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Comparison of ultrasound and ultrasound plus nerve stimulator guidance axillary plexus block.

Byline: Gokhan Demirelli, Semih Baskan, Isil Karabeyoglu, Ismail Aytac, Dilsen Hatice Ornek, Alper Erdogmus and Mustafa Baydar


Objective: To evaluate the characteristics of axillary plexus blockade applied using ultrasound only and using ultrasound together with nerve stimulator in patients undergoing planned forearm, wrist or hand surgery.

Methods: This randomised, prospective, double-blinded, single-centre study was conducted at Ankara Numune Training and Research Hospital, Ankara, Turkey, from November 2014 to August 2015, and comprised patients undergoing forearm, wrist or hand surgery. Participants were separated into 2 groups. In Group 1, the nerve roots required for the surgical site were located one by one and local anaesthetic was applied separately to each nerve for the block. In Group 2, the vascular nerve bundle was located under ultrasound guidance and a total block was achieved by administering all the local anaesthetic within the nerve sheath. In the operating room, standard monitorisation was applied. Following preparation of the skin, the axillary region nerve roots and branches and vascular structures were observed by examination with a high-frequency ultrasound probe.

In both groups, a 22-gauge, 5cm block needle was entered to the axillary region with visualisation of the whole needle on ultrasound and 20ml local anaesthetic of 0.5% bupivacaine was injected. SPSS 19 was used for data analysis.

Results: Of the 60 participants, there were 30(50%) in each group. The mean age was 39.1+-15 years in the group 1 which was the ultrasound nerve stimulation group, and 41.5+-14.3 years in group 2. The duration of the procedure was longer in group I than in group 2 (p<0.05). Patient satisfaction values during the procedure were higher in group 2(p<0.05). In the ulnar sensory examination, the values of the patients in group 1were higher at 10, 15, 20 and 25 minutes (p<0.05). In the median, radial and ulnar motor examination, the values of the patients in group 1were higher at 15 and 20 minutes (p 4). The number of patients who required additional analgesic drugs was noted.

Patient's satisfaction was evaluated as poor (1), moderate (2), good (3) or very good (4) during the initial procedures, during the operation and post-operatively.

SPSS 19 was used for statistical analysis. In the evaluation of the study data, descriptive statistical methods (frequency, percentage, mean, standard deviation) were used. In the comparison of qualitative data, Pearson's chi-squared test, Fisher's exact test or Yates's tests were used. Conformity of the data to normal distribution was evaluated with the Kolmogorov-Smirnov test. In the evaluation of quantitative data showing normal distribution, the independent samples t-test was used, and for non-parametric data the Mann-Whitney U-test was used. P<0.05 was considered statistically significant.


Of the 60 participants, there were 30(50%) in each group. The mean age was 39.1+-15 years in the USNS group and 41.5+-14.3 years in US group. There were 10(33.3%) females and 20(66.7%) males in group USNS compared to 11(36.7%) females and 19(63.3%) males in group US (Table-1).

Table-1: Demographic data.

###Group USNS###Group US


Age, year###39.1 +- 15.0###41.5 +- 14.3

Height, cm###166.9 +- 9.7###169.8 +- 10.1

Weight, kg###72.9 +- 13.9###79.8 +- 13.3

BMI###26.0 +- 3.8###27.8 +- 4.9







The mean procedure time of group USNS (237.0+-59.8 seconds) was found to be higher than that of group US (123.9+-20.2 seconds) (p<0.05).

In the sensory examination (median, radial, ulnar), a statistically significant difference was determined between the groups in respect of the total block duration and in the block onset times (p0.05) but a statistically significant difference was determined in the total block duration (p0.05). Of all, 2(3.3%) patients required ulnar nerve block in the wrist because of an incomplete block at 30 minutes. There were no conversions to general anaesthesia.

No statistically significant difference was determined between the groups in respect of the VAS values (p>0.05) (Figure).

No statistically significant difference was determined between the groups in respect of the VAS values at all the measured times (p>0.05).

No statistically significant difference was determined between the groups in respect of the time of additional analgesia (p>0.05). The mean value of the need for additional analgesia was 19.6+-4.1 hours in group USNS and 17.7+-4.4 hours in group US.

No statistically significant difference was determined between the groups in respect of patient satisfaction during the operation and post-operatively (p>0.05), while a statistically significant difference was determined between the groups during the procedure (p<0.05). The patient satisfaction values of the patients in group US were found to be higher (Table-3).

Table-3: Comparison of patient satisfaction.

