A Simple Interscalene Block: The Manani`s Technique. Some

Article ID: WMC004162
ISSN 2046-1690
A Simple Interscalene Block: The Manani's
Technique. Some Elements of Distinction from
Supraclavicular Perivascular Techniques
Corresponding Author:
Dr. Gastone Zanette,
Senior Lecturer in Anaesthesiology, University of Padua, Department of Neurosciences,Chair of Dental
Anaesthesia, via Venezia 90, 35125 - Italy
Submitting Author:
Dr. Gastone Zanette,
Senior Lecturer in Anaesthesiology, University of Padua, Department of Neurosciences,Chair of Dental
Anaesthesia, via Venezia 90, 35125 - Italy
Article ID: WMC004162
Article Type: Original Articles
Submitted on:24-Mar-2013, 07:17:21 PM GMT
Published on: 25-Mar-2013, 01:30:08 PM GMT
Article URL: http://www.webmedcentral.com/article_view/4162
Subject Categories:ANAESTHESIA
Keywords:Interscalene block, Supraclavicular block, Subclavian perivascular block, Anatomical landmarks,
Brachial plexus anatomy, Omohyoid muscle
How to cite the article:Manani G, Facco E, Zanette G. A Simple Interscalene Block: The Manani's Technique.
Some Elements of Distinction from Supraclavicular Perivascular Techniques . WebmedCentral ANAESTHESIA
2013;4(3):WMC004162
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution
License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Source(s) of Funding:
Funding or research contracts: None
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Conflict of interest: None
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Comments to this revised manuscript.
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A Simple Interscalene Block: The Manani's
Technique. Some Elements of Distinction from
Supraclavicular Perivascular Techniques
Author(s): Manani G, Facco E, Zanette G
Abstract
Aim: The aim of this study is an anatomical review
regarding the brachial plexus and its relationships with
contiguous anatomical structures to better define the
Interscalene Brachial Plexus Block Technique already
described by Manani (IBPBTM), specifically
concerning the point of needle penetration, needle
direction and its relationship with OmoClavicular
Triangle (OCT) and the inferior belly of omohyoid
muscle. Moreover, IBPBTM was compared with other
Supraclavicular Perivascular Brachial Plexus Block
Techniques (SPBPBT).
Materials and methods: The IBPBTM was performed
in 80 randomly selected patients scheduled for
shoulder surgery. After identification of the OCT and
inferior belly of omohyoid muscle, fascial click
perception and evocation of adequate muscular
contractions, injection of 30 ml of 0.5% bupivacaine in
the interscalene space (IS) was performed; the angles
delimited by the penetrating needle on the transverse
and frontal planes, going across the cutaneous
penetration point, were measured and recorded.
Moreover, the time of complete anaesthetic block
development and failure rate were evaluated by
means of an electric stimulation applied on the skin of
C3-T1 dermatomes.
Results: In almost all patients identification of the
OCT, omohyoid inferior belly muscle and fascial click
perception were possible. The stimulating needle
resulted to be directed with a 14.0±5.2 and
-5.1±1.3 degree angle to the frontal and transverse
planes going across the cutaneous penetration point,
respectively. Deep surgical blocks developed more
rapidly on C3, C4 and C5 dermatomes, with respect to
the C6, C7, C8-T1 dermatomes. Failure rate was
about 8%.
Discussion and conclusions: Our results confirm the
efficacy of the IBPBTM and provide new insight for a
better performance of this block, specifically regarding
to the needle penetration angles, the identification of
precise anatomical landmarks (OCT and omohyoid
inferior belly muscle). The block efficacy was
WebmedCentral > Original Articles
dependent on a correct performance, including the
identification of the IS located medially, behind and
above the OCT; on the contrary, in the SPBPBT the
needle penetration points are located inside the OCT.
From this comparison IBPBTM seems to be superior
to SPBPBT in shoulder and peri-shoulder surgery.
Introduction
Previous studies have shown that interscalene
brachial plexus block techniques can be divided into
two types of approach depending on whether the local
anesthetic solution is injected in the vicinity of the
spine or in the thickness of the interscalenic space
(IS). In the first case, the area of anesthesia is larger
despite lower volumes of local anesthetic; in the
second case, the area of anesthesia is more limited,
mainly correspondent to the area of innervation of the
primary upper trunk of the brachial plexus. Greater
extension of the area of anesthesia, using each
technique may be achieved using higher volumes of
local anesthetic.(1,2) Anesthesia of the brachial plexus
innervation area can also be obtained in other ways,
among which the supraclavicular and subclavian way.(3)
The different ways of approach have generated a
multiplicity of techniques, some of which are easy to
perform, while others have a more difficult execution
and are associated to a higher or lower incidence of
success due to the complex anatomy of the region.
