Importance of the Upper Extremity Position for a Safe and Effective Axillary Block: a Comparative Study/Guvenli ve Etkili Bir Aksiller Blok Icin Ust Ekstremite Pozisyonunun Onemi: Karsilastirmali Bir Calisma.
Objective: Our aim was to determine the ideal position of upper extremities during ultrasonography guidance for axillary block. The position that provides the shortest distance between the median and musculocutaneous nerves was assumed to be the most appropriate position for axillary block.
Methods: In this cross-sectional study, 120 (45 female and 75 male) patients were placed in a position with a shoulder at 90[degrees] /elbow 90[degrees] (position 1) and a shoulder 90[degrees] / elbow 0[degrees] (position 2). The intersection point of the biceps brachii muscle with the lower border of the pectoralis major muscle is defined as the proximal level (P). Distal level (D) is reffered as 5 cm below the proximal level. In the positions described above, the distance between median and musculocutaneous nerves was measured proximal (positions 1P and 2P) and distal levels (positions 1D and 2D). It was investigated whether these measurements differed between the groups and whether the body mass index or the gender.
Results: The shortest mean distance (10.24[+ or -]3.95 mm) between the two nerves was determined when the shoulder position 90[degrees]/elbow position 0[degrees] at the distal level (1D) and the longest mean distance (13.4l[+ or -]4.26 mm) was determined when shoulder position 90[degrees]/elbow position 90[degrees] at the proximal level (2P). In all four cases, there was no difference in the results between men and women. There was no relationship between the measurement results and the body mass indexes and age of the patients.
Conclusion: Appropriate positioning of the upper extremities is important for achieving optimal position during axillary block. Thereby, the procedure can be safely and effectively performed with lesser amounts of local anaesthetic solution and a decreased number of manoeuvres with needle during infiltration.
Keywords: Axillary block, ultrasound guidance, median nerve, musculocutaneous nerve
Amac: Amacimiz, ultrason kilavuzlugunda yapilan aksiller blok sirasinda list ekstremitenin ideal pozisyonunu belirlemektir. Median ve muskulokutanoz sinirler arasinda en kisa mesafeyi saglayan pozisyonun aksiller blok icin en uygun pozisyon oldugu varsayilmistir.
Yontemler: Bu kesitsel calismada 120 (45 kadin ve 75 erkek) hastada her bir kola omuz 90[degrees]/dirsek 90[degrees]'de (pozisyon 1) ve omuz 90[degrees]/dirsek 0[degrees]'de (pozisyon 2) olacak sekilde pozisyon verildi. Pektoralis major kasinin alt siniriyla biseps brachii kasinin kesisme noktasi proksimal seviye (P) olarak tanimlanmistir. P'nin 5 cm distaline distal seviye (D) denilmistir. Yukanda anlatilan pozisyonlarda median ve muskulokutanoz sinirler arasindaki mesafe proksimal (pozisyon 1P ve 2P) ve distal seviyelerde (pozisyon 1D ve 2D) olculdu. Turn bu olcumlerin gruplar arasinda farkhhgi ve hastalarin beden kitle indeksi yada cinsiyetiyle degisiklik gosterip gostermedigi arastirildi.
Bulgulat: Iki sinir arasindaki en kisa ortalama mesafe (10,24[+ or -]3,95 mm) distal seviyede omuz 90[degrees]/dirsek 0[degrees] pozisyonda (1D), en uzun ortalama mesafe (13,4l[+ or -]4,26 mm) ise proksimal seviyede omuz 90[degrees]/dirsek 90[degrees] pozisyonda (2P) iken saptanmistir. Dort durumda da sonuclar acisindan erkekler ve kadinlar arasinda herhangi bir farklilik saptanmadi. Oleum sonuclari ile hastalarm vucut kitle indeksleri ve yaslari arasinda herhangi bir iliski saptanmadi.
Sonuc: Aksiller blok sirasinda optimal basannin saglanmasi acisindan ust ekstremitenin uygun pozisyona getirilmesi onemlidir. Boylece, islem guvenle ve etkinlikle, daha dusuk miktarda lokal anestezik kullanilarak ve infiltrasyon sirasinda daha az ayida manevra ile gerceklestirilebilir.