Patient###Group I*###Group II**###P


During procedure###2.8 +- 0.8###3.4 +- 0.7###0.001

Operation###3.8 +- 0.4###3.9 +- 0.4###0.220

Postoperative###3.9 +- 0.3###4.0 +- 0.0###0.078


Current techniques available for nerve localisation mark anatomical indicators for the estimated location of the brachial plexus. In the nerve stimulator technique, it is ensured that the needle is correctly placed without causing paraesthesia. Rather than defining the nerve localisation using nerve stimulator alone, intervention with the use of ultrasonography has been reported to increase success rates and reduce complications.

Ultrasonography allows visualisation of the brachial plexus at a higher quality and helps nerve localisation, and these factors then increase the quality of the nerve block. Through ultrasonography, peripheral nerves, needle localisation and local anaesthetic distribution, all of which are required for a successful conduction block, can be directly displayed.6,7 However, the use of more than one assistive method may cause technical problems. Therefore, the use of ultrasonography alone is seen as an alternative technique.

The variables which have been identified as relevant when comparing ultrasound and ultrasound and neurostimulation in peripheral nerve blocks include block procedure time, readiness for surgery, success rate, VAS values of post-operative pain, requirement for additional analgesia and patient satisfaction.

Casati and Conceicao8,9 compared ultrasound-guided with neurostimulation-guided axillary brachial plexus block and found similar success rates for both techniques. Chan et al.10 compared ultrasound-guided to neurostimulation-guided axillary brachial plexus block in hand surgery and the ultrasound group was found to have a higher success rate and a shorter time to perform the technique. In the current study, the success rate of an effective block for all nerves was 100% in the USNS group and 93.3% in the US group. Additional LA infiltration was required by 2 patients in the US group. A lower success rate of the block was seen in the US group due to poor spread of the local anaesthetic around the ulnar nerve in 2 patients. The increased anaesthetic efficacy of the USNS group is thought to trigger a longer block performance time.

In the current study, the time needed to perform the block in both applications was extremely short, with the US group taking a statistically significantly shorter time at 123.9+-20.2 seconds than the ultrasound plus neurostimulation guidance group at 237+-59.8 seconds.

In respect of patient satisfaction, a study reported similarly good results with both techniques.8 There is some evidence suggesting an equal risk of complications and less satisfactory anaesthesia with methods using the US plus neurostimulation rather than US.

The use of low currents (0.5 mA) during nerve stimulation for neural blockade has been applied in many ultrasound-guided neural blockade techniques. Nerve stimulator-guided blocks performed by trainees can be considered to cause more patient discomfort compared to blocks performed by experts due to the prolonged time taken for block placement with unpleasant muscle contractions. The elicitation of paraesthesia or muscle twitch response was not welcome for most patients. Interestingly, patient discomfort was reduced by sonographic guidance compared to the nerve stimulator technique, even though sonographically-guided blocks were performed predominantly by trainees and nerve stimulator-guided blocks by experts. The anatomic landmark for the axillary artery was sought under ultrasonographic guidance that offered accurate placement of the injection needle while avoiding puncture of nerve structures during the injection.

Several studies have demonstrated that ultrasound-guided axillary brachial plexus blocks allow significant reductions in the use of supplementary analgesics and provide better quality of blocks compared with the nerve stimulator-guided technique.11

Soeding et al. compared conventional "landmark-based" and ultrasound-guided brachial plexus anaesthesia using both interscalene and axillary approaches, and reported that the use of ultrasonography improved the onset and completeness of sensory and motor blocks.12 Soeding et al.12 reported that the onset of sensory block was 5 minutes faster with ultrasound guidance than with nerve stimulation. Furthermore, there were no differences in the onset time of motor block, readiness for surgery and the overall success rate of the block.

Chin et al. reported that multiple-injection techniques using neurostimulation for axillary plexus block provided more effective anaesthesia than either double or single-injection techniques.13

In the current study, the higher time to onset of the sensory block in the US group was considered to be due to the local anaesthetic having been administered further from the nerve in comparison with other combined techniques, but this was not considered important as there was no statistically significant difference in the total sensory block duration. On the other hand, the longer motor block duration in the US group was considered a disadvantage. Effective analgesia was achieved in both groups in the post-operative period and the times of the requirement of the first analgesia were similar.

A limitation of the current study was that in addition to the patient satisfaction values, patient anxiety before and after the procedure could have been evaluated.


The brachial plexus blockade via the axillary approach guided by ultrasound offered excellent quality of sensory and motor block equivalent to that of the nerve stimulator-guided technique and significantly improved patient comfort compared to the established ultrasound plus nerve stimulator technique.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.


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Publication:Journal of Pakistan Medical Association
Article Type:Clinical report
Date:Apr 30, 2017
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