Anatomical knowledge, acquisition of techniques and
their application depending on the surgical
requirements, respecting the principles of the
techniques used and the skill gained fromfrequent
execution of the block, all contribute to excellent
results. In this study we want to review our
Interscalene Brachial Plexus Block Technique already
described by Manani (IBPBTM) (4,5,6,7) along with a
comparison of this block with other Supraclavicular
Perivascular Brachial Plexus Block Techniques
(SPBPBT), in relation to the anatomy of the brachial
plexus; moreover, we want to describe more carefully
the needle direction, angles and point of penetration.
Studying the anatomy of the region we have identified
an additional area represented by the inferior belly of
the omohyoid muscle that makes the IBPBTM
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impossible to compare to the SPBPBT when the
omohyoid muscle is easily identified.
Anatomy of the brachial plexus in relation to the
execution of IBPBTM and SPBPBT.(8)
The brachial plexus is located at the base of the neck
in the supraclavicular fossa and consists of the
anterior branches of C5, C6, C7 and C8 and the anterior
branch of T1. (Illustration 1) The plexus is divided into
supraclavicular and subclavian portions. The
supraclavicular part of the plexus consists of the
anterior branches and the primary trunk. Where the
supraclavicular part of the plexus joins with the
subclavian artery it is referred to as the neurovascular
bundle of the subclavian artery (Illustration 2). The
neurovascular bundle extends caudally in respect to
an imaginary plane between the clavicle and the upper
part of the body of the 7th cervical vertebra. The
SPBPBT execution area, including the Winnie and
Collins(9) and the "classical technique" by Kulenkampff, (10)
lies below this plane (Illustration 3). The
supraclavicular part of the brachial plexus nerve
sheath is surrounded by the IS(8) inside of which, the
needle must be inserted in order for the technique to
be included among the interscalene block techniques
(Illustration 4). The subclavian portion includes the
secondary trunk, the origin of the long ramus and it is
suitable for the infraclavicular and axillary block
techniques.
The anterior and middle scalene muscles are
important for the anaesthesiologist because the
cervical and brachial plexus lie between them.
(Illustration 5) The anterior scalene muscle is crossed,
in the supraclavicular fossa, by the inferior belly of the
omohyoid muscle. (Illustration 6) Between the anterior
and middle scalene muscle there is a pyramidal space
that contains the brachial plexus and, at the bottom,
also the subclavian artery, the so called "inter-scalene
triangle" (11) (Illustration 7). The anterior scalene
muscles define a depression called inter-scalene
groove. The brachial plexus, bonded to the middle
scalene muscle through a fibrous lamina, emerges on
the lateral margin of the anterior scalene muscle.
Emerging between the two scalene muscles, the
plexus draws the apex of the inter-scalene triangle
located above the upper edge of the omohyoid muscle.
The block techniques performed above this landmark
are “true interscalene” blocks, like our IBPBTM,
because the local anesthetic are introduced through
the interscalene sheath in the correspondent groove.
The subclavian artery is in relation with the brachial
plexus, medially to the scalene muscles, then in
between and finally, lateral to the scalene muscles. It
WebmedCentral > Original Articles
is important to note that the subclavian artery runs in
the triangle between the anterior scalene muscle, the
omohyoid muscle and the clavicle, also called "the
omoclavicular triangle" (Illustration 8).(12) Here, the
subclavian artery is in relation to the brachial plexus
nerves.(13) The arterial pulsations perceived represent
an useful landmark for the performance of SPBPBT
and IBPBTM. The omohyoid muscle demarcates the
limit between the inferior part of the brachial plexus,
organized as neurovascular bundle by the addition of
subclavian artery, and the superior part of the brachial
plexus which is yet to be formed in the neurovascular
subclavian bundle. The brachial plexus is not formed
in the neurovascular bundle when, coming out from
the anterior and medial scalene muscles, it does not
come in relation with the subclavian artery. ( 1 4 )
Approaches below this landmark (omohyoid muscle)
must be defined as Supraclavicular Perivascular
Brachial Plexus Block Techniques (SPBPBT) while
approaches above this landmark must be defined as
Interscalene Brachial Plexus Block Technique (IBPBT)
as that already described by Manani (IBPBTM).(4)
The neurovascular bundle (subclavian artery and
brachial plexus) is wrapped by sheaths of thin and
dense fibrous lamellar connective tissue connected to
the medium and deep cervical fascia.(15,16,17,18) Since
this sheath continues with the sheath of the cervical
plexus,(19) a single injection of a large volume of local
anesthetic in the IS is sufficient to obtain a
cervico-brachial plexus block.
