercial software, the authors explored a variety of approaches to develop a three-dimensional volume-rendered MRN image of the entire brachial plexus and used it to evaluate the accuracy of infraclavicular block approaches.
  
  
  METHODS
  With institutional review board approval, MRN of the brachial plexus was performed in 10 volunteer subjects. MRN imaging was performed on a GE 1.5-tesla magnetic resonance scanner (General Electric Healthcare Technologies, Waukesha, WI) using a phased array torso coil. Coronal STIR and T1 oblique sagittal sequences of the brachial plexus were obtained. Multiple software programs were explored for enhanced display and manipulation of the composite magnetic resonance images. The authors developed a frontal slab composite approach that allows single-frame reconstruction of a three-dimensional volume-rendered image of the entire brachial plexus. Automatic segmentation was supplemented by manual segmentation in nearly all cases. For each of three infraclavicular approaches (posteriorly directed needle below midclavicle, infracoracoid, or caudomedial to coracoid), the targeting error was measured as the distance from the MRN plexus midpoint to the approach-targeted site.
  
  
  RESULTS
  Composite frontal slabs (coronal views), which are single-frame three-dimensional volume renderings from image-enhanced two-dimensional frontal view projections of the underlying coronal slices, were created. The targeting errors (mean +/- SD) for the approaches-midclavicle, infracoracoid, caudomedial to coracoid-were 0.43 +/- 0.67, 0.99 +/- 1.22, and 0.65 +/- 1.14 cm, respectively.
  
  
  CONCLUSIONS
  Image-processed three-dimensional volume-rendered MNR scans, which allow visualization of the entire brachial plexus within a single composite image, have educational value in illustrating the complexity and individual variation of the plexus. Suggestions for improved guidance during infraclavicular block procedures are presented.
authors.affiliation: Department of Anesthesiology, Keck School of Medicine, University of Southern California, 1200 North State Street, Rm. 14-901, Los Angeles, CA 90033, USA. draphael@usc.edu
authors.forename: David T
authors.initials: DT
authors.lastname: Raphael
authors.forename: Diane
authors.initials: D
authors.lastname: McIntee
authors.forename: Jay S
authors.initials: JS
authors.lastname: Tsuruda
authors.forename: Patrick
authors.initials: P
authors.lastname: Colletti
authors.forename: Ray
authors.initials: R
authors.lastname: Tatevossian
mesh_terms: D000328:Adult; D001917:Brachial Plexus / Q000033:anatomy & histology*; D002968:Clavicle / Q000033:anatomy & histology; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D015203:Reproducibility of Results; D013126:Spinal Nerve Roots / Q000033:anatomy & histology; D016683:Supine Position