Anahtar sozcukler: Aksiller blok, ultrason kilavuzlugu, median sinir, muskulokutanoz sinir
Understanding peripheral nerve anatomy is necessary for an effective and safe nerve block. However, variation from standard anatomical organisation is relatively common, and localisation and identification of target nerves must be carefully and precisely made (1). Recently, the use of high-definition ultrasound has been popularised in peripheral regional anaesthesia (2).
Although ultrasound is used to directly visualise nerves and plexus, extremities must be maintained in certain positions for determining landmarks. For instance, the brachial plexus in the axillary region should be approached with the extremity positioned as described in relevant publications (3).
Attributed to shoulder mobility, the brachial plexus at the axilla level is vulnerable for the re-arrangement of anatomical structures according to the position. Axillary brachial plexus block is one of the most frequently used methods of regional anaesthesia (4). Separate blockade of the four main brachial nerves (radial, median, ulnar, musculocutaneous) remarkably increases the success rates (5).
These nerves are arranged within a neurovascular sheath around the axillary artery. Nevertheless, the position of the nerves inside the sheath is not fixed and does not allow a certain extent of movement. Moreover, fibres, to a variable degree, are exchanged between individual nerves (3). Variability of the axillary fossa anatomy may challenge blockage of the main brachial nerves one by one. Interestingly, the radial, median and ulnar nerves are located in the common neurovascular sheath at the level of the pectoralis major and biceps humeri muscles intersection. This point is the frequent site of axillary brachial plexus block application (3).
For regional nerve blocks, the injection of a local anaesthetic must be administered as close to the nerves as possible. Thus, landmarks must be properly identified to ensure that all parts of the nerves are properly exposed to the anaesthesia (6). Determining the optimal position of the arm for visualisation of target nerves during ultrasound-guided axillary brachial plexus block may enhance the efficacy and safety of the procedure (3). Axillary nerve block may be performed via paraesthesia or trans-arterial techniques, as well as peripheral nerve stimulation or real-time ultrasound guidance. There has been no apparent superiority of any of these modalities, but specific blocking of the terminal nerves may improve success (7).
Localisation of the musculocutaneous nerve may be difficult based on simple anthropomorphic data. This point must be considered during ultrasound-guided axillary blocks and the use of nerve stimulation. Understanding peripheral nerve anatomy is essential for effective nerve block, and variations from standard anatomical organisation are not rare (1).
In this study, we investigated whether the anatomical course of median and musculocutaneous nerves changed with arm position in ultrasound guidance. Seconder aim of the study is to evaluate the impacts of different positions of upper extremity on the association between the median and musculocutaneous nerves and to assess whether this association is influenced by body mass index, age or gender.
This cross-sectional study was implemented in the anaesthesiology and reanimation department in a university hospital after the approval of local institutional review board. Written informed consent was obtained from each participant.
A total of 120 patients (45 women, 75 men) who were planned for axillary block were enrolled in the present trial. Exclusion criteria were age <18 years, restriction in shoulder movement, history of infection, trauma or surgery in the axillary region. Age and gender were recorded for every patient at the beginning of the study. The height and weight of all patients were measured and each patient's body mass index (BMI) was calculated (kg [m.sup.-2-1]). BMI <18.5 kg [m.sup.-2-1] defined as underweight, BMI between 18.5-25 kg [m.sup.-2-1] defined as normal weight, BMI between 25-30 kg [m.sup.-2-1] defined as overweight, BMI >30 kg [m.sup.-2-1] defined as obese. Volunteers lay in the supine position for the ultrasonographic measurement of the axillary region. "Resolution mode" was selected on the ultrasound device for depth and gain after optimisation. A portable ultrasound machine (UEGO HM 70A, Samsung, Seoul, South Korea) and a 10-18 MHz linear multi-frequency probe were used. The probe was placed in vertical angle to the nerves, artery and humerus. It was noted not to press the skin with the probe to prevent from movement of nerves by compression to the veins and arteries. Each arm was placed in two different positions as shoulder 90[degrees]/elbow 0[degrees] (Position 1) and shoulder 90[degrees]/elbow 90[degrees] (Position 2). The intersection point of the biceps brachii muscle with the lower border of the pectoralis major muscle is defined as the proximal level (P). Distal level (D) is reffered as 5 cm below the proximal level. And two different measurement points (proximal and distal) were defined at these two positions. The distance between the median nerve and musculocutaneous nerve was measured with ultrasound in four different shoulder positions (position 1P, 1D, 2P, 2D) while the patients lay in the supine position (Figure 1, 2).