Bias in performing brachial plexus blocks.
These notes about brachial plexus anatomy and
relations with contiguous structures, especially with
the subclavian artery, suggest that there are some
factors that influence the spread of the local anesthetic.
Illustration 9 shows the typical distribution of surface
anesthesia after IBPBT, SPBPBT, axillary technique
and after the combination of IBPBT and axillary
technique. Finger pressure was used to impede or
facilitate the cephalic progression of the local
anesthetic after IBPBT, though Urmey et al.(23) deem
there to be no difference in the extension of
anesthesia. The search for the "fascial click”, for local
anesthetic reflux,(24) for the paresthesias,(25) and for
muscle contraction during electric stimulation(26,27) are
the prerequisites for the proper execution of the block.
These methods seem to be surpassed by the recent
ultrasound-guided techniques.(28) The direction of the
needle is very important to reach the target. When
using IBPBTM, the correct execution requires directing
the needle towards the interscalene groove and the IS,
although the secondary extensions of connective
tissue that wrap the blood vessels and nerves(29) can
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be a barrier to the spread of the local anesthetic within
the neurovascular space.
SPBPBT and IBPBTM: common and different
features.
The SPBPBT.
The SPBPBT has anatomical landmarks which can be
used all together or in part. (30,31,32,33) These points are: a)
the middle part of the clavicle; b) the outer edge of the
clavicular head of the SternoCleidoMastoid muscle
(SCM); c) the inner edge of the trapezius muscle at
the clavicular insertion; c) the pulsation of the
subclavian artery d) Sedillot's triangle which is defined
by the two heads of the SCM and the upper margin of
the clavicle e) the external jugular vein; f) anterior
scalene muscle g) the omoclavicular triangle. SPBPBT
occurs when the needle goes through the
omoclavicular triangle area involving the primary trunk
of the brachial plexus. Kulenkampff's SPBPBT(10) also
called "traditional technique", adjusted by Winnie and
Collins(9) and the techniques of Alemanno et al.,(34)
Vongvises and Panijayanon,(35) Dupre and Danel(34)
and the plumb bob technique essentially consist of
injecting the local anesthetic in the subclavian
perivascular space using a supraclavicular approach.
For this reason they are simply called "supraclavicular
blocks." The common feature of these techniques is
represented by the penetration of the needle in the
omoclavicular triangle with many different orientations
of the needle, in respect to to the cranio-caudal axis in
the techniques of Kulenkamff,(10) Winnie and Collins,(9)
Vongvises and Panijayanond (35) and Dupre and
Danelàs. (36) The axis of the syringe in Winnie and
Collins,(9) Vongvises and Panijayanond(35) and Dupre
and Danel(36) techniques is oriented towards the arterial
groove of the first rib in the cranio-caudal direction with
the risk of an unintentional puncture of the subclavian
artery in 20-25% of cases.(37,38) In the plumb-bob and
Alemanno's(39-41) techniques, the target is the brachial
plexus located in the inferior-medial supraclavicular
fossa and the risk is haematoma formation after
subclavian artery puncture. The injection of local
anesthetic in the subclavian perivascular space,
whose section draws a circular surface (Illustration 3A)
or ellipsoidal (Illustration 3B) depending on the
SPBPBT used, causes a predominant nerve block
from C5 to C8.
anesthetic injection happens with the piercing of the IS
sheath above the inferior belly of omohyoid muscle,
the technique, obviously, must be called
"INTERSCALENE brachial plexus block technique"
(IBPBT). Therefore, IBPBT includes the techniques of
Winnie(17), the "double-needle technique" of Pippa et al.(42)
and the Manani’s technique(4). The injection of local
anesthetic into the IS causes a predominant nerve
block from C2 to C5.
