Article Text

Download PDFPDF

Ultrasound-Guided Root/Trunk (Interscalene) Block for Hand and Forearm Anesthesia
  1. Sarah J. Madison, MD*,
  2. Julie Humsi, MD*,
  3. Vanessa J. Loland, MD,
  4. Preetham J. Suresh, MD*,
  5. NavParkash S. Sandhu, MD*,
  6. Michael J. Bishop, MD*,
  7. Michael C. Donohue, PhD*,
  8. Dong Nie, MS*,
  9. Eliza J. Ferguson, BS*,
  10. Anya C. Morgan, MA, CCRC* and
  11. Brian M. Ilfeld, MD, MS*
  1. *University California, San Diego, San Diego, CA; and †Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
  1. Address correspondence to: Brian M. Ilfeld, MD, MS, University of California, San Diego, W Arbor Dr, MC 8770, San Diego, CA 92103 (e-mail: bilfeld{at}


Background Historically, the anterolateral interscalene block—deposition of local anesthetic adjacent to the brachial plexus roots/trunks—has been used for surgical procedures involving the shoulder. The resulting block frequently failed to provide surgical anesthesia of the hand and forearm, even though the brachial plexus at this level included all of the axons of the upper-extremity terminal nerves. However, it remains unknown whether deposition of local anesthetic adjacent to the seventh cervical root or inferior trunk results in anesthesia of the hand and forearm.

Methods Using ultrasound guidance and a needle-in-plane posterior approach, a Tuohy needle was positioned with the tip located between the deepest and next-deepest visualized brachial plexus root/trunk, followed by injection of mepivacaine (1.5%). Grip strength and the tolerance to cutaneous electrical current in 5 terminal nerve distributions were measured at baseline and then every 5 minutes following injection for a total of 30 minutes. The primary end point was the proportion of cases in which the interscalene nerve block resulted in a decrease in grip strength of at least 90% and hand and forearm anesthesia (tolerance to >50 mA of current in all 5 terminal nerve distributions) within 30 minutes. The primary hypothesis was that a single-injection interscalene brachial plexus block produces a similar rate of anesthesia of the hand and forearm to the published success rate of 95% for other brachial plexus block approaches.

Results Of 55 subjects with blocks placed per protocol, all had a successful block of the shoulder as defined by inability to abduct at the shoulder joint. Thirty-three subjects had measurements at 30 minutes following local anesthetic deposition, and only 5 (15%) of these subjects had a surgical block of the hand and forearm (P < 0.0001; 95% confidence interval, 6%–33%). We therefore reject the hypothesis that the interscalene block as performed in this study provides equivalent anesthesia to the hand and forearm compared with other brachial plexus block techniques. Block failures of the hand and forearm were due to inadequate cutaneous anesthesia of the ulnar (n = 27; 82%), median (n = 26; 78%), or radial (n = 22; 67%) distributions; the medial forearm (n = 25; 76%); and/or the lateral forearm (n = 14; 42%). Failure to achieve at least a 90% reduction in grip strength occurred in 16 subjects (48%).

Conclusions This study did not find evidence to support the hypothesis that local anesthetic injected adjacent to the deepest brachial plexus roots/trunks reliably results in surgical anesthesia of the hand and forearm.

Statistics from


  • The majority of study contributions of Dr Loland occurred while at the University of California, San Diego, CA.

    Funding for this project was provided by the National Institutes of Health grant GM077026 (principal investigator: Dr Ilfeld) from the National Institute of General Medical Sciences (Bethesda, Maryland); the Clinical and Translational Research Institute, University California, San Diego (San Diego, California), with funding provided by the National Institutes of Health National Center for Research Resources grant UL1RR031980; and the Department of Anesthesiology, University California, San Diego.

    The authors declare no conflict of interest.

    The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding entities.

    This report describes human research. IRB contact information: University of California, San Diego, Institutional Review Board, 858-657-5100 and This study was conducted with written informed consent from the study subjects.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.