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POSTERIOR INTERSCALENE BLOCK
Ercan KURT
GÜLHANE MILITARY MEDICAL FACULTY
DEPARTMENT OF ANESTHESIOLOGY AND REANIMATION
ANKARA
INTERSCALENE BRACHIAL PLEXUS BLOCK
ANTERIOR APPROACH
•SINGLE – DOSE TECHNIQUE
•CATHETER TECHNIQUE
POSTERIOR APPROACH
•SINGLE – DOSE TECHNIQUE
•CATHETER TECHNIQUE
INTERSCALENE BRACHIAL PLEXUS BLOCK
₡
INDICATIONS
Shoulder and upper arm surgery
Immobility of shoulder joint
Shoulder manipulations
Chronic pain therapy
Arthroscopic shoulder surgery
₡
ADVANTAGES
Easily performed in any position of the arm
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DISADVANTAGES
Ulnar nerve may not be blocked
Serious complications may occur
ISB CONTRAINDICATIONS
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Skin infection
Refusal of the procedure by the patient
Haemorrhagic diathesis
Contralateral phrenic nerve or recurrent nerve paralysis
Known neuropathy involving the arm undergoing surgery
Severe bronchopulmonary disease
Known allergy to the trial drugs
Previous neurologic damage to the brachial plexus
INTERSCALENE BLOCK
ANATOMY OF BRACHIAL
PLEXUS
V.J.Interna
A. C.Communis
Phrenic nerve
Subclavian a.
Subclavian v.
Cupola of
lung
Anterior and
middle scalene
Subclavian a-v
Vertebral a.
Phrenic nerve
Middle scalene m.
Anterior scalene m.
Subclavian a.
SCM
muscle
ANATOMICAL LANDMARKS
OF BRACHIAL PLEXUS
 Arteria carotis communis
 Apex of lung
 Phrenic nerve
LOCAL ANESTHETICS MAY SPREAD INTO
SUBARACHNOIDAL SPACE THROUGH
THREE WAYS
1- INTERVERTEBRAL FORAMEN
2- DURAL SHEATH
3- INTRANEURALLY
SINGLE - DOSE ISB USING
POSTERIOR APPROACH
ISB USING POSTERIOR APPROACH
ANATOMICAL LAYERS IN
TRANSVERSE SECTION
1- Skin-subcutaneous tissue
2- M. trapezius
3- M. splenius capitis
4- M. semispinalis capitis
5- M. semispinalis cervitis
6- M. scaleneus posterior
7- M. scaleneus medius
ISB USING POSTERIOR APPROACH
C-7 SPINOUS PROCESS
BRACHIAL PLEXUS
POSTERIOR ISB
SITTING POSITION
LATERAL DECUBITIS POSITION
SINGLE - DOSE ISB USING
POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
SINGLE - DOSE ISB USING POSTERIOR APPROACH
LOCAL ANESTHETICS FOR ISB
A TOTAL VOLUME OF 40 – 50 ML
 20 -25 ml 0,5 %
 20 - 25ml 0,5 %
 20 - 25ml 0,2 %
bupivacaine + 20 - 25 ml 1 % prilocaine
bupivacaine + 20 - 25 ml 1 % lignocaine
ropivacaine + 20 - 25 ml 1 % lignocaine
INDICATIONS FOR CATHETER
 Acute pain therapy (postoperative)
 Management of chronic pain (CRPS)
 Supportive adjunct to physiotherapy/exercise
therapy
 Sympatholysis (for improving wound healing)
 Preventive analgesia (phantom pain prophylaxis)
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
CONTINUOUS ISB USING POSTERIOR APPROACH
STIMULATING CATHETERS
• Does Interscalene Catheter Placement with
Stimulating Catheters Improve Postoperative
control catheter placement
Pain or Precisely
Functional
Outcome After Shoulder
Improved onset of motor nerve block
Surgery?
Regional Anest Vol 104(2) 2007
Stevens M.F.
Brachial Plexus Block With Catheter Using
The Posterior Interscalene Approach
Decreased likelihood of catheter
• In The
Management
Neuropathic
dislodgement
due Of
to neck
movement
Cancer Pain (2 Case Report)
TÜRKER G.
Uludağ Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, BURSA
ISB COMPLICATIONS
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Horner syndrome
N. recurrens paralysis
Phrenic nerve paralysis
Bronchospasm
Total spinal anesthesia
Acute respiratory insufficiency
Contralateral anesthesia
Loss of consciousness and apnea
Hematoma
Nerve injury
ACCIDENTAL EPIDURAL
CATHETERIZATION
• During continuous interscalene block via the
posterior approach
Gurbet A.
2005 Journal The Pain Clinic
•the patient should be awake and conscious during catheter placement
•radiographic confirmation of catheter position should be
obtained before the first injection
•after each local anesthetic injection the patient should be monitored.
5 ml of contrast medium were injected and a C-arm fluoroscopic
imaging showed contrast medium in the epidural space with catheter opacification
INTRACORD INJECTION
• Permanent Loss of Cervical Spinal Cord
Function Associated with Interscalene
Block Performed Under
General
Anesthesia
• Benumof Jonathan L
• Volume 93(6), December 2000, 1541- 4
How to Prevent Catastrophic
Complications When Performing ISB
In our institution, we only perform
interscalene blocks before or after
surgery in awake patients
PRECAUTIONS IN ISB
 ISB should not be performed in patients with a
history including contralateral hemidiaphragmatic
paralysis, pneumothorax and pneumonectomy
 The patients who can not tolerate a 25 % reduction
of FVC are not appropriate for ISB
 Pulse oxymetry should be used
 Supplemental nazal oxygen should be given
IN CASE OF DISPNEA AFTER ISB
 The patient should be closely observed
 Patient is positioned in reverse Trendelenburg or sitting
position
 Breath
sounds
should
be
oscultated
to
evaluate
diaphragmatic hemiparesis
 A chest radiogram is required to check pneumothorax
 Ventilatory support or endotracheal intubation is indicated, if
necessary
AS A RESULT
₪Prevention of these complications
includes the proper selection of
patients
₪The performance of blocks either
before or after anesthesia in patients
who are awake or mildly sedated