Brachial plexus blocks: a review of approaches and techniques.
OBJECTIVE
The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding established approaches and techniques for brachial plexus anesthesia.


METHODS
Using the MEDLINE (January 1966 to November 2006) and EMBASE (January 1980 to November 2006) databases, key words "brachial plexus", "nerve blocks", "interscalene", "cervical paravertebral", "suprascapular", "supraclavicular", "infraclavicular", "axillary", "brachial canal" and "humeral canal" were searched for full text articles pertaining to the evaluation of recognized approaches and techniques for brachial plexus anesthesia. The search was limited to RCTs involving human subjects and published in the English language. Seventy-six RCTs were identified.


RESULTS
Many of the published studies were underpowered and contained various methodological limitations. We found that, for shoulder and proximal humeral surgery, interscalene and cervical paravertebral approaches to the brachial plexus appear to provide equally effective surgical anesthesia. Intersternocleidomastoid supraclavicular blocks are not associated with improved postoperative analgesia despite eliciting more complete anesthesia of the brachial plexus. For surgery at or below the elbow, an infraclavicular block may result in decreased performance time and block-related pain while providing similar efficacy compared to (multiple-stimulation) axillary and brachial canal approaches. With respect to technique, it is unclear if nerve stimulation provides a more effective interscalene block than elicitation of paresthesiae. For supraclavicular blocks, nerve stimulation with a minimal threshold of 0.9 mA is recommended, whereas a double-stimulation technique is optimal for infraclavicular blocks. For the axillary approach, a triple-stimulation technique, involving injections of the musculocutaneous, median and radial nerves, is the most effective option.


CONCLUSIONS
Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for brachial plexus anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasound or combining neurostimulation and echoguidance.
Montreal General Hospital, Department of Anesthesia, McGill University, Montreal, Quebec, Canada. de_tran@hotmail.com
Quang Hieu De
QH
Tran
Antonio
A
Clemente
Julian
J
Doan
Roderick J
RJ
Finlayson
D001365:Axilla; D001917:Brachial Plexus; D002574:Cervical Vertebrae; D002968:Clavicle; D005154:Facial Nerve; D006801:Humans; D006811:Humerus; D007269:Injections, Intra-Arterial; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D004561:Transcutaneous Electric Nerve Stimulation / Q000295:instrumentation