Data was analysed with IBM Statistical Package for Social Sciences Statistics 20 software (IBM SPSS Statistics; Armonk, NY, USA). The normality of distribution for the variables was tested with the Kolmogorov-Smirnov test. Comparison of dependent groups was made with the repeated measures ANOVA test. Homogeneous groups were compared with the Bonferroni test. Correlation between variables was evaluated with Pearson's correlation test. Comparison of two independent groups was made with the independent samples t-test, while more than two dependent groups were carried out with the one-way ANOVA. Quantitative data was expressed as mean, standard deviation and minimum and maximum values. The confidence interval was 95%, and the level of significance was set at p<0.05. Since the assumption of sphericity was not met, the Greenhouse-Geisser correction was used to evaluate the difference within groups (p<0.001).
One-way [alpha]-value was 0.05; the [beta]-value accepted as 0.20. The number of patients required for total patient as statistical
80% power should be at least 62, which is calculated by using the standard effect size according to the literature (STATISTICA 9.0 30-day trial version was used for calculating statistical power analysis.)
This study comprised 45 women (37.5%) and 75 men (62.5%). The average age was 46.62[+ or -]15.61 (range, 21-85) years, and the average BMI was 26.42[+ or -]5.48 (range, 16.34-44.97) kg [m.sup.-2-1]. There were significant differences between the distances measured in the four distinct positions during ultrasonography for axillary block (Table 1). There were significant differences between the measurements made at proximal and distal levels. The shortest mean distance (10.24[+ or -]3.95 mm) between two nerves was detected at position 1D, while the longest mean distance (13.4l[+ or -]4.26 mm) was noted in position 2P (Table 2).
According to Levene's test for equality of variances, there was no difference between men and women in terms of the results acquired in the four measurements (Table 3). Correlation analysis demonstrated that there was no association between the results of measurements and age or BMI (Table 4). Similarly, no difference could be detected between different BMI groups (underweight, normal, overweight and obese) and distances between the median and musculocutaneous nerves (Table 4).
The study aimed to evaluate the distance between the median and musculocutaneous nerves in various positions of the shoulder and elbow. Our results suggest that shoulder 90[degrees]/elbow 0[degrees] position provides the smallest gap at the distal level. Hence, setting to this position of the patient's arm and adjusting the optimum ultrasound technique can facilitate axillary block and decrease the likelihood of risks during intervention.
Determining the optimal position of the arm for visualising the target nerves while performing ultrasound-guided axillary brachial plexus block may improve the efficiency and safety of the procedure (3). Our results may aid in the identification of landmarks for axillary nerve block and facilitate the performance of axillary nerve block. Because these nerve blocks are usually effective for early relief, their popularisation can lead to a reduced need for post-operative analgesics (6). Hopefully, earlier rehabilitation and quick recovery can be possible because of the widespread use of axillary nerve blocks by the results we reported.
Recently, distal peripheral nerve blocks have facilitated hand and wrist surgery. Attributed to ultrasound guidance, distal nerve blocks of the upper limb have become a technically more feasible, safe and effective modality (8). Because better visualization ensures minimum tissue trauma, nerve damage and lower dose local anesthetic usage. Another advantage of distal peripheral nerve blocks is the maintenance of proximal muscle function of the upper limb. The inability to use the limb that underwent intervention notably decreases the satisfaction of the patient (8).
Ultrasound-guided selective nerve block can be accomplished by means of tracing the nerve branching from axillary brachial plexus. This method can provide safe and efficient anaesthesia at a relatively low anaesthetic dose and concentration (9).
