Brachial plexus examination and localization using ultrasound and electrical stimulation - A volunteer study

Background Current techniques of brachial plexus block are "blind," and nerve localization can be frustrating and time consuming. Previous studies on ultrasound-assisted brachial plexus blocks are mostly performed with scanning probes of 10 MHz or less. The authors tested the usefulness of a state-of-the-art, high-resolution ultrasound probe (up to 12 MHz) in identifying the brachial plexus in five locations of the upper extremity and in guiding needle advancement to target before nerve stimulation. Methods: In this prospective observational study, 15 volunteers underwent brachial plexus examination using an L12-L5 MHz probe and a Philips-ATL 5000 ultrasound unit in the interscalene, supraclavicular, infraclavicular, axillary, and midhumeral regions. Thereafter, an insulated block needle was advanced under direct ultrasound guidance to target nerves before confirmation by electrical nerve stimulation in five volunteers in each of the interscalene, supraclavicular, and axillary regions. The quality of brachial plexus images, anatomic variations, and the technique of needle advancement for nerve localization were recorded. Results: The brachial plexus components were successfully identified in the transverse view as round to oval hypoechoic structures with small internal punctuate echos in all regions examined except the infraclavicular area (visualized in 27% of the cases). The authors' technique of advancing the needle in-line with the ultrasound beam allowed moment-by-moment observation of the needle shaft and tip movement at the time of nerve localization. Hypoechoic structures were stimulated electrically and confirmed to be nerves. Conclusions: These preliminary data show that the high-resolution L12-L5 probe provides good quality brachial plexus ultrasound images in the superficial locations i.e., the interscalene, supraclavicular, axillary, and midhumeral regions. The needle technique described here for ultrasound-assisted nerve localization provides real-time guidance and is potentially valuable for brachial plexus blocks.