Complications: SPBPBT and IBPBTM can cause a
number of complications which include pneumothorax
(incidence of 0.5 to 5.0%), the Claude Bernard-Horner
syndrome (incidence of 70-90%), vascular punctures,
spinal anesthesia,(43,44), in particular, using Winnie's
technique.(17) Finally, there are several neurological
complications and unilateral diaphragmatic paralysis
even after a low IS block ( 4 5 ) associated with
unnoticeable changes in respiratory volumes.(7,46) With
SPBPBT, the unilateral diaphragmatic block effect is
less frequent, because the different anatomical
location of the phrenic nerve on the anterior scalene
muscle.(34,46)
Methods
The patients: The research was carried out on 80
subjects, randomly selected and scheduled for
shoulder surgery in the Orthopaedic Department of the
University of Padua, after approval of the Ethics
Committee of the Department of Medical and Surgical
Specialities of Padua University.
The IBPBTM.
Patients age was between 49 and 80 years, of both
gender. The patients physical and anthropological
parameters are shown in illustration 10. Patients were
informed in detail about the technique of regional
anesthesia they would undergo. In particular, they
were informed that, on the involved arm, they might
experience heat sensation, tingling and loss of
sensitivity up to a loss of muscle strength. Furthermore,
they had been informed about possible side effects of
the regional anesthesia technique. Consent was
obtained in accordance with the Hospital of Padua No.
776 of 5 July 2010 through the acquisition of a
consent/refusal form for the proposed treatment.
Patients with respiratory problems or cognitive
impairment and patients scheduled for day surgery
were excluded from the study.
IBPBTM involves the injection of local anesthetic into
the IS space after penetrating the IS sheath, where the
brachial plexus has not yet met the subclavian artery
to create a neurovascular bundle with ellipsoidal
surface section (Illustration 3B). Therefore, if the local
The technique: The block technique had been
performed in accordance with the procedure already
described(4) excluding some modifications proposed in
this study. All patients had been placed on the
operating table with the chest slightly raised in order to
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optimize diaphragm function, and legs raised in order
to avoid sudden hypotension due to Bezold-Jarish
reflex. The patients were treated with 0.01 mg fentanyl
or midazolam 2 mg intravenously (Illustration 11).
Standard monitoring was by ECG, SpO2 and NIBP.
After rotation of the patient's head to the other side in
respect to the block, the first step was to mark on the
skin the subclavian artery pulsation, at the
mid-clavicular upper margin (the short red line in
illustration 12). From this first landmark, the
anesthesiologist drew a vertical line about 2 cm long
directed cranially, then, from the apex of this line,
another horizontal line about 2 cm long, directed
laterally; the outer end of the second, horizontal line
corresponds to the needle penetration point.
(illustration 13). The inferior belly of the omohyoid
muscle was identified by palpating its skin relief with
the second and third fingers moving slowly upward
from the edge of the clavicle, where the muscle slides
forward and up to get to the SCM and then to join the
intermediate tendon. The identification of the inferior
belly of the omohyoid muscle represents an additional
effort to increase safety, allowing the identification of
that part of the brachial plexus, situated in a cranial
position in respect to the belly muscle, that has not yet
formed the neurovascular bundle. To perform the
block we used a 50 mm long Uniplex Lanoline Pajunk®
22G needle along with a Multistim Sensor Pajunk®
neurostimulator that supplies current from 0 to 60 mA
with a stimulation frequency of 1 or 2 Hz. After local
anesthesia of the skin, the needle directed in a dorsal,
cranial and medial direction, penetrated the
interscalenic sheath above the omoclavicular triangle
giving the feeling of a “fascial click”. After appropriate
muscle response (shoulder abduction, forearm flexion,
etc) to appropriate electrical stimulation (0.5 mA), 30
ml of bupivacaine 0.5% were injected within 120
seconds. In many patients it was possible to observe,
during the local anesthetic administration, the
formation of a typical “sausage swelling” between the
anterior and meddle scalene muscles, meaning a
correct distribution of the local anesthetic into the IS
(illustration 14). The angles formed by the stimulating
needle with the transverse and frontal planes, passing
through the point of needle penetration, were
evaluated after appropriate muscles twitch response.
The extension of skin surface anesthesia was
assessed by pinprick test, as usual. The evaluations of
the skin sensitivity of C3 , C 4 , C 5 , C 6 , C 7 , C 8 -T 1
dermatomes were made every 5 minutes for 30
minutes after the end of the local anesthetic injection.