Ultrasonography at the axillary level outlines the alignment of nerves and vessels. At this level, the nerves exist as round or oval hypoechoic structures with punctuated internal echoes (1). Axillary usage of ultrasound is a useful technique to describe the brachial plexus anatomy in the fossa. Median, ulnar and radial nerves make a totally consistent triangle-shaped design around axillary artery that can be easily recognised with US. As arterial visualization, brachial nerves and venous relation is clearly demonstrated with ultrasound guidance (10). In contrast, the musculocutaneous nerve differs from the other terminal nerves of the upper extremity and lies outside the neurovascular bundle (1). Identifying anatomical variants from expected patterns of peripheral nerve location can be challenging during a nerve block procedure. In the arm, variations of the nerves innervating the ventral compartment such as musculocutaneous and median nerves are more frequent (1). Because aberrations of the association between these two nerves are frequent and occur in up to 20% of cases, recognition and orientation of the median and musculocutaneous nerves before axillary nerve block is particularly important (11-16). To achieve the anaesthesia of the forearm completely, blocking the musculocutaneous nerve is essential. Nevertheless, variations in its course and position can interfere with the exact localisation of the nerve.
Identification of the musculocutaneous nerve for neural blockage is crucial for providing surgical anaesthesia for the distal forearm. Ultrasonography is supposed to enhance the localisation and local anaesthetic block of the musculocutaneous nerve (11).
Similar with our data, Ruiz et al. (17) reported that the depth of the brachial plexus is reduced with the abduction of the arm. Frkovic et al. (3) implied that improved visibility of nerves at abduction of the arm may be linked with the anatomical re-arrangement of the plexus or compression of tissues in various positions. We suggest that the evaluation of anatomical variations is crucial in regional anaesthesia and that failure to determine the alignment of the musculocutaneous and median nerves may both frustrate the physician and cause patient discomfort or complications. Ultrasound guidance, appropriate positioning and detailed knowledge of pertinent anatomy are key points for successful axillary block without repeated attempts, and avoidance of repeated attempts.
Ultrasonographic visibility of the median and musculocutaneous nerves was significantly affected by position of the shoulder or elbow and the probe distance from the axilla. Consequently, we attempted to outline the optimal arm and scan position for improved visibility and a more effective block. The position that provides the shortest distance between the median and musculocutaneous nerves was assumed to be the most appropriate position for axillary block.
Limitations of this study include the small sample size, data derived from the experience of a single institution and ethnic genetic factors that may interfere with interpretation of our data. Furthermore, technical limitations linked with equipment and operator must be considered.
We suggest that appropriate positioning of the upper limbs and good anatomical knowledge are crucial for identifying the median and musculocutaneous nerves during distal peripheral nerve block under ultrasound guidance. Our results indicated that the position in which these two nerves lie close to each other was found to be shoulder 90[degrees]/elbow 0[degrees] at the distal level. Thus, this position can be selected to achieve a safer and more effective axillary nerve block procedure.
Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Kafkas University School of Medicine (Decision dated 11.11.2015 no:08).
Informed Consent: Written informed consent was obtained from katilimcilardan who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - O.O.; Design - O.O., B.D.; Supervision - A.B., E.E.; Resources - O.O., H.Y.; Materials - A.B.; Data Collection and/or Processing - O.O., A.H.T.; Analysis and/or Interpretation - B.D., O.O., A.H.T., H.Y.; Literature Search - E.E., B.D., O.O.; Writing Manuscript - O.O., A.H.L.; Critical Review B.D., A.B., H.Y.; Other - B.D., A.B., O.O.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
Etik Komite Onayi: Bu calisma icin etik komite onayi Kafkas Universitesi Tip Fakultesi'nden (Karar tarihi 11.11.2015 numara:08) alinmistir.
Hasta Onami: Bu calismaya katilan katihmcilardan yazili bilgilendirilmis onam alindi.
Hakem Degerlendirmesi: Dis bagimsiz.
Yazar Katkilari: Fikir - O.O.; Tasanm - O.O., B.D.; Denetleme A.B., E.E.; Kaynaklar - O.O., H.Y; Malzemeler - A.B.; Veri Toplanmasi ve/veya Islemesi - O.O., A.H.T.; Analiz ve/veya Yorum - B.D., O.O., A.H.T., H.Y.; Literatur Taramasi - E.E., B.D., O.O.; Yaziyi Yazan - O.O., A.H.T.; Elestirel Inceleme - B.D., A.B., H.Y.; Diger - B.D., AB., O.O.
Cikar Catismasi: Yazarlar cikar catismasi bildirmemislerdir.
Finansal Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.
(1.) Orebaugh SL, Pennington S. Variant location of the musculocutaneous nerve during axillary nerve block. J Clin Anesth 2006; 18: 541-4. [CrossRef]
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(3.) Frkovic V, Ward C, Preckel B, Lirk P, Hollmann MVV, Stevens MF, et al. Influence of arm position on ultrasound visibility of the axillary brachial plexus. Eur J Anaesthesiol 2015; 32: 771-80. [CrossRef]
(4.) Hadzic A, Vloka JD, Kuroda MM, Koorn R Birnbach DJ. The practice of peripheral nerve blocks in the United States: a national survey [p2e comments]. Reg Anesth Pain Med 1998; 23: 241-6. [CrossRef]
(5.) Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia. Anesth Analg 1999; 88: 847-52. [CrossRef]
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(13.) Macchi V, Tiengo C, Porzionato A, Parenti A, Stecco C, Bassetto F, et al. Musculocutaneous nerve: histotopographic study and clinical implications. Clin Anat 2007; 20: 400-6. [CrossRef]
(14.) Choi D, Rodriguez-Niedenfuhr M, Vazquez T, Parkin I, Sanudo JR. Patterns of connections between the musculocutaneous and median nerves in the axilla and arm. Clin Anat 2002; 15: 11-7. [CrossRef]
(15.) Beheiry EE. Anatomical variations of the median nerve distribution and communication in the arm. Folia Morphol (Warsz) 2004; 63: 313-8.
(16.) BudhirajaV, Rastogi R, Asthana AK, Sinha P, Krishna A, Trivedi V Concurrent variations of median and musculocutaneous nerves and their clinical correlation--a cadaveric study. Reg Anesth Pain Med 2005; 30: 385-90.
(17.) Ruiz A, Sala X, Bargallo X, Hurtado P, Arguis MJ, Carrera A. The influence of arm abduction on the anatomic relations of infraclavicular brachial plexus: an ultrasound study. Anesth Analg 2009; 108: 364-6. [CrossRef]
Omur Ozturk (1), Aysu Hayriye Tezcan (1), Ali Bilge (2), Esref Erdem (1), Hatice Yagmurdur (1), Burhan Dost (3)
(1) Department of Anaesthesiology and Reanimation, Kafkas University School of Medicine, Kars, Turkey
(2) Department of Ortopedics and Traumatology, Kafkas University School of Medicine, Kars, Turkey
(3) Department of Anaesthesiology and Reanimation, Besni State Hospital, Adiyaman, Turkey
Address for Correspondence/Yazisma Adresi: Omur Ozturk E-mail: firstname.lastname@example.org
[c] Copyright 2017 by Turkish Anaesthesiology and Intensive Care Society - Available online at www.jtaics.org
[c] Telif Hakki 2017 Turk Anesteziyoloji ve Reanimasyon Dernegi - Makale metnine www.jtaics.org web sayfasindan ulasilabilir.