In patients who had not achieved complete analgesia
30 minutes after the local anesthetic injection, the
block was evaluated for another 15 minutes. The block
WebmedCentral > Original Articles
was considered a failure when, after 45 minutes
following the local anesthetic injection, the patient
continued to perceive the pinprick sensation evoked
by the needle. Statistical surveys. The data obtained
were expressed as average±SD and, where
necessary, the statistical evaluation was performed
using χ2 adjusted according to Yates.
Results
The needle’s angles to perform the block were higher
to the frontal plane and lower to the transverse plane.
In dorsal needle orientation, angle values ranged
between +10 and +20 degrees to the frontal plane; in
cranial needle orientation, angles ranged between -2
and -8 degrees to the transverse plane going across
the cutaneous penetration point. The average values
of the angles to the frontal plane were about 14
degrees and those to the transverse plane were about
-5 degrees approximately. Identification of the
omohyoid muscle was positive in approximately 75%
of patients, indicating that this anatomical landmark is
reliable, although not always identifiable; the block
failure rate was about 8%. In the first 30 minutes, the
Manani’s technique caused a rapid onset of the block
in the C3, C4 and C5 cutaneous innervation areas and
a slower onset of block in C6, C7, C8-T1 cutaneous
innervation areas. Illustration 15 shows the evolution
of the block in the C3 and C4 dermatomes of the
cervical plexus and in C5, C6, C7, C8-T1 dermatomes
of the brachial plexus in the first 30 minutes after the
injection of local anesthetic. In the 15 minutes after the
local anesthetic injection, the trend towards the
complete block was higher in the innervation areas of
C3, C4 and C5, with respect to C6, C7, C8-T1. 15
minutes after the onset of anesthesia, the number of
patients who had a complete block in C5 was found to
be greater than in C3 (χ2 = 4.4, p <0.05), C6 (χ2 = 31 ,
4, p <0.01), C7 (χ2 = 29.2, p <0.01) and C8-T1 (χ2 =
34.4, p <0.01). After 30 minutes, the same effect was
found to be greater than C7 (χ2 = 7.2, p <0.01) and
C8-T1 (χ2 = 37.4, p <0.01). These results indicate that
this technique is to be preferred for shoulder and
clavicle surgery.
Discussion
A recent survey carried out to describe brachial plexus
anesthesia techniques (28) has shown that IS and
cervical paravertebral approaches ensure a higher
percentage of success in shoulder and proximal
humerus surgery and that the differences between
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IBPBT and SPBPBT are related to the local anesthetic
injection onto the nervous and neurovascular
compartments respectively. Previous studies by
Winnie and Collins (9) performed after a careful
re-evaluation of the brachial plexus anatomy and by
applying the subclavian perivascular space concept
developed SPBPBT. At the same time Burnham(47) and
Eather(48) confirmed this concept by describing the
same technique performed at the axilla and obtained
by administering large volumes of local anesthetic into
the axillary neurovascular compartment. The IBPBTM
causes an extension of anesthesia comparable to that
obtained with the IBPBT described by Winnie.(17) Our
technique offers a complete anesthesia of the cervical
plexus' lowest roots and the highest roots of brachial
plexus which are necessary to perform shoulder
surgery.(49-52) The high rate of success of this technique
comes from having identified a plane were the needle
lies in relation to the frontal plane, passing between
the anterior and medium scalene muscle and being
directed anteriorly and externally according to an
average angle of 10-20 degrees. The angle of the
needle to the transverse plane, variable from -2 to -10
degrees, allows us to reach the IS cranially at
somewhat higher levels, compared to the point of
cutaneous penetration. Therefore with our technique,
after injection of local anaesthetic through the IS
sheath in a point slightly lower than that indicated by
Winnie,(17) we obtain a cervico-brachial plexus block (20)
useful for shoulder and clavicle surgery. Concluding, in
order to obtain a cervico-brachial surgical anesthesia
distribution, the important factors include: correct
execution of the block, continued use of the technique,
good anatomical knowledge.1
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42. Pippa P, Cominelli E, Marinelli C, Alto S. Nuove
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prospettive nel blocco del plesso brachiale per via
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46. Neal JM, Moore JM, Kopacz DJ, Kramer DJ,
Plorde JJ. Quantitative analysis of respiratory, motor,
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Illustrations
Illustration 1
Illustration 1. Brachial plexus anatomy. The first, more cranial, transverse line divides the
ventral ramus of C5 – T1 (blue colour), located between the scalene muscles, from the
brachial trunks (upper, middle, lower), located in the supraclavicular region. Peripherally, each
trunk splits forming the anterior and posterior divisions, the cords (lateral, posterior, medial)
and finally the terminal branches (radial, ulnar, median, axillary, musculocutaneous nerves).