Received / Gelis Tarihi : 17.01.2017
Accepted / Kabul Tarihi: 17.04.2017
Table 1. Comparison of measurements performed in two positions at the proximal (P) and distal (D) levels Position Position Shoulder 90[degrees] /elbow 0[degrees] (P) Shoulder 90[degrees]/elbow 0[degrees] (D) Shoulder 90[degrees]/elbow 90[degrees] (P) Shoulder 90[degrees]/elbow 90[degrees] (D) Shoulder 90[degrees] /elbow 0[degrees] (D) Shoulder 90[degrees]/elbow 90[degrees] (P) Shoulder 90[degrees]/elbow 90[degrees] (D) Shoulder 90[degrees]/elbow 90[degrees] (P) Position P Shoulder 90[degrees]/elbow 0[degrees] (P) <0.001 (*) 1.000 <0.001 (*) Shoulder 90[degrees]/elbow 0[degrees] (D) <0.001 (*) 0.009 (*) <0.001 (*) (*) statistically significant; P: proximal level; D: distal level Table 2. Measurement results according to the four different points Distance between Position and Level nerves (mm) Shoulder 90[degrees]/elbow 0[degrees], proximal (1P) 13.28[+ or -]4.22 Shoulder 90[degrees]/elbow 0[degrees], distal (1D) 10.24[+ or -]3.95 Shoulder 90[degrees]/elbow 90[degrees], proximal (2P) 13.41[+ or -]4.26 Shoulder 90[degrees]/elbow 90[degrees], distal (2D) 10.91[+ or -]4.22 Table 3. Measurement results of the four different points according to the gender Distance between nerves Position Gender (mm) Shoulder 90[degrees]/elbow 0[degrees] (1P) Men 13.46[+ or -]4.31 Women 12.98[+ or -]4.11 Shoulder 90[degrees]/elbow 0[degrees] (1D) Men 10.50[+ or -]4.07 Women 9.81[+ or -]3.74 Shoulder 90[degrees]/elbow 90[degrees] (2P) Men 13.10[+ or -]4.10 Women 13.93[+ or -]4.52 Shoulder 90[degrees]/elbow 90[degrees] (2D) Men 10.97[+ or -]4.12 Women 10.79[+ or -]4.23 Position P Shoulder 90[degrees]/elbow 0[degrees] (1P) 0.55 Shoulder 90[degrees]/elbow 0[degrees] (1D) 0.36 Shoulder 90[degrees]/elbow 90[degrees] (2P) 0.30 Shoulder 90[degrees]/elbow 90[degrees] (2D) 0.82 P: proximal level; D: distal level Table 4. Comparative overview of distances between the median and musculocutaneous nerves measured in patients with various body mass index (BMI) groups. (Groups were constituted as follows: BMI<18.5: underweight; 18.5[less than or equal to]BMI<25: normal; 25[less than or equal to]BMI<30: overweight; BMI[greater than or equal to]30: obese) Body mass Distance Position index group (mm) Shoulder 90[degrees]/elbow Underweight (n=3) 12.13[+ or -]5.14 0[degrees] (1P) Normal (n=42) 13.50[+ or -]4.22 Overweight (n=51) 13.42[+ or -]4.61 Obese (n=24) 12.75[+ or -]3.4l Shoulder 90[degrees]/elbow Underweight (n=3) 8.70[+ or -]4.44 0[degrees] (1D) Normal (n=42) 10.29[+ or -]3.21 Overweight (n=51) 10.66[+ or -]4.54 Obese (n=24) 9.46[+ or -]3.82 Shoulder 90[degrees]/elbow Underweight 13.83[+ or -]6.88 90[degrees] (2P) Normal 13.00[+ or -]3.55 Overweight 13.84[+ or -]4.73 Obese 13.17[+ or -]4.26 Shoulder 90[degrees]/elbow 9 Underweight 8.90[+ or -]4.26 0[degrees] (2D) Normal 10.84[+ or -]3.50 Overweight 11.56[+ or -]4.78 Obese 9.90[+ or -]4.05 Position P Shoulder 90[degrees]/elbow 0[degrees] (1P) Shoulder 90[degrees]/elbow 0[degrees] (1D) 0.584 Shoulder 90[degrees]/elbow 90[degrees] (2P) 0.805 Shoulder 90[degrees]/elbow 9 0[degrees] (2D) 0 355 P: proximal level; D: distal level
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|Title Annotation:||Original Article / Ozgun Arastirma|
|Author:||Ozturk, Omur; Tezcan, Aysu Hayriye; Bilge, Ali; Erdem, Esref; Yagmurdur, Hatice; Dost, Burhan|
|Publication:||Turkish Journal of Anaesthesiology and Reanimation|
|Date:||Jun 1, 2017|
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