Illustration 2
Illustration 2. Cross-section of the subclavian perivascular space , at level of the 7th cervical
vertebra. The 5th and 6th root of the plexus run in between the fascia that wraps the anterior
and middle scalene muscles.(9)
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Illustration 3
Illustration 3. The brachial plexus sheath on the left. Section A represents the needle
penetration point according to the subclavian perivascular block techniques. Section B
represents the needle penetration point for the subclavian perivascular block by Winnie and
Collins.(9)
Illustration 4
Illustration 4. Cross section at the level of the 6th cervical vertebra. Notables are the anterior
and middle scalene muscles in which space run the ventral rami and the brachial plexus
trunks. The local anaesthetic must penetrate into this space to perform IBPBTM and the
needle must have passed the superficial cervical fascia and the IS nerve sheath.
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Illustration 5
Illustration 5. Anterior, middle and posterior scalene muscles. The brachial plexus and the
subclavian artery run between the anterior and middle scalene muscles through the IS triangle.
Illustration 6
Illustration 6. Omohyoid muscle. The omohyoid muscle crosses the anterior and middle
scalene muscles in the supraclavicular fossa.
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Illustration 7
Illustration 7. Position of the interscalene triangle between the middle and anterior scalene
muscles. This pyramidal space contains the brachial plexus and, at the bottom, also the
subclavian artery.
Illustration 8
Illustration 8. The omoclavicular triangle, the area where the needle enters to perform
Supraclavicular Perivascular Brachial Plexus Block Techniques.
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Illustration 9
Illustration 9. Areas of skin anaesthesia obtained after interscalene block, after supraclavicular
perivascular block, after axillary block and after a combined interscalene-axillary technique.
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Illustration 10
Illustration 10. Patients and surgery features.
Illustration 10. Patients and surgery features. Average±SD.
Anthropological characteristics / Pathologies
Numbers
Patients (n)
Age (years)
Gender (M / F)
Weight (kg)
Height (cm)
ASA (1/2/3)
80
63.2±10.8
24/56
63.6±9.6
162.4±4.9
21/51/8
Pathologies
Humeral neck fracture
Rotator cuff tear
Humeral shaft fracture
Clavicle fracture
Supraspinous ligament tear
38
21
12
7
2
Surgical
procedures
Osteosynthesis
Arthroscopy
Osteosynthesis
Osteosynthesis
Arthroscopy
Legend: ASA = American Society of Anesthesiologists
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Illustration 11
Illustration 11.  Anaesthesia management.
Illustration 11. Characteristics of anesthesia management. Average±SD.
Patients (n)
80
Posture: semi-recumbent
80
Preanesthesia: fentanyl/midazolam
46/34
Skin wheal (yes/no)
76/4
Omohyoid muscle inferior belly identification (yes/no)
64/16
Fascial click (yes/no)
73/7
Bupivacaine 0.5%
80
Volumes: 30/40 ml
69/11
Injection time (sec)
109±7.6
Needle angle to transverse plane
-5.1±1.3 °
Needle angle to frontal plane
14.0±5.2 °
Block failures (yes/no)
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Illustration 12
Illustration 12. Projection on the skin of the interscalene space (black dashed line) and
interscalene groove (pink dashed line). SCM = sternocleidomastoid muscle, TR = trapezius
muscle; omohy = projection on the skin of the supraclavicular area of the omohyoid muscle;
CLAV = clavicle. The red horizontal dotted line and red vertical line (subclavian artery pulse)
are important landmarks for the execution of interscalene block.
Illustration 13
Figure 13. Needle penetration into an upper-outer point in respect to the subclavian artery
pulsation, on the midpoint of the clavicle; the depicted 20G needle is 50 mm long; X = middle
of the clavicle, x1 = subclavian pulsation point, x2 = far end of the first line, x3 = far end of the
second line .
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Illustration 14
Figure 14. The two black lines outline the so called “sausage”, typical sign of interscalene
sheath relaxation caused by the spread of the local anaesthetic into the interscalene space.
Illustration 15
Figure 15. Indicative curves representing the percentage of patients who experienced
complete analgesia from electrical stimulation to the dermatomes examined in the first thirty
minutes after the block. The most sensitive dermatomes were C3, C4 and C5 (black dots).
The effect of complete analgesia in dermatomes C8-T1, C7 and C6 was relatively minor (white
